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Prakash Chandran (Host): It's easy to ignore a little aches and pains as the day goes on. But what if that pain starts to extend into weeks or months or gets significantly more severe? What might that mean? What are your options and who should you talk to about it? Here to tell us more is Dr. Asghar Rizvi, Board Certified in Anesthesiology and Pain Medicine and a Pain Medicine Specialist for AMITA Health.

This is AMITA HealthCast, the podcast from AMITA Health. I'm your host Prakash Chandran. So, Dr. Rizvi, thank you so much for joining me today. You know, it's funny, as I get older, I feel like aches and pains seem to come out of nowhere. So, I'm excited to learn more about this topic. I guess I'd like to start by asking what are the most common types of pain that patients report to you and why do you think these kinds of pain are so prevalent?

Asghar Rizvi, MD (Guest): Well, first of all, thank you for that great introduction. Yeah, so as a pain management specialist, we see a lot of different types of patients with all sorts of pain, but I would have to say probably our most common pain that we see is spine related pain, whether it's chronic neck pain, lower back pain. We also see a lot of joint related pain, but I would probably say spine pain is probably the most common type of pain we see.

Host: Okay. And why do you think that is?

Dr. Rizvi: I think the reason that it's so prevalent is as we get older and you know, also depending on the type of work and job we do, especially if it's labor intensive, we tend to put a lot of weight on our spine in our day to day activities. And as a result of that, with normal wear and tear of the body, and also depending on the type of job that you do, it's not uncommon to start to develop degeneration in your lower back or neck with repeated activity over time. So, it's a very common aspect of just day-to-day living is to have back pain. They actually say that statistically someone will have back pain at least once in their life.

Host: Yeah. I know it's very common, especially for example, the men in my family, all of them have suffered from back pain at one point in their life, which actually leads me to my next question. What is the breakdown of people who are affected by pain? Does it affect men more than women? Can you maybe speak to this a little bit?

Dr. Rizvi: Yeah. So, actually it's a very interesting question that you ask because we see all sorts of age groups that present with pain. Believe it or not, I've seen a patient as young as 14, a cheerleader actually, that had two level disc herniation. I've even seen a football player that was 16 that had a disc herniation in his middle back/thoracic spine.

So, and all the way up to age in the 90s, I see people with chronic back pain. So, it really can affect almost like any age from teens, all the way to late adulthood. You know, in terms of men versus women, it's pretty much almost about an even split I would say. And I think it really more than the gender itself, it really comes down to the type of work that you do too.

A lot of times we see patients who are in construction work or labor intensive work. They tend to develop a lot of chronic spine and lower back pain or neck pain. But what's interesting is during the pandemic, what we've seen is since a lot of people have been quarantining themselves and working from home, we've seen a lot of patients come to see us for chronic neck pain, right? Like that constant strain of looking down at the keyboard or working at home, I think it's causing a lot of neck related issues. So, that's something that we're also seeing as well, recently.

Host: Yeah. That totally makes sense to me. One of the things I wanted to ask you about is I imagine when patients come to see you about pain, it can be difficult by way of, you know, trying to pinpoint exactly where it is or why it happened. So, maybe talk to us about what the hardest part about talking to patients about their pain is.

Dr. Rizvi: Yeah. I mean, that's a great question that you ask. I would probably say for most patients, probably the most difficult aspect of their pain is how it affects their daily life and their quality of life every single day. That's probably the most toughest thing. Cause a lot of the patients that come to see us, prior to seeing us and experiencing the pain, they live pretty great lives. You know, they're usually very active, especially like our younger patients. They participate in sports, they work out, they go to work and even like some of our patients who are older you know, they work around their house. They like to stay active.

So, probably the most difficult thing to hear from these patients is like, you know, I used to be active. I used to work out. I used to work around the house and now I'm completely debilitated. I can't move around. And sometimes, you know, unfortunately we see patients who get emotional because their quality of life revolves around a lot of their ability to do certain types of activity and their inability to do that all of a sudden due to this severe pain that they're having, is really difficult for them to talk about because it not only affects them physically, but from an emotional standpoint, it completely impedes them as well.

Host: I can completely understand that. So, I guess the next question would be, how do you work around that challenge? When someone comes to you, their quality of life has been so affected and they're even emotional about it, where do you even begin?

Dr. Rizvi: Yeah. So, again what we do in our clinic is first of all, when the patient comes in, we do a very comprehensive evaluation on them. You know, when someone comes in, initially what we do is we start by getting what we call a history from the patient. We ask them details about you know, when the pain started, how long it's been going on for, what specific activities of their life it's affecting, you know, how they would rate their pain, you know, where it's starting from, where's it going?

Is it getting better with time? Is it getting worse? We ask a lot of detailed questions in terms of how their pain is evolving, where they have it. And once we get a sense of how or where the nature of the pain is, then we go into a very comprehensive physical evaluation and we actually examine the area of pain in vivid detail.

And then what we do is if there's any image, imaging available of the area where they have the pain, whether it's an x-ray, MRI, we kind of piece the entire story together with their history, their physical exam and their imaging. And we put it together. And then once we're able to gather all that information, we're able to come up with a comprehensive diagnosis and then followed by a specific treatment plan to help them with that pain.

Host: Yeah. I definitely want to talk about the treatment plan and that analysis. But one of the things that you mentioned in the initial diagnostics was rating the pain. And I imagine that it's hard to put pain into words or agree on a scale of severity because you know, my dad, everything hurts all the time. Right. Everything is severe. My wife, it's like everything is a one or a two, even if you know that she's in more pain. So, how do you go about agreeing on that rubric or that scale to try to translate pain into words or into numbers?

Dr. Rizvi: Yeah. So, that's another great question. And it's a really interesting question you ask. You know, when I started working in this field, I used to rely heavily on that numerical scale. Right? But what I've come to realize over the last eight years that I've been doing this is that scale that you mentioned is very subjective, right? From person to person, as you alluded to, for someone, if they're telling me that their pain is like an eight out of 10, they're eight out of 10, maybe completely different than someone else's pain who's an eight out of 10. Right? So, what I've sort of moved away from and sort of evolved into is I ask patients more about their functionality, right?

So, when I assess a patient, I ask them what they're able to do and what they're not able to do. And I'm able to assess from that, what their level of pain is. And what I mean by that is, for example, if a patient comes to see me and they're complaining of, you know, let's say lower back pain that radiates into their leg, right. I ask them first of all, since you've had this radiating pain in the back or wherever you've had this, what are you not able to do any more that you could do before? And they tell me, you know, before I used to walk eight blocks and now I can only walk one block, right. And then they tell me, like, in that one block that I walk it's miserable.

So, and they can tell me, yeah, my pain is like an eight out of 10, but to me what's more important is their functional limitation. Right. And then all the treatment that we do to help these people with pain, I focus more on their functional improvement. And I use that as a scale to see if they're actually getting better or not.

So, let's say I do a treatment on this patient, right. And they come back to me three weeks later and they're like, well, you know, when I initially saw you, I could only walk one block, but now I can walk eight blocks and they may tell me, hey, you know, when I first saw you, my pain was eight out of 10. Now it's a six out of 10, but then, you know, I also realize that, okay, he first, he or she first could only walk one block. Now they can walk eight blocks. To me, that's a success and that's a functional improvement. So, I focus more on their functionality rather than just a numerical score that can be very subjective.

Host: Yeah, that seems like a much better way to analyze the pain. You talked before about your approach to treatment. So, I guess my next question is how does a pain severity or location change your strategy for treating it?

Dr. Rizvi: It again, depends on the whole evaluation. Right. And what we find, right? So, we encounter different types of pain, you know, sometimes patients come to see us, the evaluation essentially starts right the moment they walk in the door, or I walk in the door to see them in the room. If I'm seeing them, I come in the room. For example, I've had this with several patients where they're standing and they're not able to walk straight. They're hopping on their leg and they're just seeming in complete agony, then it starts to tell me in the back of my mind, like, oh, okay, you know, we see people who have a lot of different types of pain, chronic pain; but to me, this person is not able to walk. They're not able to sit down, they have to stand during this evaluation. Then it starts to alert me that maybe there's something more serious going on. And then that level of severity alerts me to a more prompt or a more comprehensive evaluation or a quicker evaluation, because I know that maybe they have some sort of herniated disc that just started and maybe it's severely impinging the spinal cord or nerve roots.

And as a result of that, I need to, first of all, evaluate this patient comprehensively and then immediately have this patient get imaging, whether it's in the form of an MRI, x-ray whatever the appropriate imaging for that pain is. And as soon as I get that imaging result, I need to start treating them immediately. Right. And even before getting the imaging results, I'll help them by giving them the appropriate medication, at least to sort of fend off or decrease their symptoms until I can do a more comprehensive interventional type treatment on them.

Host: So, Dr. Rizvi, I wanted to move on to asking what exactly is the most challenging type of pain to treat?

Dr. Rizvi: That's another great question. I'd say probably the most difficult type of pain that we treat is like peripheral nerve pain. You know, a classic example of that is diabetic peripheral neuropathy, right? There are patients who develop diabetes and sometimes if the diabetes is not well controlled or not optimized, they can start developing damaged nerves or nerves in the periphery. Typically with diabetic patients, we see that damage in either the hands or the feet where they'll have severe pain in the hands and the feet. And it's a more challenging pain to treat because when you have peripheral nerve damage, versus central nerve damage, it's a much more difficult pain to treat. And what I mean by that is, you know, like our typical patient that we see is like, you know, patients who have neck pain or lower back pain. When they usually come to us with neck or back pain, we have several treatment options for them that have been proven.

Right. We can do an epidural injection on them or people commonly know it as a cortisone shot or a radio-frequency procedure, and we can provide them pretty quick relief from those types of procedures, but with diabetic neuropathy or just peripheral nerve pain in general, there's really no quick fix to it. Lot of different medications are tried to help with the nerve pain, different injections, but there's nothing really proven. So, I would have to say that's probably the most challenging pain to treat, but that being said, technology is evolving quite a bit, right? So, we're using a lot of new types of nerve blocks to help with even those types of pain and even newer procedures such as spinal cord stimulation therapy, which can actually help with diabetic nerve pain and peripheral types of pains. But yeah, to answer your question, I would say that's probably one of the most challenging pains to treat.

Host: Yeah, I want to talk a little bit more about technology, but beforehand I wanted to ask, like, what's the worst pain you've ever treated? Is it that peripheral nerve pain? I'm curious as to the people that come in that are just completely incapacitated or just completely debilitated by the pain. Tell us a little bit about that and how you go about treating it.

Dr. Rizvi: Diabetic nerve pain is a challenging pain to treat. And obviously patients suffer, but it's the type of pain that's more chronic in nature that kind of evolves over time. If you're asking me, probably hands down, what is the most difficult pain in terms of severity of pain? I would have to say patients who come to see us with fractures of the spine, right? If there's a patient you know, who has an acute compression fracture in their lumbar vertebral bodies or their thoracic in the middle or lower back, I mean, those patients, doing this for quite some time now, there they are definitely by far the most debilitated patients.

A lot of times when we come to see them or they come to see us for an evaluation, most of the time they cannot move. They're essentially, almost immobile. They'll come to us. Their family member will bring them on like a, in a wheelchair or when they come into the room, they'll have to be laying flat. I actually had one patient who had a fracture of their spine, where they were actually brought in on a stretcher because they were that immobilized where they literally could not move because that pain, once you have a fracture in the spine, that's new, you cannot move.

It's extraordinarily painful. But the one saving grace about that particular pain, is there's a solution for it, which immediately renders like almost near 100% relief in pain. Where if patients like that come in and they have an acute fracture, we actually can do a procedure called a kyphoplasty on them, where we actually inject cement into their spine, which stabilizes their fracture.

And what's profound about that procedure, and it's actually one of my most favorite treatments to do on patients because it's one of those treatments, as soon as you do the kyphoplasty, literally when they're coming off the procedure table, their pain is almost 80, 90% gone, right from the moment the procedure is done and they get off the table. It's actually really rewarding to see that.

Host: Yeah, that's absolutely amazing. And I guess this dovetails into the next question about treatment. You know, you mentioned spinal cord stimulation therapy, the amazing kyphoplasty where you're injecting cement into the spine, but what, in your opinion is the most important recent breakthrough in how we treat chronic pain?

Dr. Rizvi: Yeah so pain management in general has evolved quite a bit. Right. When, this specialty actually is a relatively new specialty in medicine in general. When pain management originally evolved, started, it probably started about 25, 30 years ago. And when we started, what we really depended on heavily was using medications for pain control, right.

Because the whole concept of using x-ray guidance or ultrasound guidance to do procedures to help pain was still sort of evolving. So we used a lot of medication management for pain. And then we had cortisone shots started back then, but we were very limited in terms of what we could do with pain. So, pretty much all the patients used to come in, we used to do cortisone shots on them, steroid shots, but not every patient benefits from an epidural injection, right. And not every patient may benefit from just giving oral medication therapy. So, what's actually interesting about our specialty is in the last 10 to 15 years, our specialty has pretty much exploded.

We've gone really away from just using medications to help people with pain, to just really more of a procedural based specialty, because the reason we've done that is because x-ray technology and ultrasound technology is now allowing us to pinpoint and localize and target pain very specifically, which we were not able to do before. To give you a basic example of that is, you know, kind of going back to lower back pain. I keep using that because that's what we see all the time is people who come into us with lower back or neck pain. Right.

If like, for example, if a patient has like a disc herniation at a very specific level, let's say at their L4 L5, or L5 S1 level. Now what we can do is with an x-ray machine, we can actually use the x-ray machine to show us the location of the herniated disc, and we can advance the needle as close as possible to the nerve and inject the medication right at the source of the pain. What's amazing about that is number one, it makes procedures safe because we can actually see where we're going. And number two, it makes them more efficacious because we're literally putting the needle at the source of the pain. Even with ultrasound, which has evolved a lot over the last five, 10 years, we can use ultrasound guidance to block a lot of peripheral nerves outside of just the spine and selectively target them to help with pain.

You asked about recent technology that's available, right? So, spinal cord stimulation is a classic example of that. The technology has been there for about 25, 30 years, but it's exploded in the last three to four years. That procedure is used a lot for patients let's say who've had multiple lower back surgeries. They've tried like eight different injections and, you know, their pain doctor or whatever doctor they were seeing has put them on all these different medications and nothing is working. The technology is amazing because essentially what we're doing is we're taking these two plastic catheters that have metal contacts at the tip of them, and we're implanting it into the epidural space of the spine.

And all it does is it basically sends these small electrical impulses into the spinal cord and that blocks pain signals or your ability to perceive pain signals from your lower back and leg. And the technology, even, it sounds like it's pretty advanced already, but in the last five years, it's even evolved more. When the technology originally came out, what used to happen is when people had this device placed into them, to get the pain relief, what the device used to do, is used to create like a buzzing sensation in their legs. So, when they used to turn the device on, it would create this buzzing sensation and that buzzing sensation would prevent the patient from perceiving the pain.

But in the last few years, technology has evolved so much that buzzing sensation is gone. So, now when you turn on the device, you essentially just feel no pain. There's no buzzing. There's just no sensation. It's just no pain. And what's really cool about it is now, you know, the device is controlled with almost like an iPhone like device.

You can turn it on and off when, or if you want to use it or not. And you know, even outside of that, there's a lot of other great procedures that are coming out. I mentioned radio frequency ablation. You know, essentially with radio frequency ablation what we're doing is patients who have chronic neck pain from like whiplash injury, from a car accident, you know how those patients have neck and headache pain?

Or lower back pain. What we can do now is we can actually place these needles that have heating probes at the tip of them. And we can actually cauterize the nerves in the joints or in the bones of their spine. And we can actually get like almost six to eight months of continuous relief from those procedures, or sometimes even longer up to a year.

Host: Yeah, it's truly fascinating to hear about all of the advancements in treatment technology. The last part of this conversation, I kind of wanted to focus on people that are dealing with chronic pain. And specifically, I'm reminded of my dad, like he's better now, but at some point he had a lot of back pain that he was just dealing with. And we would always say like, why I don't understand, why don't you go see a specialist? Why don't you go see a doctor to deal with this? And I know that there's a lot of people that are like this. So, why do you think, or what do you think is holding most people back from seeking treatment for their chronic pain?

Dr. Rizvi: Probably the biggest hurdle is misinformation. Lot of times what happens is I would actually say two fold it's misinformation and also the stigma of just having chronic pain. Right. Number one, I think there's a misconception of what we do, right. A lot of times when patients come to see us, believe it or not, they don't need to know why they're sent to see us.

Right. They, they know that we're pain management, but they have no idea what we do as pain managers. What I mean by that is sometimes patients who come to see us they'll be sent by their doctor and they'll be like, well, you know, I was sent to pain management, but I don't know what you guys do. And so a lot of times we have to educate the patients on what they do, and they actually get surprised when we tell them that, hey, you know, the reason you are sent to us is because we want to help you with the pain, but we can also offer these additional treatments that maybe your family doctor, internal medicine doctor may not be able to offer you such as these injections, where you can selectively target these areas of pain. So, that's one thing is that they don't really know what the pain management specialist sometimes does.

The other roadblock that we often get is there's a stigma about the injections that we do. Right? A lot of times when patients come to see us, they're very apprehensive about getting these treatments done because they hear some anecdotal story of some family member that, you know, had this procedure like several years ago. And it made their pain worse or someone got paralyzed and these misconceptions. It is true that with the injections that we do, there are, there is some inherent risks to them, but the risk is very low. The key is if you go to someone who's Board Certified and trained in this specialty and has special training in them, these procedures are actually very safe.

And the reason why it's important to seek these treatments, again, in my opinion, is because if we selectively target where your pain is coming from and get to the source of the pain, then you don't need to really rely on taking oral medications to help with the pain as much, or you may not need to be as dependent on these medications, so it can really improve your quality of life. So, I would probably say to answer your question, the biggest barrier that we get is just misinformation and not really knowing like what we specifically do here in pain management.

Host: Yeah. I also imagine that there is a cultural stigma, you know, like I think, I come from an Asian household and there's this whole thing around, like, you know, when you endure pain, it makes you stronger. Right. Or, you know, pain is just weakness, leaving the body. Is that something that you experience?

Dr. Rizvi: Yeah, in certain patients I do experience that. Certain patients can be very stoic and you know, having pain can sometimes in certain cultures or not even just cultures, even amongst people of various cultures can just be as, can sometimes be viewed, unfortunately as a sign of weakness. That is something that we definitely see all the time, but you know, what I tell my patients is like, yeah, you know, the reason they feel that way is because they're used to, what I said earlier, they're used to living a certain quality of life and certain lifestyle, right? And then when you develop this pain, all of a sudden you become debilitated and you're not able to participate in the things that you do, be with your family in some cases.

And that can really like a mental toll on the person. And you know, what we try to tell these patients is when they come to see us, yes, you know, unfortunately you're suffering with this pain at this moment in time, but you know, we're going to do whatever we can do in a safe, comprehensive, and effective manner to try to minimize that. So, you can try to go back to some of the original types of things that you used to do prior to seeing us.

Host: Yeah. Last question that I wanted to ask, you know, you've probably seen hundreds, if not thousands of patients that are dealing with pain. You've helped them a lot. Based on all of your experience, everything that you know to be true, what is one thing that you wish more patients knew before they came to see you?

Dr. Rizvi: I would say hope and it may sound kind of cheesy, but I really mean that. I think, you know, one of the things that we always see with patients is when they come to see us, unfortunately, they're at their worst. Sometimes when they see us for the first time, they're very emotional because as I kind of alluded to you know, they come in with this debilitating condition where they're not able to do what they want to do, and they just don't know how to deal with it. And sometimes they feel like, oh my God, this is just, is this going to be me for the rest of my life? I mean, that's probably the most, one of the most common questions I get asked is like, you know, I have this whatever issue I have, whether it's a bad disc in the back or shoulder or whatever the issue is like, am I going to have this for the rest of my life?

Or this is how I'm going to be for the rest of my life. And I tell them that look, there is hope with this. Because, you know, I'm not claiming that every single patient that we see will get 100% results, but I would say vast majority of the patients that we do see they do get results and their quality of life improves. You know, I'll give you a quick classic example. There is a patient who came to see me about six or seven months ago, she suffered from a really bad car accident and she had severe pain in the neck. And after the car accident, you know, they did imaging of her neck and, you know, they found a little bit of arthritis in the neck, but not really much.

And she tried some physical therapy and she did it for about six weeks and the physical therapy wasn't working. And she started becoming increasingly nervous about the pain, because she was like, okay, my car accident was like six weeks ago. I should be getting better. And six weeks turned into two months, three months.

And she was getting frustrated because she's like, you know, I had this accident like several weeks or several months ago now, why is my pain not getting better? And then when she saw me, you know, I won't forget the first time she saw me, she broke down crying because she's like, I feel like I'm going to be like this for the rest of my life. I'm not going to get better. I thought this was going to better. The accident was now like almost several months ago. Why am I not getting better? And, you know, we came up with a comprehensive treatment plan, right. You know, when I examined her, I identified that her pain was most likely coming from the facet joints of her neck.

And so what I did is I did these procedures on her, where I actually did the radio frequency procedure and cauterized the nerves that go to the bones of her neck, her facet joints of her neck. And, you know, after the procedures were said and done, she achieved almost 80, 90% improvement or pain. So her quality of life improved.

,When she initially came to see me, she was barely able to move her neck less than not even three or four degrees in either direction, extension, flexion, basically no movement of the neck. By the time we were done, she had complete almost not a hundred percent, but almost complete range of motion of the neck. The headache pain that she was getting into the posterior aspect of her neck and the back of the head was pretty much essentially gone. And there was a profound improvement in pain. And then, you know, she became hopeful again, right? Because when she initially came to see us, there was no hope. But then when we were done, she came to realize that there is treatments and there's ways to make it better.

Host: Well, I love it. This has been an inspiring conversation Dr. Rizva, I truly appreciate your time today.

Dr. Rizvi: Thank you very much.

Prakash Chandran (Host): That was Dr. Asghar Rizvi, Board Certified in Anesthesiology and Pain Medicine and a Pain Medicine Specialist for AMITA Health. Thanks for listening to AMITA HealthCast, the podcast from AMITA Health. For more information, please visit Amitahealth.org/painhelp. I'm Prakash Chandran. Thanks so much for listening and we look forward to you joining us again.