David Rosenblum, MD, creator of ABAStageExam.com for the Basic and Applied Exams in Anesthesiology, AnesthesiaExam and the Pediatric Anesthesia Board review (PedsAE.com) discusses Anesthesiology Board Review and Practice Management.
Dr. Rosenblum has also published a children's book:
Welwyn Ardsley and the Cosmic Ninjas: Preparing your child and yourself for anesthesia and surgery
Available at Amazon.com and www.MyKidsSurgery.com
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What is Kratom? Effects, Side Effects and Benefits in Pain Reduction (00:11:14)
🎙️ PainExam Podcast Show Notes Kratom (Mitragyna speciosa): What Pain Physicians Must Know for the Boards In this episode, Dr. David Rosenblum reviews the current science, pharmacology, risks, and clinical relevance of Kratom — an herbal substance widely discussed by pain patients and increasingly appearing on pain-medicine board exams. The discussion focuses on evidence-based mechanisms, safety considerations, and counseling points essential for ABA/ABPM/ABIPP/FIPP board preparation. 🔍 Key Board-Relevant Takeaways 1. Pharmacology & Mechanism Kratom's primary alkaloids are mitragynine and 7-hydroxymitragynine. They act as partial mu-opioid receptor agonists and demonstrate G-protein biased signaling, which may reduce β-arrestin–mediated respiratory depression seen with full opioids. No FDA-approved medical use; pharmacokinetics and dose-response remain inconsistent. 2. Reported Effects Potential Benefits (mostly anecdotal or preclinical): Analgesia for chronic pain Mood elevation and increased energy Reduction of opioid withdrawal symptoms Major Limitations: No high-quality randomized controlled trials Not a recommended analgesic for evidence-based pain practice 3. Adverse Effects & Safety Concerns Commonly reported: Nausea, vomiting, constipation Tachycardia, palpitations Hepatotoxicity in some users Dependence and withdrawal syndrome similar to mild-moderate opioid withdrawal Serious risks: Product variability and contamination Potential interactions with CNS depressants Unpredictable potency of alkaloids 4. Regulatory Status Kratom is unregulated, with significant variability in purity and composition. FDA and multiple public-health agencies caution against its use due to safety concerns. Not recommended as a first-line or adjunct pain therapy. 5. What Boards Like to Test Expect questions on: Mechanism: partial MOR agonist, G-protein bias Differences from classical opioids Adverse effects and withdrawal Toxicology and contamination risks Counseling patients who self-medicate Lack of clinical trial data and regulatory approval 🎓 Board Prep Resources Prepare for the ABA, ABPM, ABIPP, FIPP, and AOBPM exams with the PainExam Board Review and full curriculum at the NRAP Academy: 👉 https://www.NRAPpain.org 🫁 Hands-On Ultrasound Training for Pain Physicians Boost your procedural skills with live ultrasound-guided interventional pain and regional anesthesia workshops: 👉 https://www.nrappain.org/pages/ultrasound-training 📚 References (Condensed) Kruegel AC, Grundmann O. Neuropharmacology of kratom alkaloids. Neuropharmacology. Eastlack SC et al. Kratom: Pharmacology & clinical implications. Phytother Res. Striley CW et al. Health effects of kratom. Front Pharmacol. FDA Public Health Advisory on Kratom. Educational Offerings & Learning Opportunities PainExam / NRAP Academy Training & Programs: Neuromodulation & Regional Anesthesia Workshops Ultrasound-Guided Pain Procedures Regenerative Pain Medicine Training Virtual Pain Fellowship Pain Management Board Review & Question Banks Learn More / Register: 🔹 https://PainExam.com 🔹 https://NRAPpain.org Board Prep & Certification Support Prepare for: ABA Pain Boards ABPM ABIPP Pain Management Board Certification Exams (No reference to FIPP included, per request) Access Board Prep Courses & Q-Banks: ➡️ https://PainExam.com ➡️ https://NRAPpain.org Clinical Practice AABP Integrative Pain Care (Brooklyn & Great Neck, NY) To schedule a consultation or referral: 🌐 https://AABPpain.com 📞 Brooklyn: 718-436-7246 About the Host – David Rosenblum, MD Dr. Rosenblum serves as Director of Pain Management at Maimonides Medical Center and Managing Partner at AABP Integrative Pain Care in Brooklyn, NY. He is recognized as an early adopter and leading educator in ultrasound-guided pain procedures, neuromodulation, and regenerative medicine. He has: Developed regional anesthesia training programs Published widely in pain medicine literature Lectured nationally and internationally through ASIPP, ASPN, NANS, IASP, and more Helped over 3000 physicians pass pain board exams Hosted the PainExam, AnesthesiaExam, and PMRExam podcasts Awards (Selected): New York Magazine Top Doctors: 2016–2025 Top Doctors NY Metro Area: 2016–2025 Schneps Media Honors: Multiple Years Connect with Dr. Rosenblum LinkedIn: https://www.linkedin.com/in/davidrosenblummd/ Instagram: https://www.instagram.com/painexam/ Facebook: https://www.facebook.com/david.rosenblum.16 X (Twitter): https://x.com/AlgoSonic Episode Call-to-Action ✅ Join the NRAP Community ✅ Register for an Upcoming Workshop ✅ Access Pain Board Review Training Start here → https://NRAPpain.org | https://PainExam.com
Caudal Epidural Steroid Injeciton with PRP (00:18:28)
Caudal Epidural Steroid Injection with PRP Case Reports and a Testimonial! Upcoming Training Courses and Services Regional Anesthesia and IV Vascular Access Courses: New York and Detroit locations scheduled Pain Management Board Preparation Private Coaching Services: Ultrasound guidance Preceptorship Board preparation coaching Contact available via email Info@NRAPpain.org for interested physicians PRP Caudal Epidural Research Review Study Overview: Randomized double-blind controlled pilot study comparing leukocyte-rich PRP versus corticosteroids in caudal epidural space 50 patients randomly assigned to two groups Treatment options: triamcinolone 60mg or leukocyte-rich PRP from 60ml autologous blood Follow-up assessments at 1, 3, and 6 months using VAS and SF-36 surveys Key Findings: Both treatments showed significant pain reduction compared to baseline Steroid group had lower VAS scores at one month PRP group demonstrated superior results at 3 and 6 months PRP group showed significant improvement across all SF-36 domains at 6 months No complications or adverse effects in either group during 6-month follow-up Personal Treatment Experience Dr. Rosenblum received transforaminal PRP injection 9-10 weeks ago Gradual improvement noted from weeks 4-8, with more noticeable benefits from weeks 8-10 Current status: minimal pain (0.5/10) only during weather changes Clinical Practice Philosophy Treatment Approach: Minimalist philosophy focusing on turmeric, PRP, and Pilates Medication Strategy: Low-dose naltrexone as go-to medication, avoiding long-term drugs with side effects Surgical Avoidance: Prioritizing conservative treatments over unnecessary surgical interventions Emergency Department PRP Implementation Case Study Results: Ultrasound-guided caudal epidural steroid injection in ER setting 100% pain resolution achieved Patient discharged directly from ER Cost savings: reduced from $33,000 to $4,800 (approximately $28,000 savings) Training Opportunities: Private training sessions available for ER physicians interested in ultrasound-guided procedures Patient Testimonial Highlights Case Background: Nurse with herniated disc from March, previously considering $30,000 surgery Treatment Outcome: PRP injection completed two months ago with nearly complete pain relief Reduced from multiple pain medications to one Advil daily Eliminated antalgic posture and muscle spasms Returned to full 12-hour hospital shifts without difficulty Overall quality of life restored to normal levels David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures. Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023 Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more! Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques. Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call Brooklyn 718 436 7246 Reference Irvan J. Bubic, Jessica Oswald, Ultrasound-Guided Caudal Epidural Steroid Injection for Back Pain: A Case Report of Successful Emergency Department Management of Radicular Low Back Pain Symptoms, The Journal of Emergency Medicine,Volume 61, Issue 3,2021,Pages 293-297,ISSN 0736-4679 Ruiz‐Lopez, Ricardo, and Yu‐Chuan Tsai. "A randomized double‐blind controlled pilot study comparing leucocyte‐rich platelet‐rich plasma and corticosteroid in caudal epidural injection for complex chronic degenerative spinal pain." Pain Practice 20.6 (2020): 639-646. #prppain #paincme #sciatia #ultrasoundmsk #ultrasoundprp #epidural #nypaindoctor #prppainwindsor
Supplements for Pain: Does the Evidence Support it? (00:19:29)
Episode Overview In this episode, Dr. David Rosenblum discusses the role of supplements and complementary strategies in the management of chronic pain. Drawing from clinical practice at AABP Integrative Pain Care, as well as his teaching and training programs, Dr. Rosenblum reviews how nutraceuticals, regenerative therapies, ultrasound-guided procedures, and neuromodulation can work together to improve patient outcomes and reduce opioid reliance. This episode also highlights educational opportunities and exam-prep resources for pain fellows, residents, anesthesiologists, physiatrists, and APPs looking to expand their interventional pain, ultrasound, and regenerative medicine skill sets. Key Topics Discussed Evidence and clinical rationale for select supplements in chronic pain management The role of ultrasound guidance in improving accuracy and safety in interventional pain procedures How regenerative medicine techniques such as PRP and BMAC are shaping personalized pain care Practical considerations when combining supplements with neuromodulation, RFA, or injections Patient case applications and real-world treatment planning Educational Offerings & Learning Opportunities PainExam / NRAP Academy Training & Programs: Neuromodulation & Regional Anesthesia Workshops Ultrasound-Guided Pain Procedures Regenerative Pain Medicine Training Virtual Pain Fellowship Pain Management Board Review & Question Banks Learn More / Register: www.AABPpain.com 🔹 https://PainExam.com 🔹 https://NRAPpain.org Board Prep & Certification Support Prepare for: ABA Pain Boards ABPM ABIPP Pain Management Board Certification Exams (No reference to FIPP included, per request) Access Board Prep Courses & Q-Banks: ➡️ https://PainExam.com ➡️ https://NRAPpain.org Clinical Practice AABP Integrative Pain Care (Brooklyn & Great Neck, NY) To schedule a consultation or referral: 🌐 https://AABPpain.com 📞 Brooklyn: 718-436-7246 About the Host – David Rosenblum, MD Dr. Rosenblum serves as Director of Pain Management at Maimonides Medical Center and Managing Partner at AABP Integrative Pain Care in Brooklyn, NY. He is recognized as an early adopter and leading educator in ultrasound-guided pain procedures, neuromodulation, and regenerative medicine. He has: Developed regional anesthesia training programs Published widely in pain medicine literature Lectured nationally and internationally through ASIPP, ASPN, NANS, IASP, and more Helped over 3000 physicians pass pain board exams Hosted the PainExam, AnesthesiaExam, and PMRExam podcasts Awards (Selected): New York Magazine Top Doctors: 2016–2025 Top Doctors NY Metro Area: 2016–2025 Schneps Media Honors: Multiple Years Connect with Dr. Rosenblum LinkedIn: https://www.linkedin.com/in/davidrosenblummd/ Instagram: https://www.instagram.com/painexam/ X (Twitter): https://x.com/AlgoSonic Practical Takeaways Evidence strength varies widely; preclinical support is more robust than human RCT data for most supplements. Potentially reasonable adjuncts in select contexts Vitamin D: plausible benefit in deficiency states, including diabetic neuropathy and chronic pain-related quality-of-life factors; confirm deficiency and monitor. Magnesium: consider IV regimens for refractory neuropathic components (e.g., cancer pain, PHN); oral efficacy uncertain. Curcumin: consider as adjunct, especially formulated phytosome combinations; monitor for additive effects and tolerability. B vitamins: consider B12 in deficiency or neuropathy with suspected demyelination; overall human evidence limited. Zinc: mechanistic rationale with preclinical support; limited human data—consider deficiency correction rather than supraphysiologic dosing. Cautions and contraindications St. John's wort: significant drug–drug interaction potential via CYP/P-gp induction. Alpha lipoic acid: may cause hypoglycemia; monitor glucose, especially in diabetes. Agent-specific toxicity thresholds should guide safe upper limits; prioritize lab-confirmed deficiencies. Risks, Limitations, and Research Gaps Heterogeneity in study designs, small samples, lack of controls, and multi-ingredient formulations limit causal inference. Need for large, well-designed RCTs stratified by neuropathic pain etiology (e.g., CIPN vs. DPN vs. PHN) with standardized outcomes. Translational gap between animal models and human clinical efficacy remains significant. References Frediani, Jennifer K., et al. "The role of diet and non‐pharmacologic supplements in the treatment of chronic neuropathic pain: A systematic review." Pain Practice 24.1 (2024): 186-210. Huang, Wei MD, PhD*,†; Shah, Shivani DO†; Long, Qi PhD‡; Crankshaw, Alicia K. MD†; Tangpricha, Vin MD, PhD§,∥. Improvement of Pain, Sleep, and Quality of Life in Chronic Pain Patients With Vitamin D Supplementation. The Clinical Journal of Pain 29(4):p 341-347, April 2013. | DOI: 10.1097/AJP.0b013e318255655d Haddad, H.W., Mallepalli, N.R., Scheinuk, J.E. et al. The Role of Nutrient Supplementation in the Management of Chronic Pain in Fibromyalgia: A Narrative Review. Pain Ther 10, 827–848 (2021). https://doi.org/10.1007/s40122-021-00266-9 Abdelrahman, K.M.; Hackshaw, K.V. Nutritional Supplements for the Treatment of Neuropathic Pain. Biomedicines 2021, 9, 674. https://doi.org/10.3390/biomedicines9060674
BMAC and PRP for ACL Tears- Journal Club (00:18:16)
Pain Exam Podcast Recent Conference Activities London Conference Weekend: Successfully attended and spoke at ISPN and SOMOS care conferences Somos Care Conference: Delivered presentation on pain management for primary care physicians Presentation consisted of 50+ slides with only one slide dedicated to opiates Emphasized shift away from opiate-based treatments in interventional pain management Recommended primary care physicians refer patients to pain specialists for comprehensive treatment options ISPN Conference: Participated in international pain management conference Met with doctors from London, Iraq, and various other countries Observed different international approaches to pain treatment including increased phenol use and varying regenerative medicine restrictions Upcoming Events and Workshops New York-New Jersey Pain Conference: November (NRAP Academy booth presence) IV Ultrasound Placement Workshops: Monthly sessions in New York Regional Anesthesia and Ultrasound-Guided Interventional Pain Medicine Workshops: New York: December 13th, January 10th Florida (Fort Lauderdale/Hollywood): November 8th Detroit: January 18th, February 15th Alternative Options: Online ultrasound courses and shadowing opportunities available Board Prep and NRAP Community at PainExam.com or NRAPpain.org ABA ABPM ABIPP FIPP Pain Management Board prep, Question Banks, and Virtual Pain Fellowship Educational Offerings and Events Training and Courses: Research Review: ACL Treatment Study Study Focus: Non-surgical treatment of ACL tears using bone marrow concentrate (BMAC) and platelet products versus exercise therapy Key Findings: BMAC group showed significantly greater improvement in Lower Extremity Function Scale (LEFS) and Single Assessment Numeric Evaluation (SANE) scores at three months Sustained improvement in function and decreased pain maintained through two-year follow-up Patients reported median subjective improvement of 90% at final follow-up No significant improvements observed in exercise-only group during initial three months Treatment Protocol: Bone marrow harvest from posterior superior iliac crest (60-90ml from 6-8 sites) PRP preparation from 60ml whole blood Fluoroscopy-guided injection directly into ACL ligament Comprehensive 52-week rehabilitation protocol with activity restrictions Clinical Practice Implications Current ACL Treatment Landscape: Over 400,000 ACL reconstruction surgeries performed annually in the US Surgical Limitations: Risk of graft failure, persistent instability, cartilage injury, and increased arthritis risk Return to Sport Statistics: Post-surgical rates vary significantly (33-92% return to sport, 65% return to pre-injury level) Practice Integration Considerations: Potential incorporation of BMAC/PRP protocols for ACL tears, though insurance coverage remains limited David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures. Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023 Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more! Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques. Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call Brooklyn 718 436 7246 References Centeno CJ, Berger DR, Pitts J, Markle J, Pelle AJ, Murphy M, Dodson E. Non-surgical treatment of anterior cruciate ligament tears with percutaneous bone marrow concentrate and platelet products versus exercise therapy: a randomized-controlled, crossover trial with 2-year follow-up. BMC Musculoskelet Disord. 2025 Sep 30;26(1):882. doi: 10.1186/s12891-025-09153-2. PMID: 41029301; PMCID: PMC12486544. #pccwindsor #paincareclinicswindsor #painwindsorontario #paindocwindsorontarior #paincareclinics #prpwindsorontario #prp #aabppain
Chronic Pain and the TENS Unit (00:11:11)
Project Sync / Status Update Summary Podcast Episode Overview The host discussed Transcutaneous Electrical Nerve Stimulation (TENS) as a recurring pain board topic and reviewed mechanisms, efficacy, and clinical considerations. Emphasis that TENS appears on pain boards annually and is a foundational topic from early podcast episodes. Board Prep and NRAP Community at PainExam.com or NRAPpain.org ABA ABPM ABIPP FIPP Pain Management Board prep, Question Banks, and Virtual Pain Fellowship Educational Offerings and Events Training and Courses: Monthly ultrasound courses in New York and upcoming courses in Detroit covering ultrasound-guided regional anesthesia and chronic pain. Ultrasound Guided Acute and Chronic Pain course in November near Hollywood/Fort Lauderdale with venue pending confirmation. Multiple instructors to offer diverse perspectives; registration via the CME calendar at nrappain.org. Conferences and Teaching: New York–New Jersey Pain Conference in November (hosted by Soudir Duwan). ISPN conference in London next week, with ultrasound teaching participation by the host. Community and Coaching: Private coaching and shadowing opportunities available; contact via newsletter replies. Access to the NRAP community forum upon signup at nrappain.org for discussions on neuromodulation, regional anesthesia, and pain. TENS: Mechanisms and Parameters Device and Parameters: TENS delivers adjustable pulse frequency and intensity; configurations include low (50–100+ Hz), and mixed frequencies. Mechanisms of Analgesia: Activation of large-diameter, non-noxious A-beta afferent fibers in the periphery, driving descending inhibitory pathways and reducing hyperalgesia. Board-relevant point: selective activation of A-beta fibers is frequently tested. Central effects: Reduces central excitability and nociceptive dorsal horn neuron activity in uninjured and injured models. Frequency-dependent opioid receptor mediation: High-frequency analgesia blocked by delta receptor antagonists. Low-frequency analgesia blocked by mu receptor antagonists (spinal cord and rostral ventral medulla). Additional receptor involvement: muscarinic M1/M3, GABA-A, and cannabinoid (CB1) receptors; blockade reduces or prevents TENS analgesia depending on frequency. Peripheral effects: High-frequency TENS reduces injury-related increases in substance P in DRG neurons. Blockade of peripheral opioid and CB1 receptors can prevent analgesia from both low- and high-frequency TENS. Clinical dosing considerations: Adequate dosing (timing, frequency of use, intensity achieving strong but non-painful paresthesia) influences efficacy. Analgesia has rapid onset/offset and may require repeated administration throughout the day for sustained relief. Evidence and Efficacy Summary Clinical experience suggests potential adjunctive benefit for acute pain, but systematic reviews are conflicting; more rigorous studies are needed. For board preparation, the critical takeaway is A-beta fiber activation. Key Takeaways for Board Prep TENS targets large-diameter non-noxious A-beta afferents to reduce nociceptive signaling. High-frequency TENS: analgesia mediated via delta opioid receptors; blocked by delta antagonists. Low-frequency TENS: analgesia mediated via mu opioid receptors; blocked by mu antagonists in spinal cord and RVM. Additional receptor systems influencing TENS efficacy include muscarinic (M1/M3), GABA-A, and CB1. Action Items Review TENS mechanisms with emphasis on A-beta fiber activation for board prep. Verify and publish final venue details for the November Florida ultrasound course. Share registration links and schedules for Detroit and New York ultrasound and chronic pain courses via CME calendar. Prepare teaching materials for ISPN London ultrasound sessions next week. Update board prep resources on painexam.com and nrappain.org with current TENS evidence and dosing guidance. Promote NRAP community forum access and private coaching/shadowing opportunities through the newsletter. David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures. Patients can go to www.AABPpain.com or call 718 436 7246 Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023 References Johnson M. Transcutaneous Electrical Nerve Stimulation: Mechanisms, Clinical Application and Evidence. Rev Pain. 2007 Aug;1(1):7-11. doi: 10.1177/204946370700100103. PMID: 26526976; PMCID: PMC4589923. Vance, C.G.T.; Dailey, D.L.; Chimenti, R.L.; Van Gorp, B.J.; Crofford, L.J.; Sluka, K.A. Using TENS for Pain Control: Update on the State of the Evidence. Medicina 2022, 58, 1332. https://doi.org/10.3390/medicina58101332 #painnyc #painbrooklyn #prpbrooklyn #prpspine #regionalanesthsia #pccwindsor #paincareclinicswindsor #painwindsorontario #paindocwindsorontarior #paincareclinics #prpwindsorontario #prp
Exploring the Efficacy of BMAC and ADSC Injections in Knee Osteoarthritis (00:07:22)
Exploring the Efficacy of BMAC and ADSC Injections in Knee Osteoarthritis Hosts: David Rosenblum,MD Overview: In this episode, we delve into a recent study published in the Indian Journal of Orthopaedics that compares the therapeutic efficacy of Bone Marrow Aspirate Concentrate (BMAC) and Adipose-Derived Stem Cells (ADSCs) for treating knee osteoarthritis (OA). The study aims to provide insights into the effectiveness of these regenerative treatments and their correlation with mesenchymal stem cell (MSC) cellularity. Key Points Discussed: Background on Osteoarthritis: Definition and impact of OA, particularly in older populations. Overview of traditional treatments and the shift towards regenerative medicine. Study Objectives: To compare the efficacy of BMAC and ADSC injections in symptomatic knee OA patients. To analyze MSC quantity and quality in harvested tissues from both sources. Methodology: Description of the study design involving 60 patients with knee OA. Details on patient demographics, injection protocols, and follow-up assessments (VAS, WOMAC, ROM). Results: Significant improvements in clinical scores for both BMAC and ADSC groups at 6 months. Discussion on the lack of significant correlation between MSC quantity and treatment efficacy. Insights into the success rates of MSC cultures from both bone marrow and adipose tissue. Conclusions: Both treatments demonstrated clinical improvements, with no substantial differences between them. BMAC showed higher MSC counts and faster recovery rates, but further research is needed to understand the underlying factors affecting efficacy. Implications for Clinical Practice: Considerations for clinicians when choosing between BMAC and ADSC treatments. Future directions for research in regenerative therapies for knee OA. References: Vitali, M., Ometti, M., Montalbano, F., et al. (2025). Bone Marrow Aspirate Concentrate (BMAC) Versus Adipose-Derived Stem Cells (ADSCs) Intra-articular Injection Therapeutic Efficacy in Knee OA Correlated to Their Mesenchymal Stem Cell (MSC) Cellularity: An Exploratory Comparative Pilot Study. Indian Journal of Orthopaedics. https://doi.org/10.1007/s43465-025-01525-z Listener Engagement: Join the conversation! Share your thoughts on BMAC and ADSC treatments for knee OA on social media using #JournalClubPodcast. Don't forget to subscribe for more discussions on the latest research in orthopaedics and regenerative medicine.
Intra-articular Ketorolac vs Steroid for Pain: Journal Club (00:14:52)
Podcast Summary This episode of the Pain Exam Podcast, hosted by Dr. David Rosenblum, discusses an interesting article about Ketorolac injections for musculoskeletal conditions. The podcast covers: Ketorolac is an NSAID that provides analgesic and anti-inflammatory effects through inhibition of prostaglandin synthesis Multiple studies comparing Ketorolac injections to corticosteroids and hyaluronic acid for various conditions Research shows Ketorolac injections are equally effective as corticosteroids for subacromial conditions, adhesive capsulitis, carpal-metacarpal joint issues, and hip/knee osteoarthritis Ketorolac may be a safer alternative to steroids for certain patients, though it has its own contraindications for those with renal, gastrointestinal, or cardiovascular disease Dr. Rosenblum considers the potential of using Ketorolac injections directly at pain sites rather than intramuscularly Upcoming Courses and Conferences Ultrasound courses in New York and Costa Rica (check unwrappedpain.org) Private ultrasound sessions available Dr. Rosenblum will be speaking at Pain Week about ultrasound in pain practice and PRP Presenting at a primary care conference in London Teaching ultrasound at ISPN LAPS conference in Chile (Dr. Rosenblum won't attend this year) Ketorolac Injections: An Effective Alternative for Musculoskeletal Pain Management Musculoskeletal conditions such as bursitis, adhesive capsulitis, and osteoarthritis affect millions and often require injectable therapies to reduce pain and inflammation. Traditionally, corticosteroid injections have been the mainstay treatment. However, concerns over side effects like tendon rupture, cartilage damage, and systemic hyperglycemia have prompted exploration of alternatives. A recent narrative review by Kiel et al. (2024) highlights ketorolac—a parenteral nonsteroidal anti-inflammatory drug (NSAID)—as a promising substitute for corticosteroids in musculoskeletal injections. Warning: OFF Label use of Ketorolac discussed. Please consult your physician. See full article for details. Subacromial Ketorolac Injections for Shoulder Pain Subacromial bursitis and impingement syndrome are common causes of shoulder pain and disability. Several randomized controlled trials have shown that subacromial ketorolac injections provide pain relief and functional improvement comparable to corticosteroids: Goyal et al. demonstrated significant reductions in pain scores after subacromial injection of 60 mg ketorolac versus 40 mg methylprednisolone, with no difference in outcomes between groups. Taheri et al. found similar short-term pain relief at 1 and 3 months with either ketorolac or corticosteroid subacromial injections. Kim et al. reported equivalent clinical improvement in rotator cuff syndrome patients receiving ketorolac or triamcinolone injections. Min et al. noted ketorolac led to better forward flexion and patient satisfaction at 4 weeks compared to corticosteroids. These studies support ketorolac as an effective agent for subacromial injection, offering an alternative for patients where corticosteroid use is limited. Intra-articular Ketorolac Injections for Adhesive Capsulitis and Osteoarthritis Adhesive capsulitis (frozen shoulder) and osteoarthritis of the hip, knee, and carpometacarpal joint are often treated with intra-articular corticosteroids. Ketorolac injections have shown comparable efficacy in these conditions: Akhtar et al. found intra-articular ketorolac significantly reduced shoulder pain at 4 weeks in adhesive capsulitis compared to hyaluronic acid. Ahn et al. reported similar pain relief between intra-articular ketorolac and corticosteroid injections in adhesive capsulitis, with ketorolac providing superior shoulder mobility at 3 and 6 months. Koh et al. showed that adding ketorolac to hyaluronic acid injections in carpometacarpal osteoarthritis resulted in faster onset of pain relief compared to hyaluronic acid alone. Park et al. observed equivalent functional improvements with intra-articular ketorolac or corticosteroids in hip osteoarthritis. Jurgensmeier et al. demonstrated similar symptom improvement at 1 and 3 months post-injection for ketorolac and triamcinolone in hip and knee osteoarthritis. Xu et al. and Bellamy et al. confirmed ketorolac's comparable pain relief and functional benefits to corticosteroids for knee osteoarthritis, with ketorolac being more cost-effective. Lee et al. noted quicker pain reduction with intra-articular ketorolac combined with hyaluronic acid versus hyaluronic acid alone in knee osteoarthritis. aSafety and Pharmacologic Considerations Ketorolac's anti-inflammatory action stems from cyclooxygenase inhibition, reducing prostaglandin synthesis. Its half-life is approximately 5.2–5.6 hours, and it is metabolized in the liver. Unlike corticosteroids, ketorolac avoids systemic hyperglycemia and cartilage damage risks. Animal and in vitro studies suggest ketorolac may protect cartilage by inhibiting inflammatory cytokines. While gastrointestinal, renal, and cardiovascular risks associated with NSAIDs remain considerations, localized intra-articular and subacromial ketorolac injections may limit systemic exposure and adverse effects. Mild, transient post-injection pain has been reported but resolves without intervention. Conclusion Ketorolac injections, administered intra-articularly or subacromially, are a safe, effective, and economical alternative to corticosteroids for managing common musculoskeletal conditions. Their comparable efficacy in reducing pain and improving function, combined with a more favorable side effect profile, makes ketorolac an appealing option for clinicians and patients alike. Further research is warranted to fully elucidate long-term safety and optimal dosing strategies. FAQS Ketorolac Injections for Musculoskeletal Conditions: Frequently Asked Questions Musculoskeletal pain from conditions like bursitis, adhesive capsulitis, and osteoarthritis often requires injectable treatments. Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is emerging as a promising alternative to corticosteroids. Below are common questions and answers based on a recent narrative review by Kiel et al. (2024). 1. What is ketorolac and how does it work? Ketorolac is a parenteral NSAID that reduces pain and inflammation by inhibiting cyclooxygenase enzymes, which decreases prostaglandin synthesis. It can be administered orally, intramuscularly, intravenously, or by injection directly into joints or around bursae. 2. How effective is ketorolac for musculoskeletal conditions? Studies show ketorolac injections provide significant pain relief and functional improvement comparable to corticosteroids in conditions like: Subacromial bursitis and shoulder impingement (subacromial injections) Adhesive capsulitis (frozen shoulder) (intra-articular injections) Osteoarthritis of the hip, knee, and thumb carpometacarpal joint (intra-articular injections) 3. What evidence supports subacromial ketorolac injections? Randomized controlled trials found: Goyal et al. and Taheri et al. reported similar pain reduction and functional outcomes between ketorolac and corticosteroids for subacromial injections. Kim et al. and Min et al. observed comparable or better patient satisfaction and shoulder mobility with ketorolac versus corticosteroids. 4. How does intra-articular ketorolac compare to corticosteroids for adhesive capsulitis? Akhtar et al. showed ketorolac reduced shoulder pain more than hyaluronic acid. Ahn et al. found ketorolac and corticosteroids equally effective for pain relief, with ketorolac providing better shoulder mobility at 3 and 6 months. 5. What about ketorolac for osteoarthritis? Ketorolac combined with hyaluronic acid provided faster pain relief than hyaluronic acid alone in thumb carpometacarpal joint osteoarthritis (Koh et al.). Intra-articular ketorolac had similar efficacy to corticosteroids in hip (Park et al., Jurgensmeier et al.) and knee osteoarthritis (Bellamy et al., Xu et al.). Ketorolac injections were more cost-effective compared to corticosteroids (Bellamy et al.). 6. Are ketorolac injections safe? Ketorolac's side effects are similar to other NSAIDs, mainly involving gastrointestinal, renal, and cardiovascular risks. However, localized intra-articular and subacromial injections may reduce systemic exposure. Animal studies suggest ketorolac does not harm cartilage and may protect against inflammatory damage. Mild, transient local pain post-injection is possible but usually resolves without treatment. 7. What are the limitations of ketorolac use? Ketorolac is not suitable for patients with: Renal impairment Gastrointestinal ulcers or bleeding risk Cardiovascular disease or hypertension NSAID hypersensitivity, especially in asthma or chronic urticaria patients Clinicians should assess individual risks before choosing ketorolac injections. 8. How does ketorolac's pharmacokinetics affect its use? Ketorolac has a plasma half-life of about 5.2 to 5.6 hours and is metabolized in the liver. Pharmacokinetics for subcutaneous or intra-articular administration are less defined but systemic absorption occurs. Its relatively short half-life supports repeated dosing if needed. 9. Why consider ketorolac over corticosteroids? Ketorolac avoids corticosteroid-associated risks such as tendon rupture, cartilage damage, and steroid-induced hyperglycemia. It is also more cost-effective, making it a favorable option for patients and healthcare systems. 10. What further research is needed? More large-scale, long-term studies are needed to fully understand ketorolac's intra-articular effects, optimal dosing, and safety profile compared to corticosteroids and other treatments. Summary: Ketorolac injections, whether intra-articular or subacromial, offer a safe, effective, and economical alternative to corticosteroids for managing various musculoskeletal conditions. This makes ketorolac an important option in pain management and inflammation control. Reference: Kiel J, Applewhite AI, Bertasi TGO, Bertasi RAO, Seemann LL, Costa LMC, Helmi H, Pujalte GGA. Ketorolac Injections for Musculoskeletal Conditions: A Narrative Review. Clinical Medicine & Research. 2024;22(1):19-27. DOI: https://doi.org/10.3121/cmr.2024.1847 Disclaimer: This Podcast, website and any content from NRAP Academy (PMRexam.com) otherwise known as Qbazaar.com, LLC is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user's own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.
Post Herpetic Neuralgias: Epidurals, Paravertebral Blocks and more! (00:27:40)
Summary In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures. Chapters Introduction to the Pain Exam Podcast and Topic Overview Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease. Upcoming Conferences and Educational Opportunities Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities. Overview of Postherpetic Neuralgia Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life. Treatment Options Overview Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Phases of Herpes Zoster and Definitions Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash. Incidence and Risk Factors Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia. Impact on Quality of Life Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia. Literature Review and Pathophysiology Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia. Central Sensitization and Nerve Damage Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome. Different Phenotypes and Classification Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration. Deafferentation Phenotype Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial. Diagnosis and Physical Examination Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients. Sensory Testing and Assessment Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons. Prevention Through Vaccination Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions. Treatment Objectives Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation. Antiviral Medications Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised. Benefits of Antiviral Therapy Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible. Corticosteroids and Opioids Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction. Methadone and Antidepressants Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction. Antiepileptics and Pharmacological Treatment Summary Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011. Topical Agents Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group. Intracutaneous Injections Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study. Summary of Local Anesthetics Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy. Interventional Treatments: Epidural and Paravertebral Injections Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster. Comparative Studies on Injection Approaches Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster. Timing of Interventions and Continuous Epidural Blockade Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality. Interventions for Postherpetic Neuralgia Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence. Summary of Epidural and Paravertebral Injections Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy. Pulsed Radiofrequency (PRF) Evidence Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy. PRF Studies for Acute Herpes Zoster Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group. PRF for Trigeminal Neuralgia Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group. PRF Compared to Other Interventions Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate. Summary of PRF and Final Recommendations Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature. Sympathetic Blocks and Conclusion Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia. Personal Clinical Approach and Closing Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast. Q&A No Q&A session in this lecture Pain Management Board Prep Ultrasound Training REGISTER TODAY! Create an Account and get Free Access to the PainExam- NRAP Academy Community Highlights David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures. Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023 Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more! Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques. Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call Brooklyn 718 436 7246 Reference Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.
The Neurolytic Celiac Plexus Block for the Anesthesia Boards! (00:14:34)
Summary In this Pain Exam Podcast episode, Dr. David Rosenblum discusses a journal club article on low volume neurolytic retrocrural celiac plexus blocks for visceral cancer pain. The study reviewed 507 patients with severe malignancy-related abdominal pain, with data retained for 455 patients at the 5-month mark. Dr. Rosenblum explains that the procedure involves injecting 3-5ml of 6% aqueous phenol at the T12-L1 level under fluoroscopic guidance, with an average procedure time of 16.3 minutes. The study found significant pain relief lasting up to six months, reduced opioid consumption, and improved quality of life for patients with primary abdominal cancer or metastatic disease. Dr. Rosenblum shares his personal experience with celiac plexus blocks, including the trans-aortic approach he trained on, and mentions his interest in ultrasound-guided approaches. He also announces upcoming teaching engagements at ASPN, Pain Week, and other conferences, as well as CME ultrasound courses available through nrappain.org. Additionally, he mentions a new community page on the website where users can share board preparation information, though he emphasizes that remembered board questions should not be posted as he is a board question writer himself. Pain Management Board Prep Ultrasound Training REGISTER TODAY! Create an Account and get Free Access to the PainExam- NRAP Academy Community Highlights Introduction and Upcoming Events Dr. David Rosenblum introduces the Pain Exam Podcast and shares information about upcoming events. He mentions teaching ultrasound at ASPN in July, attending Pain Week in September, and participating in the Latin American Pain Society conference. Dr. Rosenblum also promotes his CME ultrasound courses available at nrappain.org and mentions he's considering organizing another regenerative medicine course in fall or winter. He offers private training for those wanting more intensive ultrasound instruction. Board Prep Community Announcement Dr. Rosenblum announces a new community page on the nrappain.org website for board preparation. He explains that registered users can access free information and keywords relevant to board exams. He emphasizes that users should not post remembered questions as this would be inappropriate, noting that he himself is a board question writer for various pain boards. Dr. Rosenblum mentions that a post about phenol in this community inspired today's podcast topic. Journal Article Overview on Celiac Plexus Block Dr. Rosenblum introduces a journal article on low volume neurolytic retrocrural celiac plexus block for visceral cancer pain, a retrospective review of 507 patients with severe malignancy-related abdominal pain. He explains that the study assessed pain relief provided by this procedure, its duration, reduction in daily opioid consumption, and quality of life improvements. The patients received neurolytic blocks without previous diagnostic blocks due to multiple comorbidities, which Dr. Rosenblum acknowledges is sometimes necessary with very sick patients despite the typical preference for diagnostic blocks before neurolysis. Dr. Rosenblum's Personal Experience with Celiac Plexus Blocks Dr. Rosenblum shares his personal training experience with trans-aortic celiac plexus blocks, where a needle is inserted through the aorta after confirming no plaques or aneurysms are present. He describes it as a safe and effective procedure despite sounding intimidating. He mentions he's only performed a handful of these procedures and doesn't do many now as an outpatient pain doctor. Study Methods and Results Dr. Rosenblum details the study methods, noting that of 507 patients studied, data for 455 was retained at the end of the review. Patients were evaluated before and after the neurolytic retrocrural celiac plexus block under fluoroscopic guidance. Assessment included procedure duration, pain scores (0-10 scale), daily opioid consumption, and quality of life improvement. Follow-up was completed six months after the procedure, showing improved pain scores, reduced opioid consumption, and better quality of life throughout the study period. Some pain returned during months 4-6 due to disease progression and the anticipated duration of the neurolytic agent. The study noted a 6.7% initial vascular contrast uptake during the procedure while using digital subtraction angiography with fluoroscopy. Study Limitations and Conclusions Dr. Rosenblum discusses the study's limitations, including the need for a larger sample size and a prospective trial with a control group, though he acknowledges this is unrealistic given the patient population. He mentions that a proven quality of life questionnaire would be beneficial, and that comparing alcohol, phenol, and RF thermocoagulation would be interesting to evaluate duration effects and side effects. The study concluded that low volume neurolytic retrocrural celiac plexus block with phenol is safe, providing up to six months of pain relief for abdominal pain due to primary malignancy or metastatic spread. Detailed Procedure Technique Dr. Rosenblum explains the detailed procedure technique used in the study. The retrocrural celiac plexus was targeted at L1 level with aim towards T12. Anterior and posterior radiographic imaging aligning the spinous process of T12-L1 junction was used with 15-20 degree oblique rotation. Local anesthetic (1% lidocaine with sodium bicarbonate) was infiltrated along the injection path. A 22 or 25 gauge 3.5-7 inch curved spinal needle was used depending on patient body habitus. Dr. Rosenblum notes he typically uses a 6-inch Chiba needle or 25 gauge spinal needle for such procedures. Procedure Execution and Monitoring Dr. Rosenblum continues describing the procedure, noting that the needle was advanced to the anterior border of T12-L1 under multiple imaging views. Contrast dye studies verified spread and location, with digital subtraction angiography used to check for intravascular uptake. A test dose of 1ml of 0.5% bupivacaine with epinephrine per site was administered, which Dr. Rosenblum finds interesting as he typically doesn't mix bupivacaine with epinephrine. After confirming no vascular uptake, 3-5ml of 6% aqueous phenol was injected in 1ml aliquots while communicating with the patient. The average procedure time was 16.3 minutes with minimal or no sedation. Patients remained prone for 30 minutes afterward to avoid neuroforaminal spread, as phenol is heavier and more viscous than alcohol. Post-Procedure Care and Study Evaluation Dr. Rosenblum explains that patients were monitored in recovery for one hour for adverse events and their ability to eat and void easily. They were discharged once hospital post-anesthetic criteria were met and received a follow-up call 24 hours later. Dr. Rosenblum praises the study and notes that the procedure looks similar to a lumbar sympathetic plexus block, which is also a sympathetic block. Ultrasound Considerations and Alternative Approaches Dr. Rosenblum shares his interest in ultrasound-guided celiac plexus blocks but acknowledges concerns about bowel perforation. He mentions a conversation with an interventional radiology colleague who suggested a transhepatic approach. Dr. Rosenblum recalls scanning a very thin patient where the aorta was easily visible and close to the anterior abdominal wall, making the celiac plexus potentially accessible if bowel perforation, liver bleeding, or gallbladder perforation could be avoided. He shares an experience with a patient suffering from severe pancreatitis pain who received temporary relief from a paravertebral thoracic nerve block at T8-T10, noting that paravertebral blocks provide some sympathetic spread. Conclusion and Community Resource Reminder Dr. Rosenblum concludes by recommending the article, noting its well-written analysis and graphs showing morphine consumption dropping over months following the procedure. He suggests neurolytic procedures are underutilized because they sound intimidating. He again encourages listeners to check out the community he created with separate chat rooms for regenerative medicine, regional anesthesia, and pain boards, where users can share keywords but not specific board questions. Dr. Rosenblum reminds listeners about upcoming courses and his website resources, mentions an upcoming PRP lecture, and asks for five-star reviews if listeners enjoy the podcast. The episode ends with a standard medical disclaimer. Reference https://www.painphysicianjournal.com/current/pdf?article=NTQwOA%3D%3D&journal=113
Epidural PRP Injections...What's the deal? (00:15:31)
PRP in the Epidural Space for Radiculopathy Brooklyn Based Pain Physician, David Rosenblum, MD known for his work publishing and teaching Regenerative Pain Medicine and Ultrasound Guided Pain Procedures hosts this podcast covering the latest and most advanced concepts in Pain Medicine. Summary Dr. David Rosenblum delivered a comprehensive lecture covering several key topics in pain management. He discussed his upcoming speaking engagements at PainWeek, ASPN and great upcoming meetings like the Latin American Pain Society, and other conferences. Dr. Rosenblum shared his extensive experience with PRP (Platelet-Rich Plasma) epidural injections, reviewing multiple research studies that support their efficacy. He highlighted three significant studies: a randomized control trial comparing PRP epidural injections to traditional treatments, a CT-guided epidural PRP study, and a 2025 meta-analysis comparing PRP to steroids. Dr. Rosenblum emphasized that PRP treatments are showing comparable or better results than traditional steroid injections, with potentially fewer required treatments and longer-lasting relief. He noted that while PRP is currently not covered by insurance, it represents a growing trend in 'natural' treatment approaches that patients increasingly prefer. Chapters Introduction and Upcoming Events Dr. Rosenblum announced his upcoming lectures at Pain Week focusing on ultrasound and regenerative medicine, followed by presentations at the Latin American Pain Society in Chile and the New York, New Jersey Pain Conference. He mentioned the SoMeDocs online pain conference accessible through nrappain.org, and upcoming ultrasound training sessions in New York City. PRP Epidural Research Review Dr. Rosenblum discussed a randomized control trial involving 30 patients receiving transforaminal epidural injections. The study showed that PRP patients demonstrated significant improvements in leg pain scores at 6, 12, and 24 weeks. He noted that while the study didn't use contrast, he personally prefers using contrast diluted with saline for better visualization. CT-Guided Epidural Study Analysis Dr. Rosenblum reviewed a study comparing CT-guided epidural PRP versus steroid injections, questioning the necessity of CT guidance. The study included 60 patients and showed similar results between PRP and steroid groups at six weeks, though he criticized the short follow-up period, noting that PRP typically takes months to show full effects. Meta-Analysis Discussion Dr. Rosenblum presented a 2025 meta-analysis comparing PRP to steroids in epidural injections. The analysis included 310 patients across five RCTs, demonstrating comparable efficacy between PRP and steroid injections without increased adverse events. He emphasized that his clinical experience shows patients typically require fewer PRP injections compared to steroid treatments. Register for Next Weeks SoMeDocs Pain Conference References Wongjarupong, Asarn, et al. ""Platelet-Rich Plasma" epidural injection an emerging strategy in lumbar disc herniation: a Randomized Controlled Trial." BMC Musculoskeletal Disorders 24.1 (2023): 335. Bise, Sylvain, et al. "Comparison of interlaminar CT-guided epidural platelet-rich plasma versus steroid injection in patients with lumbar radicular pain." European radiology 30 (2020): 3152-3160. Muthu S, Viswanathan VK, Gangadaran P. Is platelet-rich plasma better than steroids as epidural drug of choice in lumbar disc disease with radiculopathy? Meta-analysis of randomized controlled trials. Exp Biol Med (Maywood). 2025 Feb 4;250:10390. doi: 10.3389/ebm.2025.10390. PMID: 39968415; PMCID: PMC11832311.
Gender Differences and Responses to Opiates- For the Boards! (00:19:53)
Summary Dr. David Rosenblum delivered a comprehensive lecture on gender differences in opiate effects and prescribing practices. He discussed several key studies examining how opiates affect males and females differently, both in animal models and humans. Dr. Rosenblum shared findings showing that morphine has stronger analgesic effects in males, while females experience longer-lasting effects. He also addressed racial disparities in opiate prescribing, noting that white patients are more likely to receive opiates. From his personal clinical experience in Brooklyn, Dr. Rosenblum observed that certain populations tend to be at higher risk for opiate abuse. The lecture covered gender-specific risk factors for opiate misuse, with women tending toward emotional/psychological factors and men showing more behavioral issues. Pain Management Board Prep Ultrasound Training REGISTER TODAY! Chapters Introduction and Upcoming Conferences Dr. Rosenblum introduced himself as the host of the Pain Exam Podcast and announced several upcoming conferences including ASPN in July, PainWeek in September, and other events where he will be teaching ultrasound and regenerative medicine. Board Preparation and Opiate Topics Dr. Rosenblum discussed his role in board preparation through painxam.com and nreppain.org. He emphasized that opiates are a frequently tested topic across different board examinations (FIP, ABPM, ABIP, ABA). Gender Differences in Opiate Effects - Animal Studies Dr. Rosenblum presented research showing that in animal studies, morphine exhibited stronger analgesic effects in males, while females showed longer-lasting effects and could tolerate higher doses. He noted that physical dependence was more severe in male rats during spontaneous withdrawal. Racial and Gender Disparities in Opiate Prescribing Dr. Rosenblum discussed a 2025 study revealing racial disparities in opiate prescribing, with white patients more likely to receive opiates. He shared his personal clinical experience in Brooklyn, noting that young white males were often higher-risk for abuse. Gender-Specific Risk Factors for Opiate Misuse Dr. Rosenblum detailed how women tend to show emotional and psychological risk factors for opiate misuse, while men demonstrate more behavioral risk factors. Women were more likely to report distress and past trauma, while men showed higher rates of criminal behavior and substance abuse history. References Djurendic-Brenesel, Maja, et al. "Gender-related differences in the pharmacokinetics of opiates." Forensic science international 194.1-3 (2010): 28-33. Kosten, Thomas R., Bruce J. Rounsaville, and Herbert D. Kleber. "Ethnic and gender differences among opiate addicts." International Journal of the Addictions 20.8 (1985): 1143-1162. Cicero, Theodore J., Shawn C. Aylward, and Edward R. Meyer. "Gender differences in the intravenous self-administration of mu opiate agonists." Pharmacology Biochemistry and Behavior 74.3 (2003): 541-549. Jamison, Robert N., et al. "Gender differences in risk factors for aberrant prescription opioid use." The Journal of Pain 11.4 (2010): 312-320.
PVD for the Anesthesia and Pain Boards (00:22:08)
Podcast Show Notes: Peripheral Vascular Disease in PainManagement Episode Highlights: - Host: Dr. David Rosenblum - Podcast: Pain Exam Podcast - Focus: Peripheral Arterial Disease (PAD) in Pain Management Download the App Key Topics Covered: 1. Peripheral Arterial Disease (PAD) Overview - Definition: Arterial sclerosis condition developing over long term - WHO Definition: Exercise-related pain or ankle-brachial index (ABI) - Prevalence: * 3-4% in 60-65 year olds * Increases to 15-20% in 85-90 year olds * Up to 50% of patients may progress to symptomatic stages 2. Diagnostic Considerations Diagnostic Tests: - Ankle Brachial Index (ABI) - Ultrasound - CT Angiography - Physical examination - Pulse volume recordings - Transcutaneous oximetry ABI Interpretation: - 1.0-1.4: Normal - 0.9-1.0: Acceptable - 0.8-0.9: Some arterial disease - 0.5-0.8: Moderate arterial disease - 3. Pain Characteristics Types of Pain: - Intermittent claudication - Chronic limb ischemia - Nociceptive pain - Neuropathic pain - Mixed pain syndrome 4. Pain Management Strategies Pharmacological Approaches: - Mild Pain: Paracetamol, NSAIDs - Neuropathic Pain: Lidocaine patches, gabapentin, duloxetine - Severe Pain: Morphine, fentanyl, ketamine Non-Pharmacological Interventions: - Music therapy - Aromatherapy - Psychotherapy - Massage - Acupuncture - TENS - Intermittent pneumatic compression Upcoming Conferences Mentioned: - ASPN - ASIPP - Pain Week - Latin American Pain Society Additional Resources: - Pain Exam newsletter: painexam.com - Virtual pain fellowship at nrappain.org Disclaimer: Always consult with a healthcare professional for personalized medical advice. Reference Garba Rimamskep Shamaki, Favour Markson, Demilade Soji-Ayoade, Chibuike Charles Agwuegbo, Michael Olaseni Bamgbose, Bob-Manuel Tamunoinemi, Peripheral Artery Disease: A Comprehensive Updated Review, Current Problems in Cardiology, Volume 47, Issue 11, 2022,101082, Maier, J.A.; Andrés, V.; Castiglioni, S.; Giudici, A.; Lau, E.S.; Nemcsik, J.; Seta, F.; Zaninotto, P.; Catalano, M.; Hamburg, N.M. Aging and Vascular Disease: A Multidisciplinary Overview. J. Clin. Med. 2023, 12, 5512. https://doi.org/10.3390/jcm12175512 Maier, J.A.; Andrés, V.; Castiglioni, S.; Giudici, A.; Lau, E.S.; Nemcsik, J.; Seta, F.; Zaninotto, P.; Catalano, M.; Hamburg, N.M. Aging and Vascular Disease: A Multidisciplinary Overview. J. Clin. Med. 2023, 12, 5512. https://doi.org/10.3390/jcm12175512
Will JOURNAVX™ (Suzetrigine) appear on the Anesthesia Boards (00:16:42)
Summary At some point this medication may show its face on the Anesthesia boards. Whether or not Suzetrigine will appear on the Anesthesiology boards, all of us need to know about this new class of analgesic. Brought to you by NRAP Academy, home of the AnesthesiaExam Board Prep Here, Dr. David Rosenblum delivered a comprehensive lecture about a new pain medication called Journavx (Suzetrigine). He discussed its mechanism of action as a NAV 1.8 receptor inhibitor, its clinical applications, contraindications, and dosing guidelines. Dr. Rosenblum emphasized that this non-opioid medication represents a new class of pain management drugs with no addiction potential. He also shared information about upcoming educational events, including ultrasound courses and various pain management conferences. The lecture included detailed information about drug interactions, safety considerations, and clinical trial results comparing Journavx to placebo and hydrocodone-acetaminophen combinations. Key findings from clinical trials showed that Jornavix achieved pain relief in 119 minutes compared to 480 minutes for placebo in abdominoplasty trials, and 240 minutes versus 480 minutes in bunionectomy trials. The recommended dosing is 50mg tablets twice daily, with an initial loading dose of 100mg. While the drug showed promising results for moderate to severe acute pain management, it did not demonstrate superiority over hydrocodone in clinical trials. Important contraindications include CYP3A inhibitors, and special considerations are needed for patients with hepatic impairment or those taking hormonal contraceptives. The medication should be taken on an empty stomach, either one hour before or two hours after food, and patients should avoid grapefruit juice while on this medication. For more infomation.... Chapters Introduction and Upcoming Events Dr. Rosenblum announced several upcoming events, including an ultrasound course in New York City on May 17th, 2025. He mentioned offering ultrasound and IV training for healthcare professionals, particularly nurses, ICUs, PAs, and hospital doctors. He also highlighted upcoming conferences including ASPN, Pain Week, Latin American Pain Society, New York, New Jersey Pain Congress, ASIPP, and EPA. Introduction to Journavx (Suzetrigine) Dr. Rosenblum introduced Suzetrigine (Journavx), a new 50mg tablet medication. He emphasized that this discussion was not sponsored by any pharmaceutical company but rather focused on educating about a new class of pain medication. He noted its potential importance as a future board examination topic. Mechanism of Action Dr. Rosenblum explained that Jornavx works by inhibiting the NAV 1.8 receptor. He detailed how the drug blocks sodium ions from entering pain-sensing neurons, disrupting action potential initiation and propagation. He emphasized that the drug is highly selective, binding over 31,000 times more selectively to NAV 1.8 than other NAV subtypes. Contraindications and Drug Interactions Dr. Rosenblum outlined various contraindications, particularly focusing on CYP3A inhibitors and inducers. He listed specific medications in each category and emphasized the importance of careful monitoring when prescribing Journavx alongside these medications. Clinical Trial Results and Dosing Guidelines Dr. Rosenblum presented clinical trial results showing Journavx's effectiveness in treating moderate to severe acute pain. He detailed the dosing guidelines: 50mg tablets twice daily, with an initial loading dose of 100mg. He emphasized the importance of taking the medication on an empty stomach and avoiding grapefruit juice. Q&A No Q&A session in this lecture
Summary The video covers a conversation between Dr. David Rosenblum and Dr. Hamed Sadeghipour, discussing board preparation experiences and the current state of pain management practice. Dr. Rosenblum begins by announcing upcoming events, including a May 17th ultrasound course in New York City and his lectures at various conferences. He also mentions shadowing opportunities at his office. Dr. Sadeghipour shares his board preparation experience, discussing three main resources he used: Huntoon book (800 questions), Board Vitals (700 questions), and Pain Exam. He achieved notably high scores using these resources. Regarding his current practice, Dr. Sadeghipour describes working both in academic anesthesia (40-50% time) and private pain practice, managing four offices with four nurse practitioners The discussion then shifts to the changing landscape of pain management, with both doctors noting concerning trends: increasing focus on surgery center procedures over office-based ones due to reimbursement differences, the challenge of maintaining competency in advanced procedures, and competition from non-specialists entering the field. They also discuss the future of the specialty, suggesting it's moving toward becoming a hybrid of neurosurgery and orthopedic surgery with traditional pain management procedures. For pain medicine Board Prep go to NRAPpain.org For ultraound training go to NRAP Academy Highlights Introduction and Upcoming Events Dr. Rosenblum introduces the podcast and announces several upcoming events, including an ultrasound course in New York City on May 17th, appearances at ASPN and Pain Week conferences, and opportunities for shadowing at his practice. Board Preparation Experience Discussion Dr. Sadeghipour details his board preparation strategy using three main resources: Huntoon book (800 questions), Board Vitals (700 questions), and Pain Exam(700 questions videos, lectures, ultrasound training, regenerative medicine training and more). He explains the strengths and limitations of each resource and mentions achieving exceptionally high scores. Current Practice Structure Dr. Sadeghipour describes his dual practice model: Evolution of Pain Management Practice Both doctors discuss the shifting landscape of pain management, noting increased focus on surgery center procedures, reimbursement challenges, and competition from non-specialists. They address concerns about fellowship training adequacy and the financial pressures affecting new practitioners. Future of Pain Management Specialty The discussion concludes with perspectives on the specialty's future, suggesting it's evolving toward a combination of minimally invasive spine surgery and traditional pain management, with concerns about maintaining specialty integrity and the need for stronger regulatory oversight.
USG Cervical Nerve Root Block and more about PRP! (00:18:15)
Dr. Rosenblum Reviews Questions from my previous lecture, he gave at the trigeminal academy in Indonesia. Dr. Rosenblum explores techniques for rich plasma injection and preparation. He discusses centrifuge settings with plasma volume and concentration as well as the addition of hyaluronic acid to platelet rich plasma. Dr. Rosenb;um also received multiple comments on the recent video that he filmed on performing a cervical selective nerve root block under ultrasound. For more informatin go to NRAPpain.org Disclaimer: This Podcast,video, website and any content from NRAP Academy otherwise known as Qbazaar.com, LLC is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user's own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.
Scrambler Therapy for Neuropathic Pain: An Interview with Dr. Thomas Strouse (00:36:45)
Episode Summary: In this episode of NRAP's PainExam Podcast, host David Rosenblum, MD, interviews Dr. Thomas Strouse about his extensive experience with Scrambler Therapy and the evidence supporting its use in treating chronic pain. They delve into the intricacies of this innovative therapy, discussing treatment protocols, patient responses, and the overall effectiveness of Scrambler Therapy for various pain conditions. Key Topics Discussed: - Overview of Scrambler Therapy and its analgesic response. - The importance of adjusting treatment intensity based on patient feedback. - Sensations experienced by patients during therapy (from burning to tapping). - Safety considerations for patients with pacemakers during treatment. - Insights into the effectiveness of Scrambler Therapy for conditions such as discogenic back pain and peripheral neuropathy. - Discussion on treatment costs for patients and providers. - Experiences with patients who have experienced pain recurrence after treatment. - The role of booster sessions in maintaining pain relief. - Challenges faced by failed back surgery patients and the potential benefits of Scrambler Therapy. Resources Mentioned: - Contact information for Stefan Erickson at stefan@mail.scramblertherapy.com to integrate Scrambler therapy into your practice. Links to additional resources and research on Scrambler Therapy. Info] Additional Information: - For more information about upcoming webinars, including the next session on cervical ultrasound, visit www.NRAPpain.org Thank you for tuning in to NRAP's PainExam Podcast! We hope you find the insights shared in this episode valuable in your journey toward understanding and managing chronic pain. NY based anesthesiologist, David Rosenblum, MD, is one of the first interventional pain physicians in the country to integrate ultrasound guidance into his pain practice. Since 2007, he has been an international leader in the treatment of chronic pain. He has helped countless of patients suffering from back, neck, knee, shoulder, hip joint pain and has been at the forefront of regenerative pain medicine, minimally invasive pain therapies and medical education. Patients can schedule a consultation by going to www.AABPpain.com or calling: Brooklyn Office 718 436 7246 Creators Biography: David Rosenblum, MD, currently treats patients in Garden City and Brooklyn. He serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn , NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures. Dr. Rosenblum has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is working closely with the American Society of Interventional Pain Physicians (ASIPP), Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, and various state societies, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more! Doctor Rosenblum is a co-founder of the International Pain Academy and created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques. Office based Pain Physicians, Physiatrists, Emergency Room Physicians, Anesthesiologists, Neurologists and Orthopedics who treat pain, utilize Neuromodulation and use PRP, Bone Marrow Aspirate or any other Biologics will benefit from this course. #longislandpaindoctor #interventionalpain #paindoctor #scrambler #scramblertherapy
Phillip Kim, MD and the Federation for Pain Care Access (00:32:43)
Host: David Rosenblum, MD Guest: Phillip Kim, MD Date: January 24, 2025 Time: 6:30 AM Episode Summary: In this episode of the PainExam Podcast, Dr. David Rosenblum engages with Dr. Phillip Kim to discuss the Federation Pain Care Access, a newly formed organization advocating for improved access to interventional pain treatments. The episode delves into the challenges posed by restrictive insurance coverage policies and the collaborative efforts needed to address these issues effectively. Key Discussion Points: -Introduction to Federation Pain Care Access: A new entity focused on advocating for emergent and standard care in interventional pain treatments, aiming to enhance access through advocacy and legislative solutions. - Impact of Restrictive Policies: Dr. Kim highlights how insurance carriers like Evicor, AIM, and Optum impose restrictive coverage policies that harm patients and practitioners, particularly amid the ongoing opioid epidemic. AIM, Optum and Evicore are not insurance carriers. these are separate entities which oversee utilization management and prior auth requests for insurance carriers (HMO, TPA's etc) e g. BCBS plans, UHS etc. Prior Authorization Challenges: Discussion on the AMA 2022 Prior Authorization Physician Survey, which indicates significant negative impacts on patient care due to prior authorization processes. - Case Studies: Dr. Kim shares specific cases where patients faced harm due to denied claims, including issues related to medical cannabis and necessary medical equipment. - Collaboration with Medical Societies: The Federation works alongside various pain societies and stakeholders to address common concerns and push for better coverage policies. - Future Goals Plans for meetings with CMS and Medicare Administrative Contractors (MACs) regarding specific treatments like SI joint radiofrequency ablation, aiming to improve coverage and access. Fundraising and Outreach: The Federation seeks to grow its membership and funding through outreach to allied health professionals and patient care groups while launching a media campaign to raise awareness of patient struggles Legal and Advocacy Efforts: Emphasis on the need for legal considerations in advocacy efforts and the importance of public support in achieving the Federation's goals. - The No Pain Act: Discussion on recent legislation aimed at expanding access to non-opioid treatments and alternatives for chronic pain management. Guest Bio: Phillip Kim, MD is a leading advocate for pain care access and a founding member of the Federation Pain Care Access. He brings extensive experience in managing chronic pain patients and navigating healthcare policies. Resources Federation Pain Care Access Website: https://www.painfed.org # board Listeners are encouraged to support the Federation Pain Care Access by visiting their website to learn more about their initiatives and consider contributing to help advance their mission. Join Dr. Rosenblum and Dr. Kim in this vital conversation about the ongoing efforts to improve pain care access and the importance of collaboration in overcoming the challenges faced by patients and healthcare providers. Long island based anesthesiologist, David Rosenblum, MD, is one of the first interventional pain physicians in the country to integrate ultrasound guidance into his pain practice. Since 2007, he has been an international leader in the treatment of chronic pain. He has helped countless of patients suffering from back, neck, knee, shoulder, hip joint pain and has been at the forefront of regenerative pain medicine, minimally invasive pain therapies and medical education. Patients can schedule a consultation by going to www.AABPpain.com or calling: Brooklyn Office 718 436 7246 Garden City Office 516 482 7246
Spravato: Integrating Esketamine for Depression into your Practice. Sponsored by Big Leap Health (00:35:35)
Unlock new, well-reimbursed services: Spravato, a needle-mover for pain practices. Discover how Spravato, an FDA-approved esketamine treatment for depression, can drive significant financial reimbursement for your practice while improving patient outcomes. Join me as I meet with Yakov Kagan, CEO and co-founder of Big Leap Health, as he highlights the clinical efficacy of Spravato, its comparison to ketamine, and its financial impact. Learn key considerations for launching—whether independently or via an MSO—and actionable steps to get started, from staff training to billing essentials. Yakov will also share insights into future developments like monotherapy developments, helping your practice stay ahead in this rapidly evolving field. For more information and to integrate Spravato into your Pain Practice go to https://www.bigleaphealth.com Host David Rosenblum, MD Long island based anesthesiologist, David Rosenblum, MD, is one of the first interventional pain physicians in the country to integrate ultrasound guidance into his pain practice. Since 2007, he has been an international leader in the treatment of chronic pain. He has helped countless of patients suffering from back, neck, knee, shoulder, hip joint pain and has been at the forefront of regenerative pain medicine, minimally invasive pain therapies and medical education. Patients can schedule a consultation by going to www.AABPpain.com or calling: Brooklyn Office 718 436 7246 Garden City Office 516 482 7246 NRAP Academy also offers: Board Review Anesthesiology Pain Management Physical Medicine and Rehabilitation Regenerative Medicine Training Live Workshops Online Training The Virtual Pain Fellowship (online training program with discount to live workshops) Regional Anesthesia & Pain Ultrasound Course Private Training Available Email Info@NRAPpain.org **Disclaimer:** The information presented in this podcast is for educational purposes only and should not be considered medical advice. Always consult a healthcare professional for medical concerns.
Cancer, Pain and Ketamine plus a Free Ultrasound and Pain Webinar Series! (00:16:17)
Episode Title: Ketamine for Cancer and Pain Management - Journal Club Host: David Rosenblum, MD Upcoming Free Webinars: 1. Exploring Innovative Mental Health Treatments which are well reimbursed Discussing Spravato, Transmagnetic Stimulation, and Ketamine Infusion, sponsored by Big Leap Health. Register! 2. Understanding Scrambler Therapy Learn about this revolutionary approach to pain management. Register! 3. Cervical Ultrasound: Anatomy and Interventional Pain Targets Sponsored by Clarius, this session will explore advanced imaging techniques. Register! Sign up for the webinars and check out our full calendar of events. Join us for this insightful episode as we explore the potential of ketamine in transforming pain management practices! Summary In today's episode, we delve into the emerging role of ketamine in managing cancer and chronic pain. Our discussion is anchored around a comprehensive review article titled "Ketamine Use for Cancer and Chronic Pain Management," published in Frontiers in Pharmacology on February 1, 2021. This review, authored by Clayton Culp, Hee Kee Kim, and Salahadin Abdi, explores ketamine's potential as an analgesic in chronic pain conditions, particularly cancer-related neuropathic pain. Key Points from the Review Article: - Mechanism of Action: Ketamine functions as an N-methyl-D-aspartate receptor antagonist, providing analgesic effects at sub-anesthetic doses. Its ability to counteract central nervous system sensitization makes it effective in opioid-induced hyperalgesia. - Clinical Efficacy: Recent studies highlight ketamine's potential to reduce pain scores and opioid consumption, offering a promising alternative for patients with refractory pain. - Safety Profile: At lower doses used for analgesia, ketamine's safety and adverse event profile are significantly improved compared to its use as an anesthetic. - Pharmacogenomics and Interactions: The article discusses how genetic variations can affect ketamine metabolism and highlights potential drug interactions that clinicians should be aware of. Reference Culp, Clayton, Hee Kee Kim, and Salahadin Abdi. "Ketamine use for cancer and chronic pain management." Frontiers in Pharmacology 11 (2021): 599721.
Evidence-Based Pain Medicine with Guilherme Ferreira Dos Santos, MD of Barcelona (00:33:44)
Episode Title: Evidence-Based Regenerative Pain Medicine with Guilherme Ferreira Dos Santos, MD CIPS Host: David Rosenblum Guest: Guilherme Ferreira Dos Santos, MD CIPS Episode Overview: In this insightful episode of the PainExam Podcast, Dr. David Rosenblum sits down with Dr. Guilherme Ferreira Dos Santos, a distinguished expert in pain medicine who is well known for his research, educational endeavors and expertise in Regenerative Pain Medicine and Ultrasound-Guided interventions. Together, they delve into the evolving landscape of regenerative pain medicine, focusing on evidence-based practices and the standardization of Platelet-Rich Plasma (PRP) quality. Key Topics Discussed: - Evidence-Based Regenerative Pain Medicine: An exploration of current research and practices that inform effective pain management strategies. - PRP Quality and Standardization: Discussion on the importance of PRP quality in treatment outcomes and the need for standardized protocols. - Ultrasound-Guided Spine Interventions: Insights into the benefits and techniques of ultrasound guidance in performing spinal interventions, including a conversation on avoiding cervical epidurals. - Access to Pain Care: A comparative analysis of the differences in access to pain care across Portugal, Spain, the USA, and Canada, highlighting challenges and opportunities in each region. - Pain Expo Dubai: An overview of the upcoming Pain Expo in Dubai, where both Dr. Rosenblum and Dr. Ferreira Dos Santos will be presenting, sharing their expertise with a global audience. Guest Biography: Dr. Guilherme Ferreira Dos Santos is an Interventional Pain Medicine Specialist and Clinical Scientist with a career spanning Portugal, the United States, Canada, and Spain. He began his journey at the University of Lisbon, earning his Medical Degree in 2014, followed by a five-year residency program in Physical Medicine and Rehabilitation, which he completed in 2020. His fascination with Interventional Pain Medicine led him to the Department of Pain Medicine at Mayo Clinic, where he served as an Invited Clinical Research Scholar in 2018 and 2021 under the mentorship of Dr. Mark Friedrich Hurdle. At Mayo Clinic, he contributed to refining ultrasound-guided techniques for chronic spinal pain. Dr. Ferreira dos Santos further advanced his expertise with a Clinical Fellowship in Chronic Pain Medicine at the University of Toronto in 2022, training under esteemed mentors such as Dr. Anuj Bhatia, Dr. Paul Tumber, and Dr. Philip Peng. In this role, he was instrumental in advancing education on ultrasound-guided techniques nationally and internationally, which deepened his clinical skills and passion for mentorship. Currently based in Barcelona, Dr. Ferreira Dos Santos serves as the Senior Specialist and Responsible Clinical Lead for the Education and Training Excellence Center in Pain Medicine at Hospital Clínic de Barcelona. He is also the Director of the Clinical Fellowship Program in Interventional Pain Medicine. Throughout his career, he has lectured at international conferences in over 25 countries and authored more than 35 peer-reviewed Q1 articles. His contributions have earned him several accolades, including the 2018 Grant for Young Clinical Researcher of the Year in Pain Medicine from the Grünenthal Foundation, the 2020 Gofeld Academic Scholarship Award, and the 2022 Nikolai Bogduk Young Investigator Grant. His journey across four countries has shaped his approach to clinical care, research, and mentorship, fueling his mission to improve pain management globally. Listen to the Episode: Tune in to gain valuable insights from Dr. Ferreira Dos Santos and learn more about the future of pain medicine. Available on all major podcast platforms. Links and Resources: - NRAP Academy - Follow Dr. David Rosenblum on X and LinkedIn - Follow Dr. Guilherme Ferreira Dos Santos on LinkedIn Join the Conversation: We encourage our listeners to reach out with their thoughts and questions! Use the hashtag #PainExamPodcast on social media to engage with us. S ubscribe and Review: If you enjoyed this episode, please subscribe and leave a review on your favorite podcast platform. Your feedback helps us improve and reach more listeners! Next Episode Preview: Stay tuned for our next episode, where we will continue to explore the latest advancements in pain management and treatment options.
Optimizing Genicular Nerve Blocks and Phenol for Knee Pain- Journal Club (00:18:21)
Podcast Show Notes Episode Title: Optimizing Genicular Nerve Chemical Ablation: Insights from Dr. David Rosenblum Episode Summary: In this episode, we are joined by Dr. David Rosenblum, a New York-based interventional pain physician, who discusses optimizing genicular nerve chemical ablation. Dr. Rosenblum shares insights as well as his upcoming ultrasound course schedyke in New York City, focusing on regional anesthesia, interventional pain, and IV ultrasound placement. He emphasizes the significance of ultrasound in enhancing pain management procedures and the latest advancements in the field. Key Topics Discussed: Overview of Dr. Rosenblum's upcoming ultrasound courses in NYC, including regional anesthesia and IV ultrasound placement. More information can be found here or at NRAPpain.org. The role of ultrasound in interventional pain management, specifically in optimizing genicular nerve chemical ablation. Discussion on the recent study comparing genicular nerve phenol neurolysis and radiofrequency ablation. Importance of updating anatomical targets for pain management. Recommendations for expanding the number of targets in pain interventions. Insights on the safety and efficacy of chemical neurolysis versus radiofrequency procedures. Challenges and considerations in performing neurolytic blocks. Future directions in personalized treatment for chronic pain patients. For Anesthesia Board Prep go to AnesthesiaExam at NRAPpain.org Featured Article: Dr. Rosenblum references an article from The Korean Journal of Pain discussing the optimization of genicular nerve chemical ablation. Key takeaways include: The evolution of anatomical understanding related to genicular nerves. The recommendation to consider multiple targets for pain management instead of the traditional three. The need for careful patient examination to map pain effectively before intervention. Discussion on Knee Pain Management • ArticlebyAndresRochaRomero: • Discussion on knee pain targeting genicular nerve ablation. • Co-authored by Tony Ng and King K Stanley Lam. • Published in Korean Journal of Pain. • Highlights differences in pain management practices outside the U.S. Other Points on Genicular Nerve Chemical Ablation discussed Phenol ablation being used more internationally vs. radiofrequency ablations. Considerations for more extensive targeting of genicular nerves: • Importance of the median branch of the nerve to the vastus intermedius. • Expansion of targeting to include 6 nerves, not just 3. • Anatomical variations require different approaches. Recommendations and Observations • Importance of considering patient-specific anatomy and pain. • Repeat procedures and rehabilitation: • Concerns about bio intensity and fascia integrity. • Emphasizes muscle strengthening exercises to support knee. • CRPS Considerations: • Elderly patients may develop CRPS post-knee replacement. • Importance of lumbar sympathetic block in diagnosis and treatment. Host Bio: Dr. David Rosenblum, MD is an interventional pain physician based in New York City. With extensive experience in pain management techniques, Dr. Rosenblum is dedicated to advancing the field through education and innovative practices. He is particularly focused on the integration of ultrasound technology into pain management procedures. Course Information: Dr. Rosenblum's upcoming ultrasound courses are CME supported, monthly hands on workshops to give clinicians experience with ultrasound imaging to identify targets for nerve block joint injection, soft tissue injection and more.. • Monthly IV Ultrasound Course in Manhattan: • Ideal for nurses, PAs, anesthesiologists, ER docs. • Provides practice with phantoms, short lecture on IV ultrasound. • Offers CME credits. • Ultrasound Courses: • Held one Saturday a month, mostly in New York, but travels if needed. • Upcoming dates: December 21st, January 11th in Manhattan. • Presentation Invitation at Pain Expo in Dubai: April 26-27. • • Next LAPS conference in September in Chile. Call to Action: Subscribe to our podcast for more episodes on advancements in pain management. Follow us on social media for updates on upcoming courses and events. Share this episode with colleagues who may benefit from learning about ultrasound techniques in pain management. Upcoming Opportunities and Closing Remarks Dr. Rosenblum encourages attending his ultrasound courses and conferences. Mention of upcoming conferences in ASPN inMiami, Pain Expo in Dubai, and LAPS inChile. Recommendations to subscribe to newsletters for updates and free info. The podcast aims to support pain management professionals.
Using PRP or PNS to Treat Back Pain related to Multiifdus Atrophy (00:25:04)
Exploring the Efficacy of Autologous Platelet Leukocyte Rich Plasma Injections in Chronic Low Back Pain & Understanding Degenerative Lumbar Spinal Stenosis Host David Rosenblum, MD Episode Date: October 25, 2024 In this episode, Dr. David Rosenblum discusses two significant studies related to chronic low back pain and degenerative lumbar conditions. The first study focuses on the use of autologous platelet leukocyte rich plasma (PLRP) injections for treating atrophied lumbar multifidus muscles, while the second study investigates the correlation between muscle atrophy and the severity of degenerative lumbar spinal stenosis (DLSS). Featured Article 1: - Effect of Autologous Platelet Leukocyte Rich Plasma Injections on Atrophied Lumbar Multifidus Muscle in Low Back Pain Patients with Monosegmental Degenerative Disc Disease - **Authors:** Mohamed Hussein, Tamer Hussein Key Points Discussed 1. Background: Correlation between lumbar multifidus muscle dysfunction and chronic low back pain. 2. Study Overview: 115 patients treated with weekly PLRP injections for six weeks, followed for 24 months. 3. Outcome Measures: Significant improvements in NRS and ODI scores, with high patient satisfaction. 4. Conclusions: PLRP injections into the atrophied multifidus muscle are safe and effective for managing chronic low back pain. Featured Article 2: - Degenerative Lumbar Spinal Stenosis Authors:* Gen Xia, Xueru Li, Yanbing Shang, Bin Fu, Feng Jiang, Huan Liu, Yongdong Qiao Key Points Discussed 1. Background: DLSS is a common condition in older adults, often leading to muscle atrophy and disability. 2. Study Overview: A retrospective analysis involving 232 patients to investigate the correlation between muscle atrophy and spinal stenosis severity. 3. Results: - Significant differences in the ratio of fat-free multifidus muscle cross-sectional area between stenotic and non-stenotic segments. - A strong positive correlation was found between multifidus atrophy and the severity of spinal stenosis. - The atrophy was more pronounced on symptomatic sides of the spine compared to contralateral sides. 4. Conclusions: The findings suggest that more severe spinal stenosis is associated with greater muscle atrophy, emphasizing the importance of addressing muscle health in DLSS patients. Discussion: Dr. Rosenblum provides insights into how these studies inform clinical practices for treating chronic low back pain and managing degenerative conditions. He emphasizes the need for comprehensive treatment strategies that consider both muscle health and spinal integrity which may be achieved via peripheral nerve stimulation of the medial branch nerve and multifidus muscle or PRP injection in to the multifidus muscle. Closing Remarks: Listeners are encouraged to stay informed about innovative treatment options and the importance of muscle assessment in managing spinal disorders. **Follow Us:** - Subscribe to the Painexam Podcast for more episodes discussing the latest in pain management research and treatments. - Connect with us on social media [insert social media links]. NRAP Academy also offers: Board Review Anesthesiology Pain Management Physical Medicine and Rehabilitation Regenerative Medicine Training Live Workshops Online Training The Virtual Pain Fellowship (online training program with discount to live workshops) Regional Anesthesia & Pain Ultrasound Course Private Training Available Email Info@NRAPpain.org **Disclaimer:** The information presented in this podcast is for educational purposes only and should not be considered medical advice. Always consult a healthcare professional for medical concerns. References Xia, G., Li, X., Shang, Y. et al. Correlation between severity of spinal stenosis and multifidus atrophy in degenerative lumbar spinal stenosis. BMC Musculoskelet Disord 22, 536 (2021). https://doi.org/10.1186/s12891-021-04411-5 Hussein M, Hussein T. Effect of autologous platelet leukocyte rich plasma injections on atrophied lumbar multifidus muscle in low back pain patients with monosegmental degenerative disc disease. SICOT J. 2016 Mar 22;2:12. doi: 10.1051/sicotj/2016002. PMID: 27163101; PMCID: PMC4849261.
The use of Corticosteroids in Nerve Blocks- A Recent Review (00:18:55)
Podcast Show Note Summary: Episode Title: "New Guidelines for Corticosteroid Injections in Chronic Pain Management" This podcast is a discussion about the recent review article Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society In this episode, we dive into the recently published guidelines on the use of corticosteroid injections for managing chronic pain, developed by the American Society of Regional Anesthesia and Pain Medicine, along with several other prominent pain societies. These guidelines address the safety and efficacy of corticosteroid injections for sympathetic and peripheral nerve blocks, as well as trigger point injections. Key Discussion Points: Background and Need for Guidelines: Overview of potential adverse events from corticosteroid injections, such as increased blood glucose levels, decreased bone mineral density, and suppression of the hypothalamic–pituitary axis. Importance of using lower doses of corticosteroids, which studies have found to be just as effective as higher doses. Development of the Guidelines: The guidelines were approved by multiple pain societies and structured into three categories: sympathetic and peripheral nerve blocks, joint injections, and neuraxial injections. Extensive literature review and consensus-building through a modified Delphi process. Key Recommendations: The addition of corticosteroids to local anesthetics is recommended for certain nerve blocks, such as the greater occipital nerve block for cluster headaches and ilioinguinal/iliohypogastric nerve blocks for post-herniorrhaphy pain. Corticosteroid addition is not recommended for sympathetic nerve blocks, greater occipital nerve blocks for migraines, and pudendal nerve blocks for pudendal neuralgia. Imaging guidance (ultrasound or fluoroscopy) improves the safety and accuracy of certain procedures. Efficacy and Safety: Detailed analysis of various studies on the effectiveness of corticosteroid injections for different types of chronic pain. Discussion on the minimal benefit of corticosteroids in trigger point injections and the potential risks associated with their use. Clinical Implications: How these guidelines can assist clinicians in making informed decisions regarding corticosteroid use in chronic pain management. Emphasis on the need for personalized treatment plans based on individual patient characteristics and clinical data. Future Directions: Identification of gaps in the current research and the need for well-designed studies to further assess the benefits and risks of corticosteroid injections. Join us as we explore these comprehensive guidelines and their potential impact on improving chronic pain management practices. Upcoming Conferences Resources: Link to the full guidelines: Journal Online Other Announcements from NRAP Academy: PainExam App is ready for iphone Pain Management Board Prep migrated to NRAPpain.org AnesthesiaExam Board Prep migrated to NRAPpain.org PMRExam Board Prep migrated to NRAPpain.org Live Workshop Calendar Ultrasound Interventional Pain Course Registration For Anesthesia Board Prep Click Here! References https://rapm.bmj.com/content/rapm/early/2024/07/16/rapm-2024-105593.full.pdf Disclaimer Disclaimer: This Podcast, website and any content from NRAP Academy (NRAPpain.org) otherwise known as Qbazaar.com, LLC is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user's own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.
The Trigeminal Nerve Block and Cancer (Ultrasound and Flouroscopic Approaches) (00:16:59)
PainExam Show Notes: Mandibular Division of the Trigeminal Nerve Block with Dr. David Rosenblum Introduction Host: Dr. David Rosenblum Topic: Mandibular Division of the Trigeminal Nerve Block for Cancer Pain Management Techniques: Ultrasound and Fluoroscopic Guidance Overview Purpose: Alleviate chronic facial pain, specifically in cancer patients suffering from trigeminal neuralgia or other related conditions. Focus: Detailed discussion on the anatomy, clinical presentation, and procedural techniques for effective nerve block. Anatomy of the Mandibular Nerve Origin: Mandibular nerve is a branch of the trigeminal nerve (cranial nerve V). Pathway: Exits the middle cranial fossa through the foramen ovale and descends between the lateral and medial pterygoid muscles. Sensory Innervation: Anterior two-thirds of the tongue Teeth and mucosa of the mandible Skin of the chin and lower lip Skin over the mandible (excluding the mandibular angle) Tragus and anterior part of the ear Posterior part of the temporalis muscle up to the scalp Ultrasound-Guided Technique Patient Positioning: Patient lies on their side with the affected side facing upward. Transducer Selection: Curvilinear transducer preferred for deeper structures. Transducer Placement: Place distal and parallel to the zygomatic arch to bridge the coronoid and condylar processes. Anatomical Landmarks: Identify the lateral pterygoid muscle and plate. Use power Doppler to locate the sphenoid palatine artery. Needle Trajectory: Introduce the needle using an out-of-plane approach to target the pterygopalatine fossa (anterior to the lateral pterygoid plate). For the mandibular nerve block, target the area posterior to the lateral pterygoid plate between the medial and lateral pterygoid muscles. Electrostimulation (Optional): Utilize a 22G, 10 cm insulated short beveled needle connected to a peripheral nerve simulator. Position confirmed by motor response from the temporalis and masseter muscles. Fluoroscopic-Guided Technique Patient Positioning: Similar to ultrasound guidance, patient lies on their side with the affected side facing upward. C-arm Positioning: Position the C-arm to visualize the foramen ovale. Needle Insertion: Insert the needle under fluoroscopic guidance towards the foramen ovale. Contrast Injection: Confirm needle placement with contrast injection. Anesthetic Administration: Administer local anesthetic and/or neurolytic agents. Clinical Symptoms and Diagnosis Symptoms: Unilateral sharp, stabbing, or burning pain in the mandibular nerve distribution. Pain triggered by activities such as eating, talking, washing the face, or cleaning the teeth. Diagnostic Imaging: MRI or CT scans to identify causes like vascular compression, mass lesions, or fractures. Complications and Considerations Potential Complications: Bleeding, hematoma, infection, and hypersensitivity reaction to the injectate. Serious complications from neurolytic agents like permanent sensory deficit and tissue necrosis. Alternative Treatments: PNS? Radiofrequency or cryoablation for recalcitrant cases. Conclusion Efficacy: Ultrasound and fluoroscopic guidance provide precise targeting of the affected nerves, minimizing collateral damage. Safety: Routine use of power Doppler imaging to avoid injury to surrounding vessels. Recommendation: Consider these techniques for patients unresponsive to oral medications or unsuitable for surgery. These show notes provide a comprehensive overview of the discussion, highlighting key points on the anatomy, technique, and clinical considerations for mandibular nerve blocks in cancer patients. Other Announcements from NRAP Academy: PainExam App is ready for iphone Pain Management Board Prep migrated to NRAPpain.org AnesthesiaExam Board Prep migrated to NRAPpain.org PMRExam Board Prep migrated to NRAPpain.org Live Workshop Calendar Ultrasound Interventional Pain Course Registration For Anesthesia Board Prep Click Here! References Nicholas A Telischak, Jeremy J Heit, Lucas W Campos, Omar A Choudhri, Huy M Do, Xiang Qian, Fluoroscopic C-Arm and CT-Guided Selective Radiofrequency Ablation for Trigeminal and Glossopharyngeal Facial Pain Syndromes, Pain Medicine, Volume 19, Issue 1, January 2018, Pages 130–141, https://doi.org/10.1093/pm/pnx088 Allam, Abdallah El-Sayed, et al. "Ultrasound‐Guided Intervention for Treatment of Trigeminal Neuralgia: An Updated Review of Anatomy and Techniques." Pain Research and Management 2018.1 (2018): 5480728. isclaimer Disclaimer: This Podcast, website and any content from NRAP Academy (NRAPpain.org) otherwise known as Qbazaar.com, LLC is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user's own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.
Regenerative Pain Medicine Journal Club: Interosseous vs Intraarticular vs ESW Inejctions (00:17:10)
Dr. Rosenblum addresses 2 Studies on this Pain Management Journal Club Podcast Article 1: The Treatment of Bone Marrow Lesions Associated with Advanced Knee Osteoarthritis: Comparing Intraosseous and Intraarticular Injections with Bone Marrow Concentrate and Platelet Products Article 2: Autologous US-guided PRP injection versus US-guided focal extracorporeal shock wave therapy for chronic lateral epicondylitis: Aminimum of 2-year follow-up retrospective comparative study Editorial: Dr. Rosenblum poses some important questions: Why are regenerative therapies not covered? Why is CMS limiting trigger point injections and not paying for certain peripheral nerve blocks? Who is making the decision? Do lobbying groups or big pharma have a role? Other Announcements from NRAP Academy: PainExam App is ready for iphone Pain Management Board Prep migrated to NRAPpain.org AnesthesiaExam Board Prep migrated to NRAPpain.org PMRExam Board Prep migrated to NRAPpain.org Live Workshop Calendar Ultrasound Interventional Pain Course Registration For Anesthesia Board Prep Click Here! References Alessio-Mazzola M, Repetto I, Biti B, Trentini R, Formica M, Felli L. Autologous US-guided PRP injection versus US-guided focal extracorporeal shock wave therapy for chronic lateral epicondylitis: A minimum of 2-year follow-up retrospective comparative study. Journal of Orthopaedic Surgery. 2018;26(1). Centeno, Christopher, et al. "The treatment of bone marrow lesions associated with advanced knee osteoarthritis: comparing intraosseous and intraarticular injections with bone marrow concentrate and platelet products." Pain Physician24.3 (2021): E279.
