Melanie Cole (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed, so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole and joining me in this panel today is Dr. Tiffany Lin and Dr. Phillip Petrou. They're both Instructors in Anesthesiology at Weill Cornell Medical College, Cornell University. Doctors, thank you so much for joining us today to talk about the awareness of arthritis. Dr. Lin, I'd like to start with you.

Will you please kind of give the listeners a little lesson here? What is arthritis and what are the different types you most commonly see?

Tiffany Lin, M.D. (Guest): Sure. First and foremost, I would like to thank you for having myself and Dr. Petrou on this show. So arthritis definition is inflammation in the joint. And there are more than a hundred types of arthritis that's been described. The most common is osteoarthritis, which is a degenerative or non-inflammatory arthritis.

The other big category of arthritis is inflammatory arthritis which can be caused by auto immune disease, most commonly, you know, rheumatoid arthritis and ankylosing spondylitis, or you can have like crystal deposition into your joints causing inflammation. So that can be gout or you can have infection into your joints that causes inflammation such as septic arthritis or Lyme's disease. And you know, lastly there are many auto-immune connective tissue diseases that can also cause inflammation in the joints. So those could include lupus, Sjogren's syndrome, scleroderma, celiac disease, or inflammatory bowel disease.

Philip Petrou, M.D. (Guest): And I agree with Dr. Lin's excellent definitions, and they think it's important that what she keeps on reiterating is that inflammation. That arthritis, even the ones that she described, really the full, the core of each of them is this inflammation, whether that's again, osteoarthritis, when it's the breakdown of the cartilage that leads to kind of an inflammatory state or rheumatoid arthritis in itself where the immune system is on overdrive.

Host: Well, thank you both for that. And Dr. Petrou, I'd like you to tell us which joints are most commonly affected. And while you're doing that, tell us about Weill Cornell Medicine and what you can do for patients there.

Dr. Petrou: Sure. And thank you for that excellent question. So in terms of which joints we are concerned about; the reality is all the joints can be effected. As pain management specialists, the ones that we, we are most helpful with, again, especially with our medications and our interventions aree the larger joints.

So we're looking at the shoulder joint, the hip joint, the knee joint on top of which patients often forget that we are also looking at the joints in the spine. In terms of the major joints and looking at the shoulder, the hip and the knee, you know, there's definitely a role for medications and something that we, we help with our patients, but really what we specialize at Weill Cornell medicine is the addition of interventions. And we have different interventions that we'll go on that we can describe further. I'll just give our big ticket items are joint injections, and we look at radiofrequency ablation. And then we also are looking at peripheral nerve stimulation.

Host: I definitely want to get into those a little bit more so we can describe them. But before those kinds of interventions happen, Dr. Lin, what do you tell people that come to you in pain? You're a pain management specialist. This is a huge field now it's, it's a burgeoning field. But what is the first line of defense that you might tell some people because there's ice and there's heat, there's bracing, there's all of these things that can help with the pain and the limitations on movement that arthritis can cause. Can you speak to those just a little bit? And if you want to then get into some of the NSAIDs or medications that we would also start with, that would be great.

Dr. Lin: Sure. So when I first see a patient presenting with joint pain, I will first take a very thorough history and physical examination just to rule out other more serious causes of arthritis or some of the inflammatory arthritis where you know, is more helpful to treat the underlying cause. If the pain is mostly coming just from osteoarthritis or degeneration of the joints, obviously the more conservative or non-invasive management is usually our first line. So like you mentioned heat and cold. Those are, you know, good and so heat helps with relaxation, increasing circulation to the area, causes vasodilation and ice causes vasoconstriction, and in an acute injury is helpful in terms of decreasing swelling and pain.

And it can also help the chronic musculoskeletal pain. I also usually recommend patients to start physical therapy as soon as they can. Because when you have arthritic joint pain it can cause your muscles to contract in response to pain. It can limit your range of motion and mobility.

And those are usually the things that cause disability in the long term. So when you go to physical therapy, they can help you with stretching exercises, improve your flexibility, and allow your joints to be more aligned, to reduce any repetitive micro trauma that comes from, you know, imbalance and incoordination. They can also help with strengthening the muscles around the joints. As we get older our bones and the joints do just degenerate. So it is very important to build up strength around the joints to help support the joint instead of relying on the bone itself.

Host: So interesting. It's such a really prevalent problem. So you've spoken to some of the modalities, whether it's physical therapy, ice and heat. Now Dr. Petrou have at it. Tell us about some of the more innovative and exciting interventional aspects of the treatment in the field of arthritis. Tell us about pain management, injection therapy. Tell us about what's going on. And these are in office procedures for the most part, yes?

Dr. Petrou: Correct. It's my pleasure to go into further detail. And I do want to just bring back and I think Dr. Lin makes excellent comments about even when we start with these noninvasive first line, really the goal of these more advanced procedures are actually to work hand in hand with the ones that she's already recommending.

So something I remind patients is even when we offer these, you know, very exciting procedures that, that are showing very promising benefit that the goal is for them to get. To help them engage in those first lines to help them engage more in physical therapy. So with that being said, our large categories are we're looking at injections, radiofrequency ablations, and then peripheral nerve stimulation.

I remind patients, you know, first and foremost, all of these are safe and these are FDA approved procedures. So in terms of our injections, we work with both steroids as well as we look at the viscosupplementation. Steroids again, looking at that keyword that Dr. Lin mentioned before, of inflammation and helping tamp down the inflammation and then viscosupplementation looking at getting those other key word of cartilage that Dr. Lin mentioned for osteoarthritis is basically how to get those joints well lubricated again.

Next category, looking at radiofrequency ablation. This is where it's a little bit separate where we're looking, we're targeting the nerves that cause discomfort that are innervating the joint and that the idea of being if you can numb or block those nerves; in this case are more advanced procedures and looking at burning or what I, what I like to tell patients gentle warming, but ideally, but the end goal is the, is burning the nerve to help prevent that pain.

And then third category looking at peripheral nerve stimulation. Every provider is different. You know, I, I don't, I think again, is that, that first question that was brought up about first-line defense, you know, here at Weill Cornell, we take a holistic approach to the patient and we're not offering first-line of peripheral nerve stimulator, but that being said with peripheral nerve stimulation, again, looking at those nerves and essentially what we're doing is that we're distracting the nerve.

You can think of it as almost like a buzzy where we placed the device about the size of the guitar string to basically help distract that pain. So those are the, the major categories. At this time I'm happy to have Dr. Lin go into more depth on, on either of those as I know she's very, very well familiar with some of these advanced procedures.

Dr. Lin: Yeah. And I agree with what Dr. Petrou mentioned. Usually, when I first see patients, I would start with injection into the joint itself whether it's with steroid or viscosupplementation and you know how I decide whether I will inject steroid first or a hyaluronic acid, it depends on what the patients have had before, whether they have that good response. Is there an indication or contraindication for either one of them. For the nerve block and the radio frequency ablation, we can be very creative in terms of which nerve to block and which nerves to lesion.

And they kind of go hand in hand where you do the neuro block to kind of test and also treat pain on the same time to see, you know, if those nerves are the culprit of your pain. And you know, we identify the specific nerves that cause the pain. Then the next step will be to do radio frequency ablation, which would provide a longer term relief of up to six months to one year. There are some patients who don't respond as well to radio frequency ablation, and that's when peripheral nerve stimulation comes in where you're still targeting those nerves. But it's a different kind of, it's a neuromodulation where basically it helps the, disrupt the transmission of pain to the higher up central nervous system. And as we've had patients who've had really good results with those.

Dr. Petrou: And I think just to echo with that, you know, when we're looking at those procedures, especially with the radio frequency ablation, we're very excited that one of the recent items to come to market is what's called COOLIEF radio frequency ablation. And essentially for these joints, you know, again, the shoulder, the hip, the knee, as well as for the back with this ,COOLIEF radio frequency ablation, or we're able to burn a larger, a larger area of the nerve. Especially with these joints, you know, as we're trying to target these nerves, something that Dr. Lin was mentioning in terms of, especially how we do it, looking at ultrasound is that with the radio frequency ablation, there is variations in human anatomy of where the nerves are running and where we can actually target. So when we, you know, started previously where we were using smaller needles that have smaller areas of, of that gentle warming or that can be, but the exciting part with COOLIEF is that it does essentially almost get, think of it like a, like a ball of, I don't want to say a ball of fire, but, but of your cool burning that's takes intconsideration that difference in human and patient anatomy. And then secondly, again, going to that into further details of Dr. Lin's explanation of peripheral nerve stimulation. That it's very exciting that we can use ultrasound in order to identify the nerve that can be targeted. Again, with the neuromodulation procedure that Dr. Lin described, which can help patients provide pain relief.

Host: Isn't that so exciting what you can do in office now and these ultrasound guided injections, how they've helped so many people now, Dr. Lin, I would imagine the biggest question you get is. How long do they last and how many are people allowed to get? Because some people say, oh, cortisone injection, the steroid injection. I already had one, can't have another one. I've had patients getting them for years and they always ask me, why can I only get a few? Why are they limited? Can you tell us about that?

Dr. Lin: Sure. So I think that question comes more commonly with steroids. So, even though we do inject steroids, you know, into like a local area where there's not as much systemic absorption, still gets absorbed into your systemic bloodstream. So if you have history of high blood pressure, diabetes, you know, it could increase your blood pressure and blood sugar.

And also when you administer too much steroid that actually stops your body from making its own steroid. So when you come into like a stressful situation where you have inflammation or infection in your body, then your body is not able to generate its own response to those stressful situations. So that's our consideration when we kind of put a cap on how many steroid injections we can perform a year. Usually I tell patients, that I do maximum of four injections a year. And that's why it's helpful to have other forms or modalities of interventional procedures for, you know, intra articular injections. I may alternate my patients between steroids and hyaluronic acid.

So, using too much of either injectate. For the radio frequency ablation, the nerves don't grow back until six months to one year after the thermal ablation. So usually I tell people, you know, we can repeat it, every six months to one year, but obviously we don't automatically just repeat an injection.

We wait until the pain comes back. And lastly for the peripheral nerve stimulation, the wires that we put near your nerves, they actually stay in for 60 days. And after 60 days we remove their wires. But the studies have shown that even after the wire has come out, patients can get pain relief up to one year or beyond.

So that's very exciting new technology that we've been using because you only have the wires in for two months, but then you can get long-term relief up to one year or beyond. There are some patients who don't get as much long-term pain relief, and there are other kinds of peripheral nerve stimulation where we can actually implant the electrodes near the nerves, and that will provide them even longer term relief.

Dr. Petrou: And I want to echo Dr. Lin's important point that, you know, each patient is different and we, you know, we at Cornell, we want to approach each patient individually. So it's not something that, you know, as Dr. Lin mentioned, oh, here's the number of max injections, here's the number of max procedures we'll, we'll offer you because we, you know, we don't do that at Weill Cornell.

We don't want to have unnecessary, unnecessary procedures. We don't automatically book the next intervention, the next injection, the next ablation, every time you see the patient. We work individually with them to assess, you know, how, what is their benefit, how much pain relief again as Dr. Lin stressed as well as what has their impact been on the function?

You know, have they noticed less pain interference? I think these are, this is what really sets us. You know, this is how we approach patient care at our clinic.

Host: I love that you said that, and I'd love to give you each a chance for a final thought. Dr. Lin, starting with you. You are such a knowledgeable person when it comes to pain management. And there are so many things that could confuse people on the market. There's some alternative or complimentary therapies. As far as complimentary, you mentioned physical therapy and ice and heat and all those other things. But what about nutrition? And we hear about condroitin and we hear about glucosomine for arthritic pain. CBD oil and acupuncture and chiropractic care. There's all these, you know, we used to all be separate, but now we're kind of all melding into this field of, of helping people with motion limitations, and pain. Can you speak to any of those for us as your final thoughts, what you would like people to know about those things?

Dr. Lin: Sure. I do have patients asking me about alternative or complimentary medicine a lot, and I think overall they're generally safe. But I can talk about them more specifically, so in terms of acupuncture as you know, it's been practiced and Asia for more than 2000 years, treating a variety of illnesses and pain. And it's based on the Meridian theory. So, we have accupoints throughout our body and they have been shown to overlay major neuronal bundles which correlate with some of the major nerves. So, these nerves, they converge and interact at a spinal cord level. And that's kind of the theory of how they treat, you know, specific illnesses. And acupuncture generally is good in terms of chronic pain relief, because it can actually stimulate your own body to make its own opioid. It has some anti-inflammatory effects and then kind of helps decrease the central sensitization which is a phenomenon that happens when someone has chronic pain. Basically your entire pain system is just ramped up and you've just become more sensitive throughout.

And I also recommend doing meditation or mindfulness a lot to our patients. Because as you experience chronic pain, it can increase their overall pain sensitivity. It can cause anxiety, depression that's, you know, the mind body connection and what a meditation or a cognitive behavioral therapy does, is that it helps with processing pain.

And that helps you with coping strategy and helps with rewiring your brain basically. And that over a time can diminish stress, fear, and depression in response to pain. In terms of other nutritional supplements I know glucosomine and chondroitin, they've been the market for a long time. They're used to help cartilage health and also anti-inflammatory properties. The effectiveness in studies is mixed. So generally, you know, we do, we do not recommend for or against. If patients do get relief from them, there is no harm in taking it. Other nutritional things like omega three fatty acid, tumeric they all have anti-inflammatory properties and patients also can take vitamin D if they have osteoporosis, which can help promote bone health. In terms of CBD oil, there is no you know, scientific human research study in the safety and effectiveness in chronic arthritic pain, but it is generally safe. But patients should know that there are some side effects with CBD. It can cause lightheadedness, dry mouth, sleepiness, very rarely liver problems.

So Cornell has a Center of Integrative Health that have physicians that are familiar with medical marijuana, and they can help guide you in terms of, you know, what formulations at what a ratio of CBD versus THC that will be safe for you.

Host: This is such an educational podcast and so informative with so many people suffering from the pain of osteo and rheumatoid arthritis. Dr. Petrou last word to you, as far as involvement in exercise programs, and we've just touched on this briefly. I'd like you to summarize everything we've discussed here today which is really a big question, but the question of movement, the question of physical activity to keep those joints moving, because for certain types of arthritis, there are questions surrounding how much movement, whether it aggravates those joints a little bit more or not. I'd like you to speak to the listeners about prevention, about taking care of themselves and the best things they can do, lifestyle, behaviors to help them with their pain from arthritis.

Dr. Petrou: So I think that's an excellent question. And I think it it goes back to what Dr. Lin and I have tried to emphasize, which is taking a bio-psycho-social approach to pain. You know, we've talked about the interventions you know, as Dr. Lin also mentioned things with like the meditation, having patients be, you know, work on making sure that pain, their pain isn't, isn't weighing them down in their other aspects of life. And then component of exercise, physical therapy and really it's one, it's one of the three pillars of pain management. So to answer the question, exercise is important and something that I tell patients is that, you know, it shouldn't be painful. Exercise, working with the physical therapist shouldn't cause more discomfort.

These are trained professionals. And again, that's why we often, you know, we work very close with the physical therapists at Weill Cornell who are very familiar with the patients that that we're referring them to and they're not, they're not going to cause more damage. You know, I do caution patients, you know, be careful about running a marathon or pushing yourself in a way that you have, that you don't usually push yourself, but keeping up with the exercise is important. And then I think I just want to make that comment again and again, with the bio-psycho-social approach to pain, our goal at Weill Cornell is also to make sure that we're on the forefront of the advanced procedures. So in this, in these final moments that I've, that I'm offered on this podcast. I just want to reiterate again, not only just the COOLIEF radiofrequency ablation, but the peripheral nerve stimulation which again, and those techniques are very compatible with physical therapy.

I just warn patients for the peripheral nerve stimulation, you know, aqua therapy can be very helpful for different pain conditions. And then that has to be discussion though, because the pools and the peripheral nerve stimulator devices that we use right now, given that they have an external component, we need to work around that, but that's again, I think to reiterate them the most important part of that, hopefully we're able to stress in this podcast is that bio-psychosocial approach to pain incorporating the physical therapy.

Host: Well, it certainly is a comprehensive and multidisciplinary approach, as you say, many providers involved. But help is out there listeners. So you can definitely find help for your pain from arthritis, and you can contact the specialists at Weill Cornell Medicine. Thank you both for joining us so much. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits.

And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to invite our audience to download subscribe, rate, and review back to health on Apple podcast, Spotify and Google podcast.

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