Joint pain relief with Iovera

Sports Medicine Physician Andy Bays, MD, talks about a new treatment for joint pain called Iovera. It uses extreme cold to stop nerves from sending pain signals to your brain. 

Transcript

For those patients with knee pain due to arthritis, holding off on knee replacement or awaiting knee replacement, a treatment called Iovera may be for you. Doctor Andy Bay is from Sarah Bush. Lincoln Orthopedics and Sports Medicine will be here to talk about this in-office treatment that uses extreme cold to stop nerves from sending pain signals.

Doctor Bays will explain how it works. Who's a candidate and what you can expect. So if knee pain is part of your daily life. Stay tuned to hear more about Iovera

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 Welcome to Health Styles. I'm your host, Lori Banks. Doctor Andy Baize is back to talk about a new treatment for joint pain, specifically those with pain in the knees.

Doctor Bays is a sports medicine physician who specializes in non-surgical orthopedic care. Now, if you want to know more about his specialty, check out our podcast called Sports Medicine for everybody. From October of 2023. Doctor bays, it's great to see you again. Yeah. Lori, thanks for having me back. Have you been busy? It's been busy. Practice is picking up, and.

And the kids are in sports, so we're running around like crazy right now. All right, well, you've got a new treatment that you're offering called Isle Vera. Tell us a little bit more about it.

Correct. Iovera it's I o v e r a and it's a relatively novel device. Really hasn't been around more than the last couple of decades, but really started to gain traction over the last few years where the idea behind it is using targeted cold therapy to essentially change our body's perception of pain.

So, it is a pretty new and, interesting device that allows liquid nitrogen to be used to cool nerves down to a very specific temperature so that then they can no longer send pain signals. So similar to the idea of using ice when you sprain an ankle. And it helps things to feel better. This is just a targeted and longer lasting way of doing that.That allows us to be very focused and specific on where we put that medicine.

So who are the patients that will benefit from this the most?

Yeah, I think there's two main applications that we look at. And one is the patient who knows. Hey, I have to go have a total knee replacement. And we've heard that the recovery can sometimes be challenging there.

And so Iovera is a great tool to help make that recovery a little bit easier in that if you come to see me and we perform an eye over a treatment for you about 2 to 4 weeks before your total knee replacement. In theory, that will have given the nerves enough time to cause some of that degeneration of the nerve to where it won't be able to send pain signals.

And now you'll be able to do your rehabilitation on the back end after surgery. Much, much easier. And so there's some studies that support this. And anecdotally we're seeing this that patients that maybe their 2 to 3 week visit look as if they're 6 to 8 weeks out because they're progressing that quickly and doing that well their motion looks better.

They feel better. They're not using the same amount of pain medicine. So it's a great tool for the person who knows they have to undergo knee replacement. But then I'd also say, interestingly, that it's a great tool for the patient who maybe wishes they could have a knee replacement, but due to problems, maybe with lungs or heart or other risks that would make surgery just a little too much for them.

This can be a tool so that they're no longer having to just get steroid injections into the knee every few months. In theory, this tool would allow us to get them longer lasting relief. With no medications, no drugs. It simply targets the nerves and stops those pain signals from being sent up to the brain.

So explain how do you actually go about getting this procedure done?

Sure. Are you injecting something? How does it work? Yeah.

I think a lot of patients who will listen to this are probably familiar with the idea of cortisone injections. That's what we classically refer to. Steroid is going into a joint, but this is a similar concept. But instead of going to the joint, we're hitting some of those superficial nerves that go and send pain signals from the knee joint or the knee capsule.

And so what we would do, the general procedure looks like you come into the office, we use the ultrasound so that we can be very targeted and very precise in where we place the treatment. The treatment is essentially a small needle that goes down right around the nerve that again, we've located on ultrasound. And after we give you a little bit of a numbing shot around the nerve so that we can take away some of the discomfort, we then place this eye over a needle tip right next to the nerve.

We push the start button, and that's really all there is to it. The, eye over a needle creates a little ball of ice around the end of it that causes the nerve to freeze, to wear anything beyond that point. So, for example, if we were to place this in the middle of your thigh, anything that that nerve would run down to, in this case, the knee capsule is no longer going to be able to send those pain signals back up to the brain.

And so you'll find several different nerves that we commonly treat and what it amounts to is several for the patient. They're laying there hopefully in a relatively comfortable and relaxed position, and we put a little numbing shot around each nerve. And then we run the eye over a cycle around each nerve. So it's almost like getting 5 or 6 different small shots around a nerve that afterwards people should feel pretty good as soon as they leave the office.

So, pretty quick efficacy. And that certainly is a good selling point for it. I think it's true.

So how long does that treatment take?

Yeah. Good question. It depends on the number of nerves we have to treat. Generally speaking you're looking at if you only had a couple of nerves 15 to 20 minutes. But I'd say for most patients if you budgeted 30 to 45 minutes for a treatment session, that would pretty well cover any and all possibilities there.

Whether it was a nerve that's hard to find, or maybe you had several branches we needed to treat. It would, it would allow enough time to get all of that done and get you out the door.

So do you feel like on the outside of your knee, like on the skin? Does it feel like numb or is it more inside?

Good question. And everyone's going to be a little bit different. We know there's natural variations in where nerves run between patients. And so it's, it's a little bit hard to say exactly where you will feel that. And I know that that sounds a little nerve wracking for a patient who's saying, well, hey, if you don't know exactly where I'll feel this, why would I go get the procedure?

And what I mean by that is not that we don't know, generally speaking, where the nerve should run, but might you have some diminished feeling on the skin on top of your knee? Maybe. Could it just be the knee capsule? Also, that's absolutely possible too. And it's generally the knee capsule and some of that surrounding tissue right above the knee that we're really targeting because we found through some good, studies that that those were the things that were extremely sensitive in transmitting a lot of those pain impulses.

And so by treating these nerves, yes, we may sacrifice some of that sensation or some of that feeling on the skin on top of your knee. But we're treating that numbness to get rid of pain. And so I think it's one of those that I certainly don't know that it applies to every patient. And certainly if you've only had knee pain for a couple of weeks, might this not be the treatment for it?

Of course. Maybe we need to look at other options. But for someone who's dealt with pain for years and years and it's arthritis or what have you, a lot of those patients we found are very interested in, hey, I'm okay with being a little bit numb and, you know, having maybe a little bit of a different sensation when I slide a pair of jeans on over my knee because it means I'm not hurting anymore.

And so I think that it's one that we'll have to have that conversation if a patient's interested, but if it's worth it to them, I think it's a very reasonable option. So

so you've talked in terms of the knees that really the only place this works, or can you do it in someone's hip or their ankle or their shoulder?

Technically you could apply the eye over a treatment to any nerve in the body. But we know that some nerves don't just carry sensation. Some nerves are also in charge of controlling our muscle strength. And so for nerves like that, it would not be a good idea. There are still some applications around the shoulder and things like that, but it has to be a very selective patient.

Population that that would benefit. So there are plenty of other uses. And if you visited the website, I overcome there's going to be lots of information about it. But the main application that we're using it in is knees, because there's several strictly sensory nerves that their only job is to send sensation. And oftentimes in this case, we're talking about pain sensations.

And so that's why it's a great target for knees. Because the nerves that control strength are higher up and well removed. So that that worry about will. Hey, if I had this treatment done and you're telling me it lasts a long time, am I going to be weak that whole time? No you're not. All of your strength will remain intact.

This is just going to be for those sensory nerves that are sending your pain signals up to the brain.

So how long does it last? You're freezing. Freezing this nerve. It. That's a term I'm going to use. How long does the sensation lasts? Does it wear off.

Our formal terminology is targeted cryo neuro lysis, which is just a long winded way of saying exactly what you did.

Laurie, we're freezing the nerve. But the Iovera system uses a very targeted temperature range about -88°C. When we get to burning nerves, either with extreme cold or extreme heat, we see some pitfalls there where that nerve may grow in back in a different place. That nerve may, instead of growing back in a different place, may just have several branches that grow off around the ball of scar tissue from where you burned it that first time.

And so any of these nerve treatments that we're doing are technically temporary. Just like a steroid shot is oftentimes temporary for patients. But the overall system, because the outside of the nerve stays intact. And there's some great videos on the website if anyone's interested in reviewing those that kind of show how it works and why it's a good option for patients, well, the inside of the nerve will degenerate.

But the outside or the myelin sheath of that nerve stays in place. And so that means we can repeat this treatment as often technically as every three months. That's what's currently approved by the FDA. Now does that mean it only last three months? Generally no. Most people are seeing or at least a substantial portion of patients are seeing six, nine, even 12 months of relief.

But some of that depends on how high up we choose to target the nerve, meaning that for all nerves, it's about 1 to 2mm of growing back per day. So if we were to freeze really high up, you'll have a larger numb spot, but you'll also have longer lasting pain relief because of that. And so we just kind of have that conversation about how high up are you willing to go and how long are we looking for relief if we know it's a total knee replacement?

Well, they probably only need a couple of months of relief anyway. Once you get past that initial phase of your knee replacement, most people do quite well with them. This is to help for those first two months or so, 2 to 3 months while they're struggling with it. So they may not need to be frozen or have that targeted treatment quite as high up the nerve, whereas somebody who's dealing with chronic pain, maybe they're traveling from a long ways away or what have you, maybe they would be willing to give up a little bit of that skin sensation for longer lasting relief.

And so everybody's going to be different. And the beauty of this treatment and using the ultrasound is I can tailor that to what the patient wants. So if they said, look, I really don't feel like coming back and getting shots every three months, let's do this a little higher up. Perfect. I can do that. If they said, I'm a little leery about this, I want to try it, but I don't really want a large numb area.

Great. Then we can target right around the knee and we can be pretty selective on that too.

does this do any damage to the nerves long term? That's a great question.

As of right now, the data would say no because again, we're everyone's familiar with the story of Goldilocks and the Three Bears. Well, this is kind of finding that treatment temperature that is just the right temperature to where blood vessels and muscle and things like that around the nerve stay completely unharmed. The nerve itself will regrow. And because it's that right temperature and we're not destroying the entire nerve, it's going to regrow down the same path.

Which means that for you and I, if you were my patient, I could retreat the same area each time with the same results. That's what the studies are panning out to show us. And from a theoretical or mechanism of action standpoint, how the treatment works, it makes sense. The nerve sheath stays intact, but the individual little fibers within the nerve degenerate until they regrow and develop again.

At that rate of about 1 to 2mm per day. And so long lasting damage, we have not shown any risk of harm to tissues around the nerve. We haven't seen any. About the only risk that I really see with this are there are a few instances which we can talk about where maybe this wouldn't be a good treatment because you have another chronic condition, but otherwise you might have a little poke and burn from the numbing medicine and maybe a little redness or bruising from having had an injection.

And aside from that, it's a pretty safe procedure with very low risk of any sort of long term sequela or side effects because of it.

So is there anybody that shouldn't have it

Good question. And that's always we always look at the risks and the benefits for anything we do in medicine. And we want to make sure we're selecting appropriate candidates.

In this case, there were a few diagnoses or specific conditions that are oftentimes related to cold exposure. So people listening may have heard of something called Raynaud's phenomenon. And there's some other conditions that have very long names, like cold or mixed cryotherapy, anemia. I mean, there's, there's a lot of big words that if you have that diagnosis, you probably know it because they're such unique phrases.

 But we also review that with you at the time and make sure that you don't have any. So there is a full list that again, it's available. It's what we review before any procedure and make sure that that's nowhere, in the patient's history. And as long as but it's really things that would be if I'm exposed to cold bad things happen.

Frostbite isn't an issue that we worry about and things like that because we're targeted, because we're hitting that sweet spot in terms of how cold the treatment goes. But there are some very unique and rare conditions that we'd say, well, maybe this isn't the treatment option for you. Okay,

Is there a limit to how many treatments that you can have?

So maybe it works for you for six months. Can you go back and just keep having it? Maybe you've decided that it's really don't want to have a knee replacement.

I would say that the treatment itself is not going to fix or prevent the development of arthritis. And so just because I've taken away some of that pain generating impulse does not mean that you'll be 100% pain free if that arthritis progresses.

There are some nerves that simply cannot be reached that will continue to send pain signals. And on top of that, we do run the risk that as arthritis progresses, our alignment changes and it starts to cause problems with the way we walk or can get around, so that even if my knee wasn't hurting because those nerves had been treated, could you have hip issues that develop or lower back?

Those are risks. And so I would say that if you're considering or your surgeon has recommended total knee replacement, it does not mean that you'll have this treatment and want to cancel your knee replacement because those downstream effects could take place. But it means that for that patient, chronic pain may be 90 years old with a lot of health conditions.

They have bad lung disease. They have bad heart disease that can't undergo surgery because the anesthesia is too big a risk. Those patients, there's no real limit. If we decided that there's no other good alternative for them, and they elect to do this every six months or three months or nine months, whatever it amounts to for that individual patient, then no, there is no limit.

And that's the beauty of that sweet spot in terms of how cold we go. We can get consistently reproducible results. Okay, so when someone comes in they have it done. When can they get back to regular activities? Good question. Generally speaking, as with any sort of injection or procedure, we want to give you a couple of days of taking it easy.

Make sure you feel comfortable, especially because we are talking about nerves that send signals up to the brain. Now, again, these are sensory nerves. So we shouldn't have any problem with strength. But you do want to get used to that sensation because it'll be a little bit different from your normal. So before we get back out to everything or everyday activities, I would say that we generally give patients a day or two.

Take it easy. Certainly not on bedrest by any means, but we shouldn't be doing a whole lot of extra. It's not a reason that, well, hey, my knee feels better than it has in years. Let me go do a bunch of landscaping around the yard or a big to do list, or go for a jog. That's generally not the patient population that we're targeting with this treatment anyway, but certainly I wouldn't push back into strenuous activity for at least a few days until you get an idea of how it's going to feel for you.

So let's talk about athletes. I know you work with Eastern Illinois University athletics. I would imagine there might be some athletes listening to this going, oh man, I hurt my knee playing or running that marathon or doing whatever. Maybe I could just get this and then get back in the game, like next week, right?

I think for our young population.

So you mentioned specifically IU, the use in that population is going to be a little bit, a little bit less, because generally speaking, we're dealing with a knee that doesn't have a lot of arthritis, doesn't have a lot of degenerative process. And so if they're having pain, I actually want to know that so that we can treat the appropriate cause.

Now if we're looking at someone into their 40s, 50s who stayed active, continues to do things, knows that they do have arthritis, whether that's from old injuries or prior activities or whatever that may be. Those patients are candidates for it, and we'd have to have a conversation about the good and the bad again, you know, if we did this every six months and that lasted for years, but now their alignment has been thrown off.

And this, that and the other may be not a great option. So we have to strike that sweet spot and that goes into the art of medicine. You know, not every person who hurts is going to be a candidate for this. And we will talk deeply about the good, the bad and the ugly of any procedure we choose to do, whether that means something as simple as getting an MRI or fitting you for a knee brace.

We always talk about the good and the bad of each of each option so that you can make a good decision for your health, but I think that as we get into maybe the older quote unquote athlete will, then maybe we do have an application there for the I know I may need a knee replacement or that that's something that that I've been told, a common one that I see is our rural patients.

So the farmers of the world, who there are some very select times where they are extremely busy, right. And during harvest or during planting, they don't have taking the time off for a knee replacement is not an option that they have. That could be a great tool for them to where we say, hey, we know that this is probably headed this direction, but you need something that allows you to get through the next few months.

That's a perfect application for them.

So just to be clear, this is not for people who have pulled a ligament, tendon, etc. this is for people who have arthritis, degenerative joint problems. That's not that's a perfect way to do that, mainly because if you have an acute injury like the sprained ankle or say, heaven forbid you have a torn meniscus or something like that, well, to strictly go in and block that sensation and then allow you to go back and participate, we run the risk that we do more harm than good at that point.

So yes, it has to be that select patient. And generally speaking, we're looking at a degenerative process being the thing that we're targeting here is taking away pain from that degenerative or arthritic process in the knee. Okay. So I have a question. Is this covered by insurance in general? I know you're not an insurance expert, but this is not an experimental treatment.

Correct. This is covered by Medicare. There are some private insurance companies that will cover this as well. Before we do any procedure in our clinic, we do submitted for authorization and make sure that things will be covered. So this may be something that we come in to. You have a conversation about it. You tell me, hey, I'm interested in having that done.

Well, then we have a dedicated team of insurance specialists because you're absolutely right. I am certainly not an expert, but, they will run this through your insurance company and make sure that it is something that will be approved for you. So you're not hit with some huge out-of-pocket bill on the back end. Okay.

Several people that with either with whom I've trained or people that I've talked to at different large networking among the sports medicine communities who are have been doing this for years.

Nothing but great things to say, aside from the time it may take to do the procedure for which really, 30 to 45 minutes isn't too bad in my opinion. And that's about the biggest downfall. Otherwise, you know, little to no risk of infection. You. Can we ever say a 0% chance? No, but it's extremely safe in that regard.

Damage to blood vessels, nerves and things like that around the area that we're not intending to treat. Essentially no risk. And so with it, when you have a procedure that's this safe and works as quickly as it does with patients in that same visit, we'll have you rate your pain before the treatment and after. And those scores drop tremendously.

So in terms of efficacy or patient success stories, there's too many to count. And I think that any time I hear something that sounds too good to be true, I'm extremely skeptical. But the way this works, the mechanism of action and how we're doing it with targeting those specific nerves, it's hard to poke a hole in in the efficacy or the results here.

They kind of speak for themselves. And so lots of people and I've been doing geniculate nerve blocks, which means the some of the deeper nerves to the knee. I've been doing those since we started at Sarah Bush. But we didn't have this tool to be able to go say, hey, that worked really well for you. Now let's get it longer lasting, because a block just means that I'm putting numbing medicine around there and we see great results.

People feel tremendously improved as soon as they walk out of the office, but we didn't have this I overa technology here at Sarah Bush until recently to be able to. Okay, you got relief. Now let's do this. I Alvera and make it last more than just a few hours while the numbing medicine is moving around. So now we have the luxury of those patients that I've treated before.

Hey, come back in and let's get this thing to last longer than you know. That numbing medicine gives me a clue that it's going to work well for you, but the average treatment actually allows it to work for months and months. That's really exciting to think about that I've had a tremendous opportunity for patients that, again, with the fact that the nerve can regrow in the same area, it's going to regrow at the same rate of some of the older nerve treatment technology we were using.

But now it's going to grow back in the same area so that I can get those guaranteed results each time. And I think that that is the amazing piece. There's extremely safe to blood vessels and other tissues like muscle that live in the area, extremely safe from an infection risk, extremely safe in terms of we're not going to make you weak, like you're going to fall or have problems that in that regard.

And when you have a, device or a treatment that is that safe, but also that effective, I mean, the studies have consistently shown that the use of those pain pills or narcotics after surgery, if you had an eye over a treatment before your total knee replacement, you're that usage rate is cut in half or roughly cut in half for patients.

And I think that that part is just tremendous. We're helping people stay away from or avoid some of these higher risk medications, while also feeling better as they progress back to health after their, their surgery. And, and I think it's just a very unique and potentially life changing for some of our patients, treatment that we're now able to offer.

Doctor Bays is really exciting and I thank you for bringing this to our patient population, because I will say you were about the only one in our region area that's kind of doing it.

I think that's correct. I think you'd have to travel over an hour or so to find anyone else who's doing it in the area. So to be able to bring it to

our patients, I think is and it's been Sarah Bush administration has been a huge supporter of this. And they facilitated, you know, acquiring the tools and the training and things like that.

So gotta, gotta give a shout out to them as well. But I think that it is going to be something that's tremendously beneficial for our patients. So very grateful to have the opportunity to provide it. All right. Well, thanks for coming in and talking about it and educating all of us on this new option for joint pain. Absolutely.

Thanks for having me again. Just for any patients out there who are considering, I would I would encourage you to look at Iovera.com. That's Iovera.com. I'll have a lot of their handouts and information in my office so that you can read up on it, but it has links to some of the research that's been done, videos on how it works, and what you can expect during and after the procedure.

It's a tremendous resource for patients who are who are maybe considering this treatment.

To learn more about Dr. Bays, visit our website at sarahbush.org under Find a doctor. As he said, Iovera is not a cure all for every kind of joint pain, but for those with arthritis, waiting for replacement surgery or those who can’t have the surgery, this may be a pain management option for you. Remember to talk to your healthcare provider as the information we present in this podcast is for information purposes only. Thanks for listening and be sure to subscribe so you’ll be the first to know when new episodes are available. Have great day.