Do you ever wonder why pain feels the way it does? Or how to manage it effectively? We're pulling back the curtain on these questions with our esteemed guest, Dr. Jonathan Reisman, a board-certified physiatrist from the Kayal Orthopaedic Center. Together, we navigate the elusive world of pain management, shining a light on the different types of pain - nociceptive, neuropathic, somatic, and visceral - and unveiling the intricate network of nerve fibers transmitting these signals to our brains.
But it's not just about the physical. We also delve into the psychological aspect of pain, underlining the integral role the doctor-patient relationship plays in addressing secondary gain issues. Understanding pain isn't merely a medical exercise; it's a human one too. We delve into the power of patient education, setting expectations before surgery, and addressing possible roadblocks that could hinder recovery.
We wrap up by impressing upon you the critical importance of multimodal pain management. From early and aggressive treatment to prevent chronic pain, to the application of preemptive anesthesia and regional blocks, we leave no stone unturned. We also explore the role of radiofrequency ablation, medication, and the often underplayed value of exercise, physical therapy, acupuncture and chiropractic in improving mobility and reducing pain. Tune in as we demystify the fascinating world of interventional pain management with Dr. Reisman.
Do you ever wonder why pain feels the way it does? Or how to manage it effectively? We're pulling back the curtain on these questions with our esteemed guest, Dr. Jonathan Reisman, a board-certified physiatrist from the Kayal Orthopaedic Center. Together, we navigate the elusive world of pain management, shining a light on the different types of pain - nociceptive, neuropathic, somatic, and visceral - and unveiling the intricate network of nerve fibers transmitting these signals to our brains.
But it's not just about the physical. We also delve into the psychological aspect of pain, underlining the integral role the doctor-patient relationship plays in addressing secondary gain issues. Understanding pain isn't merely a medical exercise; it's a human one too. We delve into the power of patient education, setting expectations before surgery, and addressing possible roadblocks that could hinder recovery.
We wrap up by impressing upon you the critical importance of multimodal pain management. From early and aggressive treatment to prevent chronic pain, to the application of preemptive anesthesia and regional blocks, we leave no stone unturned. We also explore the role of radiofrequency ablation, medication, and the often underplayed value of exercise, physical therapy, acupuncture and chiropractic in improving mobility and reducing pain. Tune in as we demystify the fascinating world of interventional pain management with Dr. Reisman.
Hello and welcome to another edition of the Kale Ortho podcast. Today is September 5th, 2023, and our special guest today is our very own Dr Jonathan Reisman. Dr Jonathan Reisman is a board certified physiatrist in the area of physical medicine and rehab and we're so happy to have him with us today to talk to us about current concepts in interventional pain management. Welcome to the podcast, dr Reisman. It's so happy to have you with us today.
Speaker 2:Thank you, Dr Kale. I'm really happy to be here. I'm really fortunate and excited about getting a chance to educate our patients about what I do.
Speaker 1:Awesome. So why don't you, first and foremost, tell us a little bit about yourself?
Speaker 2:Okay, so my name is Jonathan Reisman. I am a PM&R physiatry certified doctor. I did a pain medicine fellowship at the University of Minnesota. I grew up in New Jersey prior to traveling to Minnesota for some of my more advanced training. I did an internal medicine internship in Staten Island. And I'm married. I have a few little children. My wife is a speech therapist and my children have got you know, five-year-old, three-year-old and eight-month-old so busy at home and at work.
Speaker 2:I'm so excited to be here at the Kale Orthopedic Center. I love taking care of patients and helping to have patients control their pain and get rid of their pain, hopefully. So as a physiatrist I am educated in the musculoskeletal system, the nervous system, and really focus on patients' function and well-being and how they function in their life and with other people. Pain is a big part of that. Pain can really challenge a person's everyday life and make ordinary tasks very difficult, make things a little upsetting, and so I'm really honored that the job that I do is to try to help people get rid of that pain. It's a very team-oriented, team approach. At the Kale Orthopedic Center we have a whole array of board-certified orthopedic surgeons in multiple disciplines physical therapy, chiropractic care, acupuncture, and I like to work with all of those in these other healthcare roles together to come up with a plan, sometimes with our patients as well, to try to decrease their pain.
Speaker 1:So let's talk about pain in general. Let's first and foremost start by defining pain and sort of how it develops. Why do we even feel pain?
Speaker 2:So that is a really important topic. Pain gets defined as a person's negative thoughts, feelings or physical feelings about actual or anticipated pain. Sometimes that can be spiritual pain, physical pain, emotional pain. All of those aspects can make our body hurt and it can happen to any part of our body. Pain is important evolutionarily speaking. It's an alert that something is wrong. If I have an injury to my hand, if my hand is on fire, I feel acute pain. If we put that fire out, I get some excellent surgeons to help my hand heal and that pain goes away. That's wonderful. But sometimes people still have pain afterwards, when there's no organic injury and someone's still experiencing pain. That's what we call chronic pain and the body is trying to warn us that we need to do something to make that pain go away. But sometimes we're not exactly sure what it is that we need to do, so whether it's acute pain or chronic pain. That's kind of the role that I bring to the practice in trying to help patients decrease it.
Speaker 1:Can you define, for our viewing and listening audience, the different types of nerve fibers that may be allowing our brain to even sense pain?
Speaker 2:Yeah, absolutely so. When we experience pain, it all starts with musculoskeletal pain peripherally. So we have an injury to our skin, to our muscle, to our bone, and that signal gets encoded and transmitted over to our spinal cord and then the signal is transmitted in a different electrical signal up to our brain and we register. I have pain in my body and I need to do something about it.
Speaker 1:Yeah, there's different types of receptors, right. There's different types of receptors in our hands and our feet and different parts of our skin that tends to allow our bodies to interpret that signal, right.
Speaker 2:There's nociceptors, there's C fibers, whether we're talking about our peripheral nervous system or our central nervous system, when we have our nerve, there's different components to the nerve and, depending on what type of pain or injury we're dealing with, we're going to send that signal a little faster. It might feel sharp, it might feel dull, it might feel burning, and I ask my patients to describe their pain so that I can get some insight into what exactly is going on with them.
Speaker 1:Right, there's pressure sensors, right, nociceptors, proprioceptors and different things like that that allow the feedback to ultimately get to the brain. Some of the nerves are sensory nerves and some of the nerves are motor nerves and some of the nerves are mixed nerves. But this is the way that sensation is transmitted ultimately to the brain Right, absolutely. And so, speaking about different types of pain, there's also nerve pain, there's somatic pain, there's visceral pain. Can you just speak to that a little bit?
Speaker 2:Yes, dr Kaili, that was an excellent question. So when we talk about pain, we kind of break it down into two main categories there's nociceptive pain and there's neuropathic pain. So nociceptive pain is pain that we feel, that is normal to be feeling. It's when we have physical or sharp experiences, whether that's from external mechanoreceptors on our skin, or visceral pain from our organs or intestines, or somatic pain from our muscles or bones. That will usually be nociceptive pain. Neuropathic pain is when there's an injury to the nervous system itself and we might feel pain that is out of proportion to the expected pain that one might experience. And so when we have no susceptive pain, we have a certain time course and we appreciate that we're going to be experiencing that pain and we might put some ice or heat and we might see a surgeon, we might do some therapy that pain will decrease and diminish.
Speaker 2:Nerve pain or neuropathic pain is a little different and it doesn't go away in the way that we expect. Sometimes it can linger, sometimes it can wax and wane and it can be very challenging for patients to really understand what's wrong. And that's a lot of the pain that I tend to focus on. If somebody has an aching pain, you fall and get up, you're playing a basketball and you get bruised in the shoulder. That muscular pain is kind of a dull aching throb but sometimes the nerve itself gets some damage to it and sometimes that feels a little bit more electric or burning.
Speaker 2:So neuropathy or nerve damage, specifically that or pain that comes from our spine. So if the spinal nerves get damaged, that pain that might shoot down our arms or legs, that will feel burning or sharp or stabbing and the experience of that pain and the way it feels is very different. I find that a lot of patients they sometimes get confused by the pain because it doesn't go away in the expected timeline. If I get a cut on my skin I expect it to kind of scab over and heal in a certain timeline. But sometimes nerve pain, it might wax and wane, it might just linger and we're left wondering why we're feeling that way.
Speaker 1:Exactly my point, because neuropathic pain is some of the most difficult pain conditions for us to treat, largely due to the fact that it's unpredictable how quickly, if at all, that nerve will recover, because a lot of that resolution of that pain will be dictated by the integrity of the nerve If the nerve is permanently injured or not, and that will often dictate the resolution, because nerves heal very slowly relative to other body parts, for instance a broken bone or a muscle tear, that type of noceoceptive pain that you described. It's predictable and when we can expect resolution of those symptoms. But that is often not the case with neuropathic pain and we'll get into the management of neuropathic pain in a little bit.
Speaker 2:Yes, absolutely. And so the thing with neuropathic pain is that some of our audience members or healthcare providers listening to the podcast might recall that different muscles or different parts of the body, different areas of skin or different reflexes, we have expected spinal levels that we associate them with. So, for instance, the triceps, we think about C, or cervical seven, but it's also a little six, it's also a little eight. Same thing with the biceps, you know it's, we think about it as a C five, but there can also be some C six component.
Speaker 2:And the reason that that's important is because there's this other type of pain called central sensitization of pain, and that's another pain that I try to focus on with my patients as well, because there are multiple levels of innervation. Sometimes, when we have an injury to one portion of our body, when that pain signal is transmitted through our spinal cord, it might start to linger or activate other spinal levels that it was not initially found in, and sometimes that can sort of create an entirely new pain. And even after we have injury, even after a disc pops back into place or a nerve is moved out of the way that was being compressed, the pain might still be there. And that's because we have this new type of pain called central sensitization of pain, and I like to try and focus on that as well.
Speaker 1:That's a great point. So, as far as pain is concerned, dr Reisman, what factors contribute to the severity of a patient's pain?
Speaker 2:So, off the bat, there's the degree of injury, there's the mechanism of injury. So if someone has an amputation of a limb, if it was due to a vascular process such as diabetes, or if it was due to a traumatic injury in an accident, automatically that's going to be a different type of pain. There's the level of trauma associated and the emotional experience with the pain as well. Sometimes you meet someone and they've undergone a really intense injury and their pain is not so severe and you're a little surprised. They're taking it pretty well. And then you can meet somebody and you know they've stubbed their toe, so to speak, and the pain is so severe and it is absolutely ruining their day.
Speaker 2:So sometimes the way we think about pain and the way we process pain can really make a big difference into how much it bothers us, how much we feel it. We can be distracted. If I had a major surgery but then I won the lottery five minutes later, for a few minutes I might not be thinking about the pain. I'll be thinking about, you know, how much the lottery winnings were. So our emotions, our thoughts, our feelings, our relationships with other people, they can help us to process that pain and I think that that's important in including in patient care is understanding when we're talking to a patient, what sort of pain are they dealing with and what challenges is it posing for them, and when we think about all of those aspects, we can control our patients pain better.
Speaker 1:What role do, for instance, mental health and social status and social issues play in one's you know interpretation of their pain level?
Speaker 2:So this is a very interesting topic that I'm very passionate about when someone is part of a community or a family that has gone through a lot of difficult times certain communities have been through a lot of trauma over time.
Speaker 2:There are actually epigenetic changes that occur that influence the way their pain is processed, and there are lab studies that show that grandchildren of people who have been through some trauma can be interpreting pain and stress and that's what we're trying to do and feeling it in a different way and they don't know.
Speaker 2:They don't know that that's part of it. They don't know why. So somebody can have their knee replaced and it might just hurt a lot, and it might hurt differently than someone else's and the surgery was done perfectly, but they just feel this pain and perhaps their parents had a lot of pain or their grandparents had a lot of pain, and so when we talk to them about that and when I talk to my patients about my pain, I want to understand do you have any relationships that are challenging right now because of the pain that you're going through? And sometimes we'll refer them to a mental health provider if there can be some extra help that they can get in processing some of those things and I'll factor that into the interventional procedures that we'll do and discuss and the timing.
Speaker 1:Do you believe in a psychosomatic component of one's patient's pain?
Speaker 2:I definitely do. I think that it's a little different for everybody. I like to start off with the assumption that pain is purely organic and do a full diagnostic evaluation of the pain, but then, once we've established what we think the pain generators are which is a term we use a lot what I mean by that is, if I told you, I have some pain here in my arm, so there's a number of things that can be the reason for it. It can be my skin, it can be the muscle, it can be the bone. And once we've figured out from imaging, from electrodiagnostics, what the reason for that pain is, we can then begin to wonder how much of it is also being influenced by the person's psychological state.
Speaker 1:Yeah, we say that when patients are told it's all in your head that is our way of saying it's a psychosomatic condition, meaning that it's a diagnosis of exclusion. We as physicians make sure that we rule out any real etiology of that patient's pain and when nothing is found, we often diagnose it as a psychosomatic condition, which is rare but it can happen, because certainly mental health issues and other secondary gain issues can contribute to one's level of pain or interpretation of pain. So, speaking of secondary gain, what are some of the issues that come to play when patients are seeing you for pain, when you've deduced that it is secondary to secondary gain?
Speaker 2:So important in the doctor-patient relationship is the doctor-patient relationship and when you have established care with a patient when I established care with a patient I have a duty to care for them, to diagnose medical illness, if there is, and work with them to figure out how to treat it. Sometimes, as you kind of alluded to, even in the presence of an injury, there can still be secondary gain with it, and so, whether it's purely secondary gain, without organic pathology, or a mix of the two, we have to have honesty in our relationship between myself and my patients and we try to focus on what elements of their injury we can heal and we expect to be hurting them in the case of pain, and we are just very honest about the anticipated recovery that somebody might be experiencing from their pain. Certainly, yeah.
Speaker 1:So we are really just expounding on these issues only because we'd like to emphasize that there are a myriad of factors that contribute to patients' pain. It's not only organic in nature. Sometimes there are secondary gains, sometimes there are social issues, mental health issues that can contribute, and it's important to discuss that these things have to be addressed by a doctor like Dr Reisman. When we're managing the patient's condition, we can't just treat the organic condition. We have to address all these issues as well in order to make that patient better. So it's important to emphasize.
Speaker 2:That brings up something that's really important to me and how I then bring that into interventional procedures.
Speaker 2:So when a patient is experiencing pain and they might have some psychosocial components trauma in the family, some depression or anxiety or concerns about work and their ability to produce an income we then have a conversation, the patient and I, and we talk about what our options are. And so, when it comes to doing an interventional procedure and trying to influence the body's ability to decrease its pain, I'll talk to the patient and educate them, and I think that education is really a big piece here. When a patient understands why they are hurting and understands that their pain is appreciated and real. To me as a physician, whether it's organic or psychosomatic, it's real. It's causing suffering and it's important to me that we try to decrease it. So we'll talk about what our procedures are, we'll talk about how they work, we'll make sure patients feel comfortable, what they can expect, and those factors end up helping them to feel a bit more comfortable, and there are studies that show that education can actually decrease the pain.
Speaker 1:That's a great great point that you just made, and it's so important to me as an orthopedic surgeon because there's so much in the orthopedic literature that supports the fact that patients undergoing orthopedic procedures with a lot of pain going into surgery or mental health issues or secondary gain issues going into surgery clearly have much lower outcome scores than other patients that are not going into these surgeries with these preexisting conditions. So it's so important for me to know that we have a physician like you on staff that can help our patients get the best outcomes after surgery. But these are all things that need to be recognized.
Speaker 2:Yeah, there's. You know, I've read some papers on that topic exactly this, that type of pain that I had discussed previously central sensitization of pain. There are some patients that can be predicted. You know who will have a better outcome after their knee surgery in terms of pain. When we can identify those patients, that's really the next level of care and we're doing a great job of that here at the Kailer orthopedic center. We communicate, myself and other team members, and when we realize that there's a patient who's having a hard time with a certain injury or experiencing a great deal of pain, sometimes we will alter and adjust the timing of pain reducing procedures so that they can have less pain going into their surgery.
Speaker 1:Absolutely. It's just so important for us because we like to have these conversations with our patients before surgery so we can set expectations. And when I have a patient that is suffering, unfortunately, from severe depression or anxiety, or a patient that is suffering from an injury that was secondary to a work related injury that may have some secondary gain and want to stay out of work a little bit longer, I do have these conversations with the patients and make it clear to them that patients with these conditions have poorer outcomes after surgery and take longer to recover. I can have the same exact x-ray after a total knee replacement, for instance. Both look perfectly aligned and positioned and sized.
Speaker 1:One patient will complain of pain and be stiff and have poor range of motion and the other patient will, for instance, have an excellent outcome and get back to work within a few weeks. And a lot of that has to do with the psychosomatic conditions or the mental health issues or social issues that the patient is bringing to the table, and those are things that need to be discussed prior to surgery so that there is a full understanding of the expectations with respect to outcome. So, dr Reisman, we talked about pain in general, the different types of pain and some of the different factors that can come to the table with the patient that may influence their level of pain that they're feeling and also their outcomes after certain procedures. How do you, as an interventional pain management specialist and a board certified physiatrist, address these patients on a case by case basis?
Speaker 2:So that's an excellent question. It all starts off with the patient's history and generally when I meet a patient I've spoken to their physician beforehand or read their chart beforehand and I've learned about what's gone on, and that helps guide the questions that I want to ask the patient. So when I listen to a patient and give the patient the opportunity to tell their story, hear the details and the things that matter to them in their story, that not only clues us into the physical parts of their body that hurt. The words that they're using might tell us the type of pain that they have, the way they describe it. But then I ask them how it's been for them in terms of the hardships, if there's any trouble with work, trouble with family, to gauge any emotional aspect to pain. Once we've discussed what they're feeling, we go to really diagnosing what the pain generators are. Physical examination, advanced imaging, electro diagnostics all of those things together tell a full story and help us to understand exactly why the patient is in pain.
Speaker 2:There are some parts of the body that figuring out the exact pain generator can be really challenging. So, for instance, around the sacroiliac joint in our low back on the left or right side. Sometimes we have pain there and that pain might travel a little bit down our thigh. So when a patient says that a lot of people think about radiculopathy, automatically we assume that there's a nerve that's injured or compressed and causing a lot of pain. But when we really listen to the patient and ask very specific questions and help guide them to think about how they want to communicate their pain to us, we might learn that it's not really radiculopathy. It might be facet mediated pain in a referral pattern that's mimicking what we might expect from radiculopathy. This can happen from the sacroiliac joint, from the lumbar facet joints. Similarly, sometimes we have headaches but they're really coming from our facet joints or pain in our trapezius. It could be coming from the shoulder, it could be coming from the neck, and so by taking the time to go through this with our patients, asking them very specifically what they're feeling and then a guided physical examination, that's kind of the starting points when we take a look at imaging.
Speaker 2:I like to pay attention to time course. So sometimes patients might show that they have some degenerative changes in their spine, pretty significant degenerative changes. But when I ask them how long they've been experiencing their pain for they say it's only been for three or four weeks and I try to figure out okay. Well, if their pain is coming from these degenerative joints, why would it have started to hurt three or four weeks ago? I would have expected it to hurt a few years ago, maybe. So that helps to guide our decision making. When we think about what procedure we want to do to try to decrease the patient's pain, we think about how fast we can get them feeling better and how safely and efficiently we can decrease their pain.
Speaker 1:So, dr Reisman, I know I've spoken to Dr Aiden about this in the past with when it comes to management of pain, but what is your take on the concept of preemptive anesthesia and addressing pain preemptively, trying to nip it in the bud, as opposed to playing catch up and addressing it after it's full blown and extremely difficult?
Speaker 2:to manage? That's a really important question. I think it's important that we aggressively treat our patient's pain, and that's because one pain is lousy and it makes us feel bad. But the other reason is because we want to decrease the pain. We don't want the tissues, the nervous system to get used to feeling the pain, Because once somebody is feeling pain for a long time, it becomes more challenging to decrease that pain. When somebody is going to have surgery, if they are feeling pain for a long time prior to that surgery or during that surgery, it makes the recovery more painful and it actually leads to other medical conditions that might develop into chronic pain, such as complex regional pain syndrome.
Speaker 2:We have our autonomic system and our autonomic system divided into sympathetic and parasympathetic systems.
Speaker 2:It's at our core as organisms and a lot of times pain and trauma can get rooted in the autonomic system.
Speaker 2:And by treating pain early and aggressively we can decrease the likelihood that we're going to have pain for a long period of time. There are studies with neonates that neonates who don't have controlled pain, they're not able to express the pain to us, that they can have changes to their nervous system as they develop. The same thing happens with adults. We can have pain that changes and my initial injury can be at my shoulder. If I don't treat that shoulder aggressively and decrease that shoulder pain quickly, I might end up with pain at my hand or at my wrist. So I think it's very important for us to quickly figure out why someone is in pain. It's important to get seen by your physician, see your orthopedist, figure out what can be done and then simultaneously, I think it's important that if you're experiencing that pain, you need to come in and get seen and we can figure out a joint plan for how to decrease that pain and prevent it from becoming chronic.
Speaker 1:I couldn't agree with you more. As I alluded to in the past, the concept of preemptive anesthesia is critical in the successful outcomes of patients' orthopedic surgeries. The orthopedic literature clearly supports that. Patients going into surgery with more pain have more pain coming out of surgery. So it's incumbent upon us as orthopedic surgeons to do everything we can to manage that patient's pain prior to any orthopedic procedure. And in addition to that, when we're undergoing major orthopedic procedures such as hip replacement, knee replacement, shoulder surgery etc.
Speaker 1:We often employ the usage of a preemptive block, a regional block, by the anesthesiologist who will block the nerve prior to surgery so that the patient's brain never interprets that pain signal from the surgical event.
Speaker 1:In other words, when I'm about to perform an incision for a knee replacement, if that nerve that goes from the brain to the knee is numbed or anesthetized by the anesthesial just prior to surgery, that patient's brain will never feel the pain from the surgical incision. So very often we employ the usage of a regional block or preemptive anesthesia to help minimize the patient's pain after surgery by blocking the nerve before surgery. And that concept is extremely important in the successful outcomes of orthopedic surgical procedures. It's not only a regional block that's often performed, but rather it's a multimodal approach to the preemptive management of that patient's pain. So we will often block the morphine receptors in the brain, for instance with some narcotic medication. There will be some local anesthetic which will block the nerve itself, and anti-inflammatories often can be given up until surgery as well to block the inflammation associated with the surgical procedure. All of this contributes to having less pain after surgery and it's very, very important in the area of orthopedics and pain management.
Speaker 2:I couldn't agree more. In my training we did a lot of radiofrequency ablation and so those nerves that you alluded to, prior to a knee surgery, those nerves can be blocked. Sometimes if a patient is going to be having knee surgery or knee replacement but they might not get around to it because something in their life is causing it to be delayed, we can do a radio frequency ablation and provide some relief of their pain for a number of months until they're able to have that knee replaced. We can do this, as you alluded to, not only with interventions but with appropriate guided medication as well. So by understanding the mechanism of the pain and if the pain is coming from a somatic nerve receptor or from a neuropathic agent. If it's nerve pain, we might want to use something like gabapentin. If it is coming from the bone, tylenol or Advil can be very effective.
Speaker 2:I find often that Tylenol itself might be one of the most underutilized medications. A lot of times when I ask a patient, when I'm meeting them, I'll ask them what have you used for your pain? And people don't really mention Tylenol or Advil. They go straight to talking about gabapentin and tramadol, and a lot of times that Tylenol. When I ask them. I said did you ever take it and did it help you? And they said, yeah, you know, tylenol helps quite a bit and I'll ask how frequently do you take it? And they'll mention that they, you know, maybe once a week.
Speaker 2:People don't want to take it and that's because there's a lot of misconceptions with medications about how much is a safe amount. We don't want to overdo medications, we don't want to use them unnecessarily, but part of my training focused on understanding the medications, why we would use different ones, and I'll speak to my patients about letting them know how much they can safely take. So sometimes it is safe to take more medication than somebody is taking. We're not speaking about opiate medications. That's generally not part of my treatment plan. There's a time and a place, but the evidence is showing that that is not really effective for long term reduction in pain. But things like Tylenol, advil, other more specific types like Celebrex, gabapentin, lyrica there's sometimes one might want to use one or another and I'll guide my patients about which one's likely right for them.
Speaker 1:Right. And the other thing that we should emphasize is and we're very fortunate at the Kaila Orthopedic Center to be surrounded by so many experts the etiology of pain is clearly multifactorial, but I think it's important to mention and emphasize that the management of pain is multi-modal as well. So at the Kaila Orthopedic Center we have orthopedic surgeons, we have rheumatologists, we have physiatrists, such as yourself, interventional pain management specialists, but we also have chiropractors and acupuncturists, massage therapists and physical therapists. All of these teammates and healthcare providers collaborate with one another to manage our patient's pain, because it is multifactorial and we don't just throw one dart at the patient's pain. We sort of attack it from many different angles with all these different services that we provide, because it's so important to recognize that pain comes from a myriad of different issues. And in addition to all of this, sometimes we'll have to refer the patients back to a mental health counselor as well, or a psychiatrist possibly for the management of their mental health illnesses and things like that. Do you agree with that, dr Reisman?
Speaker 2:I couldn't agree more.
Speaker 2:There's an entire branch of psychology, pain psychology and in physical therapy as well pain physical therapy.
Speaker 2:Sometimes a patient when I ask if they've done physical therapy, they'll share.
Speaker 2:They did, but it made it worse and that's because they didn't. They were feeling some pain, but pain psychologists will talk to the patient about good pain and bad pain and what type of pain is important to feel and is part of growth and what type of pain you want to be nervous about, and our physical therapists can do that as well. So when I put in an order for physical therapy, I'll educate the patient and I'll document and communicate to a therapist or to a chiropractor which type of therapy I think is best for that patient and somebody two people can have the same back injury, but they might have very different physical therapy prescriptions because somebody might need more strengthening and somebody might need more flexibility and pain reduction, and so it's important to keep in mind the whole picture there. Sometimes it's important that patients' families are included and then other mental health experts as well. We want to make sure that the patient's mind and is being treated, and if they need pain, pain psychologist or psychiatrist, we'll need to bring them in as well.
Speaker 1:Great, I couldn't agree more. I think that's one of the most beautiful things about our practice. I think that, since we have everything in house, it's truly a one-stop shop for all your orthopedic needs, and I mean that sincerely. A lot of our patients will end up seeing five, maybe even sometimes 10 different healthcare providers in our practice. It's only because we want to make sure we attack their problem from multiple different angles, because each one of our experts has a different service or a different level of expertise to the treatment of our patient's underlying condition, because it does need to be managed from many different angles, and we want to make sure we're not missing anything, to make sure that we adequately address every single contributing factor of their pain. And so that's. We're very fortunate to have the colleagues that we do at our practice all under one roof to manage that.
Speaker 2:I absolutely agree. We've spoken about the importance of quickly and aggressively treating pain, and part of why we can do that so well at the Kaila Orthopedic Center is because we have such efficient communication between different team members. A patient can see a physical therapist or a chiropractor and, either during their session or two minutes afterwards, come over to my office and let me know about an update with that patient, ask me my thoughts, or sometimes it goes both ways. I'll ask a colleague, a rheumatologist, a chiropractor, an orthopedic surgeon, I'll ask them what they think about something that one of my patients in the rooms are experiencing and then, on the spot, we come up with a collaborative approach to quickly and efficiently get that patient what they need in terms of their healthcare.
Speaker 1:It's important to recognize that if something's not working, we just have to try a different approach. We just can't keep doing the same thing over and, over and over again, and so that's the beauty of having so many different alternatives. So it's important to recognize that. And you know, shift gears if you have to, even midstream. So, Dr Reissman, this has been an awesome time with you today, getting to appreciate the different factors that contribute to patients' pain. We're so happy to have you. You're definitely an invaluable asset in the practice, because we do know how ubiquitous the problem of pain is, and thank God for doctors like you that can help get our patients out of pain. We really look forward to having you care for many of our patients for many years to come. So thanks so much. It's been a pleasure speaking with you today. Thank you, okay.