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PainExam Podcast Show Notes NAD+ Supplementation in Pain and Inflammation: Hype, Hope, or Emerging Science?
Hosted by: PainExam Podcast
Episode Overview
Presented by: NRAP Academy (Neuromodulation, Regional Anesthesia & Pain)
Host: David Rosenblum, MDIn this episode of the PainExam Podcast, we explore the growing interest in NAD+ (Nicotinamide Adenine Dinucleotide) supplementation and its potential role in pain management, inflammation reduction, cellular recovery, and healthy aging.
NAD+ is a naturally occurring coenzyme found in every living cell and is essential for energy production, mitochondrial function, DNA repair, and cellular resilience. As NAD+ levels decline with age, chronic stress, inflammation, and disease, researchers have begun investigating whether restoring NAD+ levels may improve outcomes in chronic pain conditions and inflammatory disorders.
We review the current science, discuss potential mechanisms of action, and examine how NAD+ therapy is being integrated into regenerative medicine, wellness programs, and pain management practices.
What is NAD+?NAD+ is a coenzyme involved in:
✅ Cellular energy production (ATP generation)
✅ Mitochondrial health
✅ DNA repair pathways
✅ Oxidative stress reduction
✅ Neuroprotection
✅ Cellular signaling
✅ Activation of longevity-associated proteins called sirtuins
Without adequate NAD+, cells become less efficient at producing energy and managing inflammation.
Why Might NAD+ Matter in Chronic Pain?Many chronic pain conditions involve:
Mitochondrial dysfunction Oxidative stress Neuroinflammation Peripheral and central sensitization Impaired cellular recoveryResearchers hypothesize that optimizing NAD+ levels may help address several of these pathways simultaneously.
Potential areas of interest include:
Neuropathic PainNAD+ may support:
Nerve repair Axonal recovery Mitochondrial function within neurons Reduction of oxidative injury Inflammatory PainNAD+ influences inflammatory signaling pathways and may help modulate:
Cytokine production Immune cell activity Cellular stress responses Fatigue and RecoveryPatients with chronic pain frequently report:
Fatigue Brain fog Reduced exercise tolerance Poor recoveryBecause NAD+ plays a critical role in energy metabolism, some clinicians report improvements in energy and recovery following supplementation.
Potential Mechanisms of Action 1. Improved Mitochondrial FunctionMitochondria generate ATP, the body's energy currency.
Reduced NAD+ levels are associated with:
Cellular aging Impaired energy production Increased inflammationSupplementation may help restore mitochondrial efficiency.
2. Activation of SirtuinsSirtuins are proteins involved in:
Cellular repair Longevity Metabolic regulation Inflammation controlNAD+ serves as a critical substrate for sirtuin activity.
3. DNA Repair SupportNAD+ is required for enzymes known as PARPs (Poly ADP Ribose Polymerases), which participate in DNA repair processes following cellular injury.
4. Reduction of Oxidative StressChronic inflammation often produces excessive reactive oxygen species (ROS).
NAD+ may help maintain cellular antioxidant defenses and reduce oxidative injury.
Routes of NAD+ Supplementation Intravenous (IV) NAD+Most commonly marketed in wellness and recovery clinics.
Potential advantages:
Direct systemic delivery Avoids gastrointestinal absorption issues Allows higher dosing protocolsPotential limitations:
Cost Time commitment Variable evidence base Oral PrecursorsRather than NAD+ itself, many supplements provide precursors such as:
Nicotinamide Riboside (NR) Nicotinamide Mononucleotide (NMN)These compounds are converted into NAD+ within the body.
What Does the Evidence Show?Current evidence remains preliminary.
While preclinical and mechanistic studies are promising, large-scale randomized controlled trials evaluating NAD+ specifically for chronic pain are still limited.
Areas under active investigation include:
Neuropathic pain Neurodegenerative disorders Chronic fatigue syndromes Recovery optimization Healthy agingPatients should understand that NAD+ therapy remains an emerging treatment rather than a standard evidence-based pain intervention.
Safety ConsiderationsReported side effects may include:
Nausea Flushing Chest tightness during rapid infusions Headache Fatigue LightheadednessMost adverse effects appear infusion-rate dependent and can often be minimized through slower administration protocols.
Patients should discuss treatment with a qualified healthcare professional, especially if they have:
Cardiovascular disease Active cancer Significant medical comorbidities Clinical Pearls for Pain Physicians✔ Consider NAD+ as a potential adjunct—not a replacement—for evidence-based pain care.
✔ Continue emphasizing exercise, sleep optimization, nutrition, behavioral health, and appropriate interventional therapies.
✔ Discuss realistic expectations with patients.
✔ Recognize that evidence continues to evolve.
✔ Focus on patient-centered outcomes rather than laboratory markers alone.
Key Takeaways NAD+ is essential for cellular energy production and repair. Declining NAD+ levels may contribute to aging, inflammation, and chronic disease. Early evidence suggests possible benefits in inflammation, recovery, fatigue, and nerve health. Robust pain-specific clinical trials remain limited. NAD+ therapy should currently be viewed as an adjunctive and investigational strategy in pain management. Resources for Physicians Pain Medicine Board PreparationPrepare for the ABA Pain Medicine Boards with:
🎯 Comprehensive Question Banks
🎯 Virtual Pain Fellowship
🎯 Flashcards and Mock Exams
🎯 Weekly Board Review Content👉 Pain Management Board Prep at NRAP Academy
Hands-On Ultrasound Courses – New YorkLearn:
Peripheral nerve imaging Ultrasound-guided injections Regenerative medicine procedures Diagnostic musculoskeletal ultrasound Advanced pain intervention techniques👉 NRAP Ultrasound Courses in New York
Ultrasound & Regenerative Medicine Training – Costa RicaJoin physicians from around the world for immersive training in:
🌴 Playa Grande, Costa Rica
☀️ Small-group hands-on instruction
🦴 Regenerative medicine applications
📡 Ultrasound-guided pain procedures
👉 Costa Rica Ultrasound Training Courses
Connect With PainExam🌐 NRAP Academy Website
🎙️ Search PainExam Podcast on your favorite podcast platform.
📚 Explore the Virtual Pain Fellowship, Board Review Programs, Ultrasound Training, and CME opportunities.
References Hudson Health. NAD+ Infusion Therapy: Full Clinical Review and Background Paper. 2023. Verdin E. NAD⁺ in aging, metabolism, and neurodegeneration. Science. 2015. Covarrubias AJ, Perrone R, Grozio A, Verdin E. NAD⁺ metabolism and its roles in cellular processes. Nature Reviews Molecular Cell Biology. 2021. Rajman L, Chwalek K, Sinclair DA. Therapeutic potential of NAD-boosting molecules. Cell Metabolism. 2018. Katsyuba E, Auwerx J. Modulating NAD⁺ metabolism for health and longevity. Nature Reviews Endocrinology. 2017.Disclaimer: This podcast is intended for educational purposes only and should not be construed as medical advice. Always consult qualified healthcare professionals before initiating any treatment.
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PainExam Podcast Show Notes Compression Fractures, Vertebroplasty, Kyphoplasty & Occipital Neuralgia for the ABA Pain Medicine Boards
In this episode of the PainExam Podcast, Dr. David Rosenblum reviews two frequently tested topics on the ABA Pain Medicine Board Examination: Occipital Neuralgia and Vertebral Compression Fractures, including the indications, techniques, complications, and evidence surrounding vertebroplasty and kyphoplasty.
Whether you are preparing for the ABA Pain Medicine Boards, ABPM, ABIPP, FIPP, or simply looking to strengthen your interventional pain knowledge, this episode covers essential board pearls, anatomy, diagnosis, imaging findings, and treatment options.
Episode Highlights Occipital NeuralgiaTopics discussed include:
Anatomy of the greater, lesser, and third occipital nerves
C2 dorsal ramus anatomy and clinical relevance
Diagnostic criteria for occipital neuralgia
Differentiating occipital neuralgia from:
Cervicogenic headache
Migraine
Cluster headache
Tension headache
Physical examination findings
Occipital nerve blocks
Pulsed radiofrequency ablation
Cryoneurolysis
Peripheral nerve stimulation (PNS)
Board PearlThe greater occipital nerve originates from the dorsal ramus of C2 and temporary pain relief following a diagnostic occipital nerve block strongly supports the diagnosis.
Vertebral Compression FracturesTopics reviewed include:
Osteoporotic vertebral compression fractures
Thoracolumbar fracture patterns
MRI findings
STIR sequence interpretation
Patient selection for vertebral augmentation
Conservative treatment versus intervention
Vertebroplasty technique
Kyphoplasty technique
Cement leakage and other complications
Evidence supporting vertebral augmentation procedures
Board PearlBone marrow edema on MRI STIR imaging is one of the most important findings suggesting an acute compression fracture.
Kyphoplasty vs Vertebroplasty VertebroplastyDirect injection of PMMA cement into the vertebral body
Stabilizes micro-motion within the fracture
Can provide rapid pain relief
KyphoplastyBalloon tamp creates a cavity before cement placement
May partially restore vertebral body height
May reduce risk of cement extravasation
Often preferred in selected patients with significant vertebral collapse
Commonly Tested ComplicationsCement leakage
Pulmonary cement embolism
Adjacent level fractures
Infection
Neurologic injury (rare)
High-Yield ABA Pain Medicine KeywordsOccipital Neuralgia
Greater Occipital Nerve
C2 Dorsal Ramus
Third Occipital Nerve
Cervicogenic Headache
Peripheral Nerve Stimulation
Vertebral Compression Fracture
Kyphoplasty
Vertebroplasty
PMMA Cement
STIR MRI
Osteoporosis
Cement Extravasation
Upcoming Educational Meetings & Conferences 2026 ASPN Annual Meeting – MiamiLearn more about the upcoming meeting hosted by the American Society of Pain and Neuroscience:
📍 ASPN Annual Conference & Miami Meeting Information
PainWeek 2026 – Las VegasJoin thousands of pain physicians, APPs, nurses, and industry professionals at:
📍 PAINWeek Las Vegas 2026
Latin American Pain Society Meeting – BrazilFor information regarding the upcoming regional pain meeting in Brazil:
📍 Latin American Pain Federation (FEDELAT) Information
CME, Ultrasound & Board Review Resources NRAP AcademyCME Courses, Virtual Pain Fellowship, Ultrasound Workshops, Regenerative Medicine Training, and Board Review Programs:
📍 NRAP Academy Website
CME CalendarUpcoming Ultrasound Workshops, Regenerative Medicine Courses, Board Review Programs, and Conferences:
📍 NRAP Academy CME Calendar
Virtual Pain FellowshipComprehensive longitudinal pain management education:
📍 Virtual Pain Fellowship Program
Pain Management Board ReviewPrepare for:
ABA Pain Medicine Boards
ABPM
ABIPP
FIPP
📍 PainExam Board Review Resources
Connect With Dr. David Rosenblum Patients Seeking CareAppointments and consultation requests:
📍 AABP Integrative Pain Care & Wellness
Physician EducationCME, Ultrasound Training, Regenerative Medicine, and Board Review:
📍 NRAP Academy
ReferencesMargetis K, Patel A, Petrone B, et al. Percutaneous Vertebroplasty and Kyphoplasty. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Updated April 6, 2025. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK525963/Daher M, Kreichati G, Kharrat K, Sebaaly A.
Vertebroplasty versus Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures: A Meta-Analysis.
World Neurosurgery. 2023;171:65-71.Masala S, Fiori R, Massari F, Simonetti G.
Kyphoplasty: Indications, Contraindications and Technique.
Radiologia Medica.
2005;110(1-2):97-105.Headache Classification Committee of the International Headache Society (IHS).
International Classification of Headache Disorders (ICHD-3).
Cephalalgia. 2018.Bogduk N.
Subscribe to the PainExam Podcast
The Clinical Anatomy of the Cervical Dorsal Rami.
Spine-related anatomy and occipital nerve pain syndromes.For weekly board review content, ultrasound-guided procedures, regenerative medicine updates, pain medicine literature reviews, and expert interviews, subscribe to the PainExam Podcast and visit:
📍 PainExam Podcast & Board Review Resources
🎓 Earn CME and advance your skills through the NRAP Academy and Virtual Pain Fellowship.
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🎙️ PainExam Podcast Show Notes CRPS & Intrathecal Pain Pumps — High-Yield ABA Pain Board Review 🔥 Episode Overview
In this episode of the PainExam Podcast, David Rosenblum reviews two essential ABA Pain Medicine Board topics:
Complex Regional Pain Syndrome (CRPS) Intrathecal Drug Delivery Systems (Pain Pumps)This episode focuses on:
High-yield board pearls Clinical decision-making Interventional treatment strategies Common exam pitfallsWhether you are preparing for the:
ABA Pain Medicine Boards ABPM ABIPP FIPP—or looking to sharpen your interventional pain knowledge—this episode delivers practical and testable concepts.
🧠 Topic 1: Complex Regional Pain Syndrome (CRPS) 🔬 What is CRPS?CRPS is a chronic neuropathic pain condition characterized by:
Disproportionate pain Autonomic dysfunction Sensory abnormalities Motor and trophic changes 📋 CRPS Types CRPS Type I No confirmed nerve injury Formerly "Reflex Sympathetic Dystrophy" CRPS Type II Confirmed nerve injury Formerly "Causalgia" ⚠️ PathophysiologyCRPS involves:
Peripheral sensitization Central sensitization Sympathetic dysfunction Neurogenic inflammation Cortical reorganization 🩺 High-Yield Clinical Features Burning pain Allodynia Hyperalgesia Temperature asymmetry Skin color changes Edema Weakness and trophic changes 📚 Budapest Criteria (BOARD FAVORITE)Diagnosis requires:
Continuing pain disproportionate to injury Symptoms in ≥3 categories Signs in ≥2 categories 💊 Treatment First-Line Physical therapy (MOST important) Early mobilization Medications Gabapentin Pregabalin TCAs Interventional Sympathetic blocks Spinal cord stimulation 🚨 Board Pearls Early treatment improves outcomes CRPS may spread beyond the initial site Immobilization worsens symptoms 💉 Topic 2: Intrathecal Drug Delivery Systems (Pain Pumps) 🔬 What Are Intrathecal Pumps?Intrathecal pumps deliver medications directly into the CSF, allowing:
Lower systemic doses Better analgesia Reduced systemic side effects 🎯 Indications Failed back surgery syndrome Cancer pain Refractory neuropathic pain Severe chronic pain not responsive to conservative therapy 💊 Common Intrathecal Medications Opioids Morphine Hydromorphone Non-Opioid Ziconotide Other Baclofen (spasticity) ⚠️ Ziconotide — HIGH-YIELD BOARD PEARLZiconotide:
Blocks N-type calcium channels Does NOT cause respiratory depression Can cause psychiatric side effects ⚠️ Major Complications Infection Catheter malfunction Pump failure Withdrawal syndromes Catheter-tip granuloma formation 🚨 Granuloma FormationHigh-dose intrathecal opioids may cause:
Catheter-tip inflammatory masses Cord compression Neurologic deficits 📋 TrialingPatients typically undergo:
Bolus trial Continuous infusion trialbefore permanent implantation.
🎯 Board Pearls Ziconotide = no respiratory depression Pump failure can cause life-threatening withdrawal Granulomas are associated with opioid concentration 📝 High-Yield Board Takeaways CRPS Budapest criteria = critical Early PT = first-line Autonomic dysfunction = hallmark Intrathecal Pumps Ziconotide is highly testable Know granuloma risks Understand pump complications and withdrawal 🎓 Pain Board Prep ResourcesPrepare for your ABA Pain Medicine boards with:
👉 https://painexam.com
🏆 Why Physicians Choose NRAP Academy Comprehensive board prep High-yield MCQs Virtual Pain Fellowship Ultrasound-guided pain training Interventional pain education 🎤 Upcoming Training
👉 https://nrappain.orgJoin upcoming:
Ultrasound-guided procedure workshops Regenerative medicine courses Pain board review sessions 📢Register today!If you're serious about:
✅ Passing your pain boards
✅ Mastering interventional pain
✅ Improving patient outcomesSubscribe to the PainExam Podcast and join the Virtual Pain Fellowship.
👉 https://nrappain.org
👉 https://painexam.comReference
https://dontforgetthebubbles.com/complex-regional-pain-syndrome/
https://www.ncbi.nlm.nih.gov/books/NBK459151/
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🎙️ PainExam Podcast Show Notes Corticosteroids & Contrast Agents in Pain Management + Evidence-Based Steroid Selection 🔥 Episode Overview
In this high-yield episode of the PainExam Podcast, David Rosenblum breaks down a must-know board topic:
👉 Injectable corticosteroids vs contrast agents in interventional pain procedures
This episode goes beyond basics and dives into:
Particulate vs non-particulate steroids Comparative profiles of dexamethasone, betamethasone, triamcinolone, and methylprednisolone Contrast agent selection and safety Critical complications including embolization and neurotoxicity A recent study comparing steroid effectiveness in transforaminal epidural injectionsThis is essential for physicians preparing for the ABA Pain Medicine boards and for clinicians performing spine interventions.
🧠 Core Concept Corticosteroids = therapeutic (reduce inflammation) Contrast agents = diagnostic + safety tools (confirm needle placement)👉 Board pearl:
💉 Corticosteroids — High-Yield Comparison 🔬 Mechanism Inhibit phospholipase A2 Reduce inflammatory mediators Decrease nerve root irritation ⚖️ Key Steroids Compared Steroid Type Particle Profile Key Advantage Major Risk Dexamethasone Non-particulate No aggregation Safest for TFESI Possibly shorter duration Triamcinolone Particulate Large particles Longer depot effect Embolic infarction Methylprednisolone Particulate Aggregates Strong anti-inflammatory Avoid in cervical TFESI Betamethasone Mixed Depends on formulation Potent Acetate = particulate risk 🚨 Major Steroid Risks
Steroids treat pain — contrast prevents complicationsLocal:
Tissue atrophy DepigmentationSystemic:
Hyperglycemia Adrenal suppression ImmunosuppressionCatastrophic (Board Tested):
Spinal cord infarction Stroke👉 Caused by intra-arterial injection of particulate steroids
📊 Contrast Agents — High-Yield Review Common Agents Iohexol (Omnipaque) Iopamidol (Isovue) Iodixanol (Visipaque) 🎯 Purpose Confirm needle placement Detect intravascular injection Prevent intrathecal injection ⚠️ Risks Allergic reaction Anaphylaxis Contrast-induced nephropathy👉 Board pearl:
⚠️ Critical Safety Topic: Gadolinium
Shellfish allergy ≠ contrast allergyGadolinium-based contrast agents are:
❌ NOT approved for epidural or intrathecal use
🚨 Intrathecal Gadolinium Risks Encephalopathy Seizures Respiratory distress Death
❌ NOT safe substitutes for iodinated contrast in spine procedures👉 Extremely high-yield board concept
📚 Evidence-Based Medicine Segment Study Review: Steroid Selection in TFESIA recent study comparing:
Dexamethasone Methylprednisolone Betamethasone 🔑 Key Findings Dexamethasone showed comparable or better outcomes No clear advantage of particulate steroids Similar rates of: Repeat injections Surgical progression 🎯 Clinical Implication👉 Efficacy differences are smaller than previously thought
🚨 Board-Level Takeaway Non-particulate steroids = safer Outcomes ≈ similar Technique matters more than steroid choice
👉 Safety is driving practice change👉 Best exam answer: dexamethasone for TFESI
🎯 Board Prep Summary Dexamethasone = safest for transforaminal injections Particulate steroids = embolic risk Contrast must be used before steroid injection Gadolinium = dangerous in neuraxial space Clinical outcomes often similar across steroid types 🎓 Pain Board Prep ResourcesPrepare for your ABA Pain Medicine boards with:
👉 https://painexam.com
🏆 Why Physicians Choose NRAP Academy High-yield board review content Thousands of MCQs Virtual Pain Fellowship Ultrasound + regenerative training Real-world clinical integration
👉 https://nrappain.orgRegister Today!
🎤 Upcoming Training Ultrasound-guided pain procedures Regenerative medicine courses (PRP, biologics) Hands-on workshopsRegister Today!
📢 Call to ActionIf you're serious about passing your boards and practicing safer interventional pain medicine:
✅ Subscribe to the PainExam Podcast
✅ Join the Virtual Pain Fellowship
✅ Visit https://nrappain.orgReferences
Calvo N, Jamil M, Feldman S, Shah A, Nauman F, Ferrara J. Neurotoxicity from intrathecal gadolinium administration: Case presentation and brief review. Neurol Clin Pract. 2020 Feb;10(1):e7-e10. doi: 10.1212/CPJ.0000000000000696. PMID: 32190427; PMCID: PMC7057078.
Moreira, Alexandra M., et al. "Comparing the effectiveness and safety of dexamethasone, methylprednisolone and betamethasone in lumbar transforaminal epidural steroid injections." Pain physician 27.5 (2024): 341.
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🎙️ AnesthesiaExam Podcast & Video Show Notes Spine Pain, Facet Syndromes, and Interventional Concepts for the Anesthesia Boards 🔥 Episode Overview
In this episode of the AnesthesiaExam Podcast, David Rosenblum delivers a high-yield, board-focused review of spine pain concepts every anesthesiologist must know:
Lumbar, cervical, and thoracic facet-mediated pain Key anatomy and spinal innervation patterns Medial branch blocks and radiofrequency ablation (RFA) Important clinical correlations for anesthesia and pain boardsThis episode bridges the gap between anesthesiology board knowledge and real-world interventional pain practice.
🧠 Key Topics Covered 🦴 Facet-Mediated Spine Pain Common cause of axial back and neck pain Mechanical pain pattern: Worse with extension Improved with flexion 🔬 High-Yield Anatomy for Boards Dual innervation of facet joints L5–S1 facet → L5 dorsal ramus (classic exam question) C2–3 facet → third occipital nerve 💉 Diagnostic & Interventional Concepts Diagnosis via medial branch blocks (MBB) RFA for longer-term pain relief Understanding procedural anatomy is key for: Regional anesthesia Pain procedures Board exams ⚡ Why This Matters for Anesthesia BoardsEven if you don't perform interventional pain procedures, these concepts are critical for:
Spine anatomy questions Regional anesthesia understanding Pain management scenarios Oral boards and OSCE-style cases 🎯 Board Prep Takeaways Facet pain = axial, mechanical Dual innervation = high-yield test concept L5 dorsal ramus = commonly tested Understand difference between: Radicular vs axial pain Facet vs discogenic pain 🎓 Anesthesia Board Prep ResourcesIf you're preparing for the ABA Anesthesiology boards, start here:
👉 AnesthesiaExam Board Review Platform:
https://nrappain.org👉 Full Question Bank + Lecture Series:
https://nrappain.org👉 Pain + Anesthesia Integrated Learning:
🏆 Why Anesthesiologists Choose NRAP Academy Comprehensive ABA anesthesiology board prep Integrated pain + anesthesia curriculum High-yield MCQs and rapid review lectures Ultrasound and regional anesthesia content Real-world clinical correlations 🎤 Live Courses & Advanced Training
https://painexam.comEnhance your skills beyond the boards:
Ultrasound-guided regional anesthesia courses Pain + regenerative medicine workshops Hands-on training for real clinical application 🔗 Connect & Learn More 🌐 NRAP Academy: https://nrappain.org 📚 PainExam: https://painexam.com 🎥 YouTube: NRAP Academy 🎓 Courses: Ultrasound + Regional Anesthesia 📢 Call to ActionIf you're serious about passing your anesthesia boards and mastering pain + regional techniques:
✅ Subscribe to the AnesthesiaExam Podcast
✅ Join the NRAP Board Review Platform
✅ Explore advanced training courses -
🎙️ PainExam Podcast Show Notes Phantom Limb Pain & Sacroiliac Joint Dysfunction — High-Yield Pain Board Review 🔥 Episode Overview
In this episode of the PainExam Podcast, David Rosenblum delivers a high-yield review of two must-know topics for the ABA Pain Medicine Board Certification exam:
Phantom Limb Pain — mechanisms, risk factors, and advanced treatment strategies Sacroiliac (SI) Joint Dysfunction — diagnosis, provocative testing, and interventional managementWhether you're preparing for the ABA, ABPM, ABIPP, or FIPP boards, or looking to sharpen your clinical practice, this episode focuses on testable concepts, real-world applications, and interventional pearls.
👉 Explore full board prep and CME: PainExam.com
🧠 Topic 1: Phantom Limb Pain — Key PointsPhantom limb pain is a neuropathic pain syndrome following amputation, driven by both peripheral and central mechanisms.
High-Yield Pearls Caused by cortical reorganization + central sensitization Strongly associated with pre-amputation pain Distinct from: Phantom sensation (non-painful) Stump pain (localized) Clinical Features Burning, cramping, or electric pain Perceived in the missing limb May be triggered by stress or environmental factors Treatment Strategies First-line: gabapentinoids, TCAs Advanced: ketamine, neuromodulation Key non-pharmacologic therapy: mirror therapy 🚨 Board PearlPreemptive analgesia reduces the risk of phantom limb pain
🦴 Topic 2: Sacroiliac Joint Dysfunction — Key PointsSI joint dysfunction is a major cause of axial low back pain, accounting for up to 25% of cases.
High-Yield Pearls Pain is typically: Unilateral Buttock-dominant Radiates to posterior thigh (rarely below knee) Physical Exam Positive provocative tests: FABER Gaenslen Thigh thrust Compression👉 3 or more positive tests = high diagnostic accuracy
Diagnosis Confirmed with image-guided intra-articular injection Imaging alone is NOT diagnostic Treatment Physical therapy SI joint injections Lateral branch RFA SI joint fusion (refractory cases) 🚨 Board PearlDiagnostic SI joint injection is the gold standard
🎯 Board Prep Takeaways Always distinguish central vs peripheral mechanisms in neuropathic pain Know diagnostic confirmation strategies (blocks vs imaging) Focus on first-line vs interventional escalation pathways Understand procedure indications for boards 🎓 Upcoming Events & Live Training 🏆 ASPN 2026 Annual MeetingJoin Dr. Rosenblum for:
Ultrasound-guided peripheral nerve blocks Spine interventions Regenerative medicine techniques (PRP, biologics) Hands-on procedural training 💉 Ultrasound-Guided Regenerative Medicine CourseLearn:
PRP injection techniques Ultrasound-guided joint and nerve procedures Real-world workflows for integrating regenerative medicine into your practice👉 Hosted through NRAP Academy
🎤 PainWeek 2026 LecturesDr. Rosenblum will be presenting on:
Precision image-guided pain procedures Ultrasound integration in clinical practice Regenerative medicine in interventional pain Future directions: AI and neuromodulation 🔗 Resources 🌐 Pain Board Review: PainExam.com 🎓 Courses & CME: NRAPPain.org 📺 YouTube: NRAP Academy 🧠 Question Bank + Virtual Fellowship: Available now 📢 Call to ActionIf you're preparing for the pain boards or want to elevate your clinical skillset:
✅ Subscribe to the PainExam Podcast
✅ Join our Virtual Pain Fellowship
✅ Attend a live ultrasound or regenerative medicine course -
PainExam Podcast Show Notes Red Light Therapy (Photobiomodulation) for Pain Evidence, Mechanisms, and Clinical Applications
Host: Dr. David Rosenblum
Red light therapy, also known as photobiomodulation (PBM) or low-level laser therapy (LLLT), is an emerging non-invasive treatment modality increasingly used in pain medicine, rehabilitation, and regenerative medicine practices.
In this episode of the PainExam Podcast, Dr. Rosenblum reviews the mechanisms, clinical evidence, indications, and safety considerations surrounding photobiomodulation therapy for pain.
Red and near-infrared wavelengths stimulate mitochondrial activity, increase ATP production, reduce inflammatory mediators, and promote tissue healing. These physiologic effects may translate into analgesic benefits for a variety of musculoskeletal and neuropathic pain conditions.
Clinical research suggests potential benefit in temporomandibular disorders, chronic neck pain, and inflammatory oral conditions, though results vary due to differences in dosing parameters and treatment protocols.
Despite these limitations, PBM has a favorable safety profile and is increasingly being integrated into multimodal pain management strategies.
Key Topics Covered• What is photobiomodulation therapy (PBM)
Mechanism of Action
• How red and near-infrared light interact with mitochondria
• Mechanisms of analgesia and tissue repair
• Evidence from clinical trials in TMD, neck pain, and oral inflammatory pain
• The biphasic dose response (Arndt-Schulz law)
• Safety profile and contraindications
• How PBM may integrate with regenerative pain medicinePhotobiomodulation works primarily through stimulation of mitochondrial chromophores, particularly cytochrome c oxidase.
This leads to:
• Increased ATP production
• Modulation of inflammatory cytokines
• Increased angiogenesis and tissue repair
• Reduced oxidative stressThese effects may improve pain, inflammation, and healing in certain musculoskeletal conditions.
Evidence Discussed in This Episode Temporomandibular DisordersRandomized trial demonstrating improvements in pain and mandibular function with red light therapy.
De Carvalho et al., Pain Research and Treatment (2019)
Chronic Neck Pain
https://onlinelibrary.wiley.com/doi/full/10.1155/2019/8578703Clinical trial demonstrating improvements in pain scores and pressure pain thresholds after photobiomodulation therapy.
Chen et al., Lasers in Medical Science (2022)
Oral Pain and Dental Inflammation
https://link.springer.com/article/10.1007/s10103-022-03540-0Randomized study demonstrating reduced pain and improved healing following PBM treatment.
Almeida et al., BMC Oral Health (2023)
Who May Benefit From Photobiomodulation?
https://link.springer.com/article/10.1186/s12903-023-02784-8Red light therapy may be considered as an adjunct treatment for:
• myofascial pain
Safety and Contraindications
• cervical spine pain
• temporomandibular disorder
• tendinopathy
• peripheral neuropathy
• musculoskeletal injury recoveryPhotobiomodulation has a very favorable safety profile.
Reported adverse effects are rare and usually mild:
• transient erythema
• warmth at treatment site
• headache
• eye irritation without proper protectionPrecautions include:
• avoiding direct retinal exposure
Resources For Patients Seeking Treatment
• avoiding treatment over malignancy
• avoiding application over the uterus during pregnancy
• caution in photosensitive disordersLearn more about integrative and regenerative pain treatments including PRP, ultrasound-guided injections, and advanced pain therapies:
AABP Integrative Pain Care & Wellness
For Pain Physicians and Advanced Practice Providers
https://www.AABPpain.comTraining in ultrasound, interventional pain procedures, and pain board preparation:
NRAP Academy CME Education
https://www.NRAPpain.org -
Dr. Rosenblum from NRAP Academy presented a webinar on the integration of regenerative medicine into pain practices, highlighting its benefits and applications. He discussed the evolution of treating pain, emphasizing the shift from neural blockade to addressing tissue health. Dave explained the use of PRP and BMAC in treating conditions like knee pain, and shared patient success stories. He addressed common misconceptions about regenerative medicine, including its cost and effectiveness. Dave also mentioned upcoming events and training opportunities in regenerative medicine.
Regenerative Medicine Pain Management EventsDr. Rosenblum announced his upcoming involvement in two significant events: a webinar on regenerative medicine for ASIPP and co-directing the ASPN Ultrasound and Regenerative Medicine Pain Workshop in Miami with Dr. Ali Valimoed. He encouraged attendees to register for these events, emphasizing their importance in the field of pain management. He also mentioned a previous lecture he gave on the integration of regenerative medicine into pain practices, though the recording was not successful.
Regenerative Medicine in Pain PracticesDr. Rosenblum discussed the integration of regenerative medicine into pain practices, emphasizing its importance in 2026 and beyond. He explained that traditional approaches like steroids and RFA only manage pain without addressing tissue health, using the knee as an example. He suggested combining visco supplements with regenerative techniques like PRP or BMAC to preserve joints in patients seeking alternatives to knee replacement. He noted that while other stem cell products are promising, more research is needed for wider adoption, and he plans to focus on PRP and BMAC for now.
Regenerative Medicine Patient EducationDr. Rosenblum discussed the importance of educating patients about regenerative medicine and pain treatment options. He explained that while regenerative treatments cannot fully reverse severe issues like meniscus damage, they can help heal and repair tissues, reduce inflammation, and improve function. He highlighted the growing demand for non-surgical, opiate-sparing solutions and mentioned the role of government and physician-led campaigns in addressing the opiate crisis.
PRP's Role in Chronic Pain ManagementDr. Rosenblum discussed the growing demand for alternative treatments to opioids and surgeries, highlighting the role of Platelet-Rich Plasma (PRP) in addressing chronic pain by modulating inflammation and stimulating tissue repair. He emphasized the importance of using high-quality PRP preparation methods, such as a double-spin kit, to achieve optimal results, and criticized studies claiming PRP's ineffectiveness, often due to poor preparation techniques. David also noted that effective PRP treatments can improve pain and function better than corticosteroids, and he expressed hope that patients would refer others, leading to business growth.
PRP Therapy: A Promising AlternativeDr. Rosenblum discussed the effectiveness of PRP (platelet-rich plasma) therapy compared to steroids and viscosupplements in treating various musculoskeletal conditions. He cited a meta-analysis showing that PRP provided better relief than steroid and viscosupplement treatments for patients with moderate arthritis after one year. David also shared a recent case where he used PRP to treat coccydynia, a condition involving pain in the coccyx, and mentioned its potential use in treating other conditions such as radiculopathy and foraminal stenosis.
PRP Injection Treatment FlexibilityDr. Rosenblum discussed a medical procedure involving PRP and lidocaine injections in various areas of the body, including the coccygeal ligaments, caudal space, and transforaminal spaces, to address pain and inflammation. He emphasized the importance of tailoring treatment to individual patients rather than adhering to insurance company guidelines, which can limit the number of injections given in a single session. David highlighted that when patients pay out-of-pocket, practitioners have more flexibility to effectively treat their conditions, potentially avoiding surgery or improving post-surgical outcomes.
PRP in Orthopedic PracticeDr. Rosenblum shared his experience treating a patient with PRP for post-operative knee surgery, despite the orthopedic surgeon's skepticism. He discussed how regenerative medicine can enhance a practice by positioning it as innovative and attracting younger patients who prefer non-surgical treatments. David noted that while some orthopedic surgeons may refer patients for PRP, others might be hesitant due to potential decreases in surgical procedures. He also mentioned that primary care doctors may not be aware of the growing evidence supporting PRP's effectiveness and safety.
PRP: A Cost-Effective AlternativeDr. Rosenblum discussed regenerative medicine, particularly PRP, highlighting its potential to avoid surgeries and improve patient satisfaction with an estimated 70% success rate. He emphasized the financial benefits for physicians, as it provides a cash stream with no need for prior authorizations or denials. David also addressed patient responsibility in healthcare costs, comparing the cost of regenerative treatments to other lifestyle expenses. He noted that while training is necessary, most interventional pain physicians possess the skills to administer PRP treatments.
PRP Treatment Success StoriesDr. Rosenblum shared patient testimonials highlighting successful outcomes from PRP (platelet-rich plasma) treatments for various pain conditions, including shoulder, back, and neck issues. Patients reported significant improvements in pain relief and mobility, with some noting long-lasting effects beyond cortisone shots or surgery. David emphasized the importance of individualized treatment approaches and quality care, encouraging both patients and physicians to reach out for training and consultations. He concluded by inviting listeners to share the content with colleagues and patients, emphasizing the value of PRP treatments when done correctly.
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Peptides in Pain Management: BPC-157, Risks, Reality, and the Business of Regenerative Medicine
Episode Length: ~12–15 minutes
🧠 Episode Overview
Target Audience: Pain physicians, anesthesiologists, PM&R, sports medicine, and regenerative medicine clinicians
Hosted by: Dr. David Rosenblum, MD
Produced by: PainExam | NRAP AcademyPeptides like BPC-157 have exploded in popularity across regenerative medicine, sports medicine, and cash-based pain practices — but does the science support the hype?
In this episode of PainExam, Dr. David Rosenblum takes a critical, evidence-based look at BPC-157 and other peptidesin pain management, examining:
The biological rationale behind peptide therapy
Preclinical and early human evidence for pain and tissue healing
Regulatory status and safety concerns
Ethical, legal, and marketing risks for physicians
How peptides are currently being incorporated — and monetized — in pain practices
This episode is designed to help clinicians separate science from marketing, and to approach peptide therapies with appropriate caution and professionalism.
⏱️ Episode Breakdown 🔹 00:00–01:30 — IntroductionWhy peptides are trending in pain and regenerative medicine
What patients are asking — and what physicians need to know
🔹 01:30–04:30 — What Is BPC-157?Origins of Body Protection Compound-157
Mechanisms: angiogenesis, inflammation modulation, tissue repair
Summary of preclinical data and animal pain models
🔹 04:30–07:00 — Evidence for Pain Relief & HealingEarly inflammatory and non-inflammatory pain studies
Intra-articular BPC-157 for knee pain: what the case series showed
Why current human data are hypothesis-generating, not definitive
🔹 07:00–09:30 — Risks, Unknowns & Regulatory IssuesFDA status and investigational use
Quality, purity, and dosing variability
Theoretical biologic risks and drug interactions
🔹 09:30–12:30 — The Business of Peptides in Pain PracticeHow peptides are marketed in regenerative clinics
Cash-based models and patient demand
Ethical marketing, informed consent, and medicolegal exposure
🔹 12:30–End — Clinical TakeawaysWhere peptides fit — and don't fit — in current pain practice
Why evidence still matters in regenerative medicine
⚠️ Key Clinical TakeawaysBPC-157 shows promising preclinical data, but human evidence remains limited
Current studies lack randomization, controls, and long-term outcomes
Peptides are not FDA-approved for pain or musculoskeletal indications
Marketing peptides without transparency poses ethical and legal risk
Physicians must clearly distinguish experimental therapies from standard of care
📚 Key References DiscussedJózwiak et al. Multifunctionality and Possible Medical Application of BPC-157 — MDPI Pharmaceuticals (2025)
McGuire et al. Regeneration or Risk? A Narrative Review of BPC-157 — Current Reviews in Musculoskeletal Medicine (2025)
Sikirić et al. Effects of BPC-157 on Inflammatory and Non-Inflammatory Pain — Inflammopharmacology (1993)
Lee & Padgett. Intra-Articular Injection of BPC-157 for Knee Pain — Alternative Therapies in Health and Medicine (2021)
📢 Sponsored Message / Advertisement 🔔 Ready to Master Evidence-Based Pain Medicine?If you're preparing for Pain Medicine boards or looking to strengthen your foundation in interventional and regenerative pain management, check out the educational resources at:
👉 https://www.nrappain.org
🎓 Offered through NRAP Academy:✅ PainExam® Pain Management Board Review
✅ ABA, ABPM, FIPP, and ABIPP exam preparation
✅ Ultrasound-guided pain procedure training
✅ Regenerative pain medicine education — grounded in evidence, not hype
✅ Virtual Pain Fellowship curriculum
All content is designed by practicing pain physicians, for practicing pain physicians.
🎯 Why Learn with NRAP Academy?Evidence-driven, board-relevant education
Practical clinical insights you can apply immediately
Trusted by physicians nationwide
Focused on ethical, safe, and effective pain care
👉 Explore courses and upcoming programs at
🎧 Subscribe & Stay Sharp
https://www.nrappain.orgIf you found this episode helpful:
Subscribe to the PainExam Podcast
Share it with a colleague
Leave a review to help other pain physicians find evidence-based content
Disclaimer:
This podcast is for educational purposes only. Discussion of investigational therapies does not constitute endorsement or clinical recommendation. Physicians should follow applicable laws, regulations, and professional guidelines when considering experimental treatments.References
Lee, Edwin, and Blake Padgett. "Intra-Articular Injection of BPC 157 for Multiple Types of Knee Pain." Alternative Therapies in Health & Medicine 27.4 (2021).
Józwiak, Michalina, et al. "Multifunctionality and Possible Medical Application of the BPC 157 Peptide—Literature and Patent Review." Pharmaceuticals 18.2 (2025): 185.
McGuire, F. P., Martinez, R., Lenz, A., Skinner, L., & Cushman, D. M. (2025). Regeneration or risk? A narrative review of BPC-157 for musculoskeletal healing. Current Reviews in Musculoskeletal Medicine, 18(12), 611-619.
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Meralgia Paresthetica Education and the PM&R Boards
This podcast episode from the NRAP Academy features Dr. David Rosenblum discussing Meralgia Paresthetica, a mononeuropathy affecting the lateral femoral cutaneous nerve. The condition involves entrapment or compression of this purely sensory nerve as it passes under the inguinal ligament near the anterior superior iliac spine, causing burning pain, tingling, and numbness in the anterior lateral thigh.
Key clinical points covered include the nerve's L2-3 origin from the lumbar plexus, common causes such as obesity, tight clothing, pregnancy, and diabetes, and the absence of motor weakness or reflex changes. Diagnosis is primarily clinical, though ultrasound can visualize nerve entrapment effectively.
Treatment approaches range from conservative management including weight loss, avoiding tight clothing, physical therapy, and neuropathic pain medications (gabapentinoids, duloxetine, tricyclics) to interventional procedures. Dr. Rosenblu strongly advocates for ultrasound-guided nerve blocks over fluoroscopic or blind approaches, citing better visualization and reduced risk of nerve trauma. Advanced treatments mentioned include peripheral neuromodulation and cryoablation for refractory cases.
The episode emphasizes that this condition is commonly tested on pain management board examinations (ABA, ABPM, FIPP, osteopathic boards) and can be significantly more painful and disabling than typically appreciated.
Upcoming Courses and Training Opportunities:
Ultrasound training available at nrappain.org Regenerative medicine training courses Comprehensive PM&R Question Bank for Pain Management board preparation covering ABA, ABPM, FIPP, and osteopathic examinations CME credits available through the platform Clinical consultation services available at Dr. Rosenblum's Brooklyn office for patients seeking treatment Meralgia Paresthetica Education and Clinical Guidance Overview: Focused on definition, anatomy, diagnosis, management, and board exam relevance for meralgia paresthetica. Anatomy and Pathophysiology: Nerve: lateral femoral cutaneous nerve (sensory only), typically arising from L2–L3. Course: traverses across the iliacus, passes under or through the inguinal ligament just medial to the ASIS, then enters the thigh. Sensory distribution: anterolateral thigh; anterior cutaneous division extends toward the knee. Etiology and Risk Factors: Common contributors: obesity, tight belts or clothing, pregnancy, prolonged sitting, diabetes, prior pelvic or hip surgery. Entrapment site: under the inguinal ligament near the ASIS (most frequent). Clinical Presentation: Symptoms: burning pain, tingling, numbness, dysesthesia localized to the anterolateral thigh. Provocation/relief: worse with standing or walking; relief with sitting or hip flexion. Neurologic exam: no motor weakness; no reflex changes. Diagnosis: Primarily clinical; Tinel's sign over the inguinal ligament may reproduce symptoms. EMG and nerve conduction studies are typically normal. Ultrasound: superficial nerve, generally easy to visualize, including in obese patients; can identify entrapment. Management Recommendations: First-line conservative care: weight loss; avoidance of tight belts/clothing; physical therapy; NSAIDs for inflammation. Pharmacologic options: gabapentin, pregabalin, duloxetine, tricyclic antidepressants; consider topical analgesic creams (e.g., lidocaine or anti-inflammatory combinations). Interventional approach: Ultrasound-guided nerve block is strongly recommended; the nerve lies lateral to the sartorius; real-time visualization enables precise, safe injection. Avoid fluoroscopic and blind approaches due to risk of further nerve trauma and post-procedure pain. Advanced interventions: Peripheral neuromodulation may provide benefit in select cases. Cryoablation has shown beneficial outcomes for the lateral femoral cutaneous nerve. Surgery is rarely required; options include neurolysis, decompression, or neurectomy as a last resort. Board Exam Preparation Emphasis: Key facts commonly tested: Involved nerve: lateral femoral cutaneous nerve. Nerve roots: L2–L3 (with population variants). Sensory-only nerve; absence of motor deficits. Compression site: under the inguinal ligament near the ASIS. First-line therapy: conservative measures; refractory cases: ultrasound-guided nerve block. Keywords to study: meralgia paresthetica; lateral femoral cutaneous nerve (also called lateral cutaneous nerve of the thigh). Practice Considerations: Severity: can be profoundly painful and disabling; often underappreciated. Referral: clinicians not trained in interventional techniques should refer patients to an interventionalist for diagnosis and treatment. Decisions and Recommendations Ultrasound guidance is the preferred modality for lateral femoral cutaneous nerve interventions, superseding fluoroscopic or blind approaches. Rationale: superior visualization, real-time feedback, and reduced risk of nerve trauma and post-procedural pain. Outreach and Resources NRAP Academy resources: Ultrasound training, regenerative medicine training, CME credits, and a comprehensive pain board question bank (ABA, ABPM, FIPP, osteopathic, and related exams). Clinical availability: Patient consultations for meralgia paresthetica offered in Brooklyn at www.AABPpain.com 718 436 7246 . -
🎙️ PainExam Podcast Show Notes Kratom (Mitragyna speciosa): What Pain Physicians Must Know for the Boards
In this episode, Dr. David Rosenblum reviews the current science, pharmacology, risks, and clinical relevance of Kratom — an herbal substance widely discussed by pain patients and increasingly appearing on pain-medicine board exams. The discussion focuses on evidence-based mechanisms, safety considerations, and counseling points essential for ABA/ABPM/ABIPP/FIPP board preparation.
🔍 Key Board-Relevant Takeaways 1. Pharmacology & MechanismKratom's primary alkaloids are mitragynine and 7-hydroxymitragynine.
They act as partial mu-opioid receptor agonists and demonstrate G-protein biased signaling, which may reduce β-arrestin–mediated respiratory depression seen with full opioids.
No FDA-approved medical use; pharmacokinetics and dose-response remain inconsistent.
2. Reported EffectsPotential Benefits (mostly anecdotal or preclinical):
Analgesia for chronic pain
Mood elevation and increased energy
Reduction of opioid withdrawal symptoms
Major Limitations:
No high-quality randomized controlled trials
Not a recommended analgesic for evidence-based pain practice
3. Adverse Effects & Safety ConcernsCommonly reported:
Nausea, vomiting, constipation
Tachycardia, palpitations
Hepatotoxicity in some users
Dependence and withdrawal syndrome similar to mild-moderate opioid withdrawal
Serious risks:
Product variability and contamination
Potential interactions with CNS depressants
Unpredictable potency of alkaloids
4. Regulatory StatusKratom is unregulated, with significant variability in purity and composition.
FDA and multiple public-health agencies caution against its use due to safety concerns.
Not recommended as a first-line or adjunct pain therapy.
5. What Boards Like to TestExpect questions on:
Mechanism: partial MOR agonist, G-protein bias
Differences from classical opioids
Adverse effects and withdrawal
Toxicology and contamination risks
Counseling patients who self-medicate
Lack of clinical trial data and regulatory approval
🎓 Board Prep ResourcesPrepare for the ABA, ABPM, ABIPP, FIPP, and AOBPM exams with the PainExam Board Review and full curriculum at the NRAP Academy:
🫁 Hands-On Ultrasound Training for Pain Physicians
👉 https://www.NRAPpain.orgBoost your procedural skills with live ultrasound-guided interventional pain and regional anesthesia workshops:
📚 References (Condensed)
👉 https://www.nrappain.org/pages/ultrasound-trainingKruegel AC, Grundmann O. Neuropharmacology of kratom alkaloids. Neuropharmacology.
Eastlack SC et al. Kratom: Pharmacology & clinical implications. Phytother Res.
Striley CW et al. Health effects of kratom. Front Pharmacol.
FDA Public Health Advisory on Kratom.
Educational Offerings & Learning OpportunitiesPainExam / NRAP Academy Training & Programs:
Neuromodulation & Regional Anesthesia Workshops
Ultrasound-Guided Pain Procedures
Regenerative Pain Medicine Training
Virtual Pain Fellowship
Pain Management Board Review & Question Banks
Learn More / Register:
Board Prep & Certification Support
🔹 https://PainExam.com
🔹 https://NRAPpain.orgPrepare for:
ABA Pain Boards
ABPM
ABIPP
Pain Management Board Certification Exams
(No reference to FIPP included, per request)
Access Board Prep Courses & Q-Banks:
Clinical Practice
➡️ https://PainExam.com
➡️ https://NRAPpain.orgAABP Integrative Pain Care (Brooklyn & Great Neck, NY)
About the Host – David Rosenblum, MD
To schedule a consultation or referral:
🌐 https://AABPpain.com
📞 Brooklyn: 718-436-7246Dr. Rosenblum serves as Director of Pain Management at Maimonides Medical Center and Managing Partner at AABP Integrative Pain Care in Brooklyn, NY. He is recognized as an early adopter and leading educator in ultrasound-guided pain procedures, neuromodulation, and regenerative medicine.
He has:
Developed regional anesthesia training programs
Published widely in pain medicine literature
Lectured nationally and internationally through ASIPP, ASPN, NANS, IASP, and more
Helped over 3000 physicians pass pain board exams
Hosted the PainExam, AnesthesiaExam, and PMRExam podcasts
Awards (Selected):
New York Magazine Top Doctors: 2016–2025
Top Doctors NY Metro Area: 2016–2025
Schneps Media Honors: Multiple Years
Connect with Dr. RosenblumLinkedIn: https://www.linkedin.com/in/davidrosenblummd/
Instagram: https://www.instagram.com/painexam/
Facebook: https://www.facebook.com/david.rosenblum.16
X (Twitter): https://x.com/AlgoSonic
Episode Call-to-Action✅ Join the NRAP Community
✅ Register for an Upcoming Workshop
✅ Access Pain Board Review TrainingStart here → https://NRAPpain.org | https://PainExam.com
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Caudal Epidural Steroid Injection with PRP
Case Reports and a Testimonial!
Upcoming Training Courses and Services Regional Anesthesia and IV Vascular Access Courses: New York and Detroit locations scheduled Pain Management Board PreparationPrivate Coaching Services:
Ultrasound guidance Preceptorship Board preparation coaching Contact available via email [email protected] for interested physicians PRP Caudal Epidural Research Review Study Overview: Randomized double-blind controlled pilot study comparing leukocyte-rich PRP versus corticosteroids in caudal epidural space 50 patients randomly assigned to two groups Treatment options: triamcinolone 60mg or leukocyte-rich PRP from 60ml autologous blood Follow-up assessments at 1, 3, and 6 months using VAS and SF-36 surveys Key Findings: Both treatments showed significant pain reduction compared to baseline Steroid group had lower VAS scores at one month PRP group demonstrated superior results at 3 and 6 months PRP group showed significant improvement across all SF-36 domains at 6 months No complications or adverse effects in either group during 6-month follow-up Personal Treatment Experience Dr. Rosenblum received transforaminal PRP injection 9-10 weeks ago Gradual improvement noted from weeks 4-8, with more noticeable benefits from weeks 8-10 Current status: minimal pain (0.5/10) only during weather changes Clinical Practice Philosophy Treatment Approach: Minimalist philosophy focusing on turmeric, PRP, and Pilates Medication Strategy: Low-dose naltrexone as go-to medication, avoiding long-term drugs with side effects Surgical Avoidance: Prioritizing conservative treatments over unnecessary surgical interventions Emergency Department PRP Implementation Case Study Results: Ultrasound-guided caudal epidural steroid injection in ER setting 100% pain resolution achieved Patient discharged directly from ER Cost savings: reduced from $33,000 to $4,800 (approximately $28,000 savings) Training Opportunities: Private training sessions available for ER physicians interested in ultrasound-guided procedures Patient Testimonial Highlights Case Background: Nurse with herniated disc from March, previously considering $30,000 surgery Treatment Outcome: PRP injection completed two months ago with nearly complete pain relief Reduced from multiple pain medications to one Advil daily Eliminated antalgic posture and muscle spasms Returned to full 12-hour hospital shifts without difficulty Overall quality of life restored to normal levelsDavid Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.
Awards
New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025
Schneps Media: 2015, 2016, 2017, 2019, 2020
Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025
Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023
Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!
Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.
Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators.
He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call
Brooklyn 718 436 7246
ReferenceIrvan J. Bubic, Jessica Oswald,
Ultrasound-Guided Caudal Epidural Steroid Injection for Back Pain: A Case Report of Successful Emergency Department Management of Radicular Low Back Pain Symptoms,
The Journal of Emergency Medicine,Volume 61, Issue 3,2021,Pages 293-297,ISSN 0736-4679Ruiz‐Lopez, Ricardo, and Yu‐Chuan Tsai. "A randomized double‐blind controlled pilot study comparing leucocyte‐rich platelet‐rich plasma and corticosteroid in caudal epidural injection for complex chronic degenerative spinal pain." Pain Practice 20.6 (2020): 639-646.
#prppain #paincme #sciatia #ultrasoundmsk #ultrasoundprp #epidural #nypaindoctor #prppainwindsor
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Episode Overview
In this episode, Dr. David Rosenblum discusses the role of supplements and complementary strategies in the management of chronic pain. Drawing from clinical practice at AABP Integrative Pain Care, as well as his teaching and training programs, Dr. Rosenblum reviews how nutraceuticals, regenerative therapies, ultrasound-guided procedures, and neuromodulation can work together to improve patient outcomes and reduce opioid reliance.
This episode also highlights educational opportunities and exam-prep resources for pain fellows, residents, anesthesiologists, physiatrists, and APPs looking to expand their interventional pain, ultrasound, and regenerative medicine skill sets.
Key Topics DiscussedEvidence and clinical rationale for select supplements in chronic pain management
The role of ultrasound guidance in improving accuracy and safety in interventional pain procedures
How regenerative medicine techniques such as PRP and BMAC are shaping personalized pain care
Practical considerations when combining supplements with neuromodulation, RFA, or injections
Patient case applications and real-world treatment planning
Educational Offerings & Learning OpportunitiesPainExam / NRAP Academy Training & Programs:
Neuromodulation & Regional Anesthesia Workshops
Ultrasound-Guided Pain Procedures
Regenerative Pain Medicine Training
Virtual Pain Fellowship
Pain Management Board Review & Question Banks
Learn More / Register:
www.AABPpain.com
Board Prep & Certification Support
🔹 https://PainExam.com
🔹 https://NRAPpain.orgPrepare for:
ABA Pain Boards
ABPM
ABIPP
Pain Management Board Certification Exams
(No reference to FIPP included, per request)
Access Board Prep Courses & Q-Banks:
Clinical Practice
➡️ https://PainExam.com
➡️ https://NRAPpain.orgAABP Integrative Pain Care (Brooklyn & Great Neck, NY)
About the Host – David Rosenblum, MD
To schedule a consultation or referral:
🌐 https://AABPpain.com
📞 Brooklyn: 718-436-7246Dr. Rosenblum serves as Director of Pain Management at Maimonides Medical Center and Managing Partner at AABP Integrative Pain Care in Brooklyn, NY. He is recognized as an early adopter and leading educator in ultrasound-guided pain procedures, neuromodulation, and regenerative medicine.
He has:
Developed regional anesthesia training programs
Published widely in pain medicine literature
Lectured nationally and internationally through ASIPP, ASPN, NANS, IASP, and more
Helped over 3000 physicians pass pain board exams
Hosted the PainExam, AnesthesiaExam, and PMRExam podcasts
Awards (Selected):
New York Magazine Top Doctors: 2016–2025
Top Doctors NY Metro Area: 2016–2025
Schneps Media Honors: Multiple Years
Connect with Dr. RosenblumLinkedIn: https://www.linkedin.com/in/davidrosenblummd/
Instagram: https://www.instagram.com/painexam/
X (Twitter): https://x.com/AlgoSonic
Practical Takeaways Evidence strength varies widely; preclinical support is more robust than human RCT data for most supplements. Potentially reasonable adjuncts in select contexts Vitamin D: plausible benefit in deficiency states, including diabetic neuropathy and chronic pain-related quality-of-life factors; confirm deficiency and monitor. Magnesium: consider IV regimens for refractory neuropathic components (e.g., cancer pain, PHN); oral efficacy uncertain. Curcumin: consider as adjunct, especially formulated phytosome combinations; monitor for additive effects and tolerability. B vitamins: consider B12 in deficiency or neuropathy with suspected demyelination; overall human evidence limited. Zinc: mechanistic rationale with preclinical support; limited human data—consider deficiency correction rather than supraphysiologic dosing. Cautions and contraindications St. John's wort: significant drug–drug interaction potential via CYP/P-gp induction. Alpha lipoic acid: may cause hypoglycemia; monitor glucose, especially in diabetes. Agent-specific toxicity thresholds should guide safe upper limits; prioritize lab-confirmed deficiencies. Risks, Limitations, and Research Gaps Heterogeneity in study designs, small samples, lack of controls, and multi-ingredient formulations limit causal inference. Need for large, well-designed RCTs stratified by neuropathic pain etiology (e.g., CIPN vs. DPN vs. PHN) with standardized outcomes. Translational gap between animal models and human clinical efficacy remains significant.References
Frediani, Jennifer K., et al. "The role of diet and non‐pharmacologic supplements in the treatment of chronic neuropathic pain: A systematic review." Pain Practice 24.1 (2024): 186-210.
Huang, Wei MD, PhD*,†; Shah, Shivani DO†; Long, Qi PhD‡; Crankshaw, Alicia K. MD†; Tangpricha, Vin MD, PhD§,∥. Improvement of Pain, Sleep, and Quality of Life in Chronic Pain Patients With Vitamin D Supplementation. The Clinical Journal of Pain 29(4):p 341-347, April 2013. | DOI: 10.1097/AJP.0b013e318255655d
Haddad, H.W., Mallepalli, N.R., Scheinuk, J.E. et al. The Role of Nutrient Supplementation in the Management of Chronic Pain in Fibromyalgia: A Narrative Review. Pain Ther 10, 827–848 (2021). https://doi.org/10.1007/s40122-021-00266-9
Abdelrahman, K.M.; Hackshaw, K.V. Nutritional Supplements for the Treatment of Neuropathic Pain. Biomedicines 2021, 9, 674. https://doi.org/10.3390/biomedicines9060674
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Pain Exam Podcast Recent Conference Activities London Conference Weekend: Successfully attended and spoke at ISPN and SOMOS care conferences Somos Care Conference: Delivered presentation on pain management for primary care physicians Presentation consisted of 50+ slides with only one slide dedicated to opiates Emphasized shift away from opiate-based treatments in interventional pain management Recommended primary care physicians refer patients to pain specialists for comprehensive treatment options ISPN Conference: Participated in international pain management conference Met with doctors from London, Iraq, and various other countries Observed different international approaches to pain treatment including increased phenol use and varying regenerative medicine restrictions Upcoming Events and Workshops New York-New Jersey Pain Conference: November (NRAP Academy booth presence) IV Ultrasound Placement Workshops: Monthly sessions in New York Regional Anesthesia and Ultrasound-Guided Interventional Pain Medicine Workshops: New York: December 13th, January 10th Florida (Fort Lauderdale/Hollywood): November 8th Detroit: January 18th, February 15th Alternative Options: Online ultrasound courses and shadowing opportunities available Board Prep and NRAP Community at PainExam.com or NRAPpain.org ABA ABPM ABIPP FIPP Pain Management Board prep, Question Banks, and Virtual Pain Fellowship
Educational Offerings and Events
Training and Courses: Research Review: ACL Treatment Study Study Focus: Non-surgical treatment of ACL tears using bone marrow concentrate (BMAC) and platelet products versus exercise therapy Key Findings: BMAC group showed significantly greater improvement in Lower Extremity Function Scale (LEFS) and Single Assessment Numeric Evaluation (SANE) scores at three months Sustained improvement in function and decreased pain maintained through two-year follow-up Patients reported median subjective improvement of 90% at final follow-up No significant improvements observed in exercise-only group during initial three months Treatment Protocol: Bone marrow harvest from posterior superior iliac crest (60-90ml from 6-8 sites) PRP preparation from 60ml whole blood Fluoroscopy-guided injection directly into ACL ligament Comprehensive 52-week rehabilitation protocol with activity restrictions Clinical Practice Implications Current ACL Treatment Landscape: Over 400,000 ACL reconstruction surgeries performed annually in the US Surgical Limitations: Risk of graft failure, persistent instability, cartilage injury, and increased arthritis risk Return to Sport Statistics: Post-surgical rates vary significantly (33-92% return to sport, 65% return to pre-injury level) Practice Integration Considerations: Potential incorporation of BMAC/PRP protocols for ACL tears, though insurance coverage remains limitedDavid Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.
Awards
New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025
Schneps Media: 2015, 2016, 2017, 2019, 2020
Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025
Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023
Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!
Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.
Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators.
He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call
Brooklyn 718 436 7246
References
Centeno CJ, Berger DR, Pitts J, Markle J, Pelle AJ, Murphy M, Dodson E. Non-surgical treatment of anterior cruciate ligament tears with percutaneous bone marrow concentrate and platelet products versus exercise therapy: a randomized-controlled, crossover trial with 2-year follow-up. BMC Musculoskelet Disord. 2025 Sep 30;26(1):882. doi: 10.1186/s12891-025-09153-2. PMID: 41029301; PMCID: PMC12486544.
#pccwindsor #paincareclinicswindsor #painwindsorontario #paindocwindsorontarior #paincareclinics #prpwindsorontario #prp #aabppain
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Project Sync / Status Update Summary Podcast Episode Overview The host discussed Transcutaneous Electrical Nerve Stimulation (TENS) as a recurring pain board topic and reviewed mechanisms, efficacy, and clinical considerations. Emphasis that TENS appears on pain boards annually and is a foundational topic from early podcast episodes. Board Prep and NRAP Community at PainExam.com or NRAPpain.org ABA ABPM ABIPP FIPP Pain Management Board prep, Question Banks, and Virtual Pain Fellowship Educational Offerings and Events Training and Courses: Monthly ultrasound courses in New York and upcoming courses in Detroit covering ultrasound-guided regional anesthesia and chronic pain. Ultrasound Guided Acute and Chronic Pain course in November near Hollywood/Fort Lauderdale with venue pending confirmation. Multiple instructors to offer diverse perspectives; registration via the CME calendar at nrappain.org. Conferences and Teaching: New York–New Jersey Pain Conference in November (hosted by Soudir Duwan). ISPN conference in London next week, with ultrasound teaching participation by the host. Community and Coaching: Private coaching and shadowing opportunities available; contact via newsletter replies. Access to the NRAP community forum upon signup at nrappain.org for discussions on neuromodulation, regional anesthesia, and pain. TENS: Mechanisms and Parameters Device and Parameters: TENS delivers adjustable pulse frequency and intensity; configurations include low (50–100+ Hz), and mixed frequencies. Mechanisms of Analgesia: Activation of large-diameter, non-noxious A-beta afferent fibers in the periphery, driving descending inhibitory pathways and reducing hyperalgesia. Board-relevant point: selective activation of A-beta fibers is frequently tested. Central effects: Reduces central excitability and nociceptive dorsal horn neuron activity in uninjured and injured models. Frequency-dependent opioid receptor mediation: High-frequency analgesia blocked by delta receptor antagonists. Low-frequency analgesia blocked by mu receptor antagonists (spinal cord and rostral ventral medulla). Additional receptor involvement: muscarinic M1/M3, GABA-A, and cannabinoid (CB1) receptors; blockade reduces or prevents TENS analgesia depending on frequency. Peripheral effects: High-frequency TENS reduces injury-related increases in substance P in DRG neurons. Blockade of peripheral opioid and CB1 receptors can prevent analgesia from both low- and high-frequency TENS. Clinical dosing considerations: Adequate dosing (timing, frequency of use, intensity achieving strong but non-painful paresthesia) influences efficacy. Analgesia has rapid onset/offset and may require repeated administration throughout the day for sustained relief. Evidence and Efficacy Summary Practical Interpretation: TENS is inexpensive, low-risk, self-administered, and titratable; commonly used by patients and physical therapists. Clinical experience suggests potential adjunctive benefit for acute pain, but systematic reviews are conflicting; more rigorous studies are needed. For board preparation, the critical takeaway is A-beta fiber activation. Key Takeaways for Board Prep TENS targets large-diameter non-noxious A-beta afferents to reduce nociceptive signaling. High-frequency TENS: analgesia mediated via delta opioid receptors; blocked by delta antagonists. Low-frequency TENS: analgesia mediated via mu opioid receptors; blocked by mu antagonists in spinal cord and RVM. Additional receptor systems influencing TENS efficacy include muscarinic (M1/M3), GABA-A, and CB1. Action Items Review TENS mechanisms with emphasis on A-beta fiber activation for board prep. Verify and publish final venue details for the November Florida ultrasound course. Share registration links and schedules for Detroit and New York ultrasound and chronic pain courses via CME calendar. Prepare teaching materials for ISPN London ultrasound sessions next week. Update board prep resources on painexam.com and nrappain.org with current TENS evidence and dosing guidance. Promote NRAP community forum access and private coaching/shadowing opportunities through the newsletter.
David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.
Patients can go to www.AABPpain.com or call 718 436 7246
Awards
New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025
Schneps Media: 2015, 2016, 2017, 2019, 2020
Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025
Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023
References
Johnson M. Transcutaneous Electrical Nerve Stimulation: Mechanisms, Clinical Application and Evidence. Rev Pain. 2007 Aug;1(1):7-11. doi: 10.1177/204946370700100103. PMID: 26526976; PMCID: PMC4589923.
Vance, C.G.T.; Dailey, D.L.; Chimenti, R.L.; Van Gorp, B.J.; Crofford, L.J.; Sluka, K.A. Using TENS for Pain Control: Update on the State of the Evidence. Medicina 2022, 58, 1332. https://doi.org/10.3390/medicina58101332
#painnyc #painbrooklyn #prpbrooklyn #prpspine #regionalanesthsia #pccwindsor #paincareclinicswindsor #painwindsorontario #paindocwindsorontarior #paincareclinics #prpwindsorontario #prp
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Exploring the Efficacy of BMAC and ADSC Injections in Knee Osteoarthritis
Hosts: David Rosenblum,MD
Overview: In this episode, we delve into a recent study published in the Indian Journal of Orthopaedics that compares the therapeutic efficacy of Bone Marrow Aspirate Concentrate (BMAC) and Adipose-Derived Stem Cells (ADSCs) for treating knee osteoarthritis (OA). The study aims to provide insights into the effectiveness of these regenerative treatments and their correlation with mesenchymal stem cell (MSC) cellularity.
Key Points Discussed:
Background on Osteoarthritis:
Definition and impact of OA, particularly in older populations. Overview of traditional treatments and the shift towards regenerative medicine.Study Objectives:
To compare the efficacy of BMAC and ADSC injections in symptomatic knee OA patients. To analyze MSC quantity and quality in harvested tissues from both sources.Methodology:
Description of the study design involving 60 patients with knee OA. Details on patient demographics, injection protocols, and follow-up assessments (VAS, WOMAC, ROM).Results:
Significant improvements in clinical scores for both BMAC and ADSC groups at 6 months. Discussion on the lack of significant correlation between MSC quantity and treatment efficacy. Insights into the success rates of MSC cultures from both bone marrow and adipose tissue.Conclusions:
Both treatments demonstrated clinical improvements, with no substantial differences between them. BMAC showed higher MSC counts and faster recovery rates, but further research is needed to understand the underlying factors affecting efficacy.Implications for Clinical Practice:
Considerations for clinicians when choosing between BMAC and ADSC treatments. Future directions for research in regenerative therapies for knee OA.References:
Vitali, M., Ometti, M., Montalbano, F., et al. (2025). Bone Marrow Aspirate Concentrate (BMAC) Versus Adipose-Derived Stem Cells (ADSCs) Intra-articular Injection Therapeutic Efficacy in Knee OA Correlated to Their Mesenchymal Stem Cell (MSC) Cellularity: An Exploratory Comparative Pilot Study. Indian Journal of Orthopaedics. https://doi.org/10.1007/s43465-025-01525-zListener Engagement:
Join the conversation! Share your thoughts on BMAC and ADSC treatments for knee OA on social media using #JournalClubPodcast. Don't forget to subscribe for more discussions on the latest research in orthopaedics and regenerative medicine. -
Podcast Summary
This episode of the Pain Exam Podcast, hosted by Dr. David Rosenblum, discusses an interesting article about Ketorolac injections for musculoskeletal conditions. The podcast covers:
Ketorolac is an NSAID that provides analgesic and anti-inflammatory effects through inhibition of prostaglandin synthesis Multiple studies comparing Ketorolac injections to corticosteroids and hyaluronic acid for various conditions Research shows Ketorolac injections are equally effective as corticosteroids for subacromial conditions, adhesive capsulitis, carpal-metacarpal joint issues, and hip/knee osteoarthritis Ketorolac may be a safer alternative to steroids for certain patients, though it has its own contraindications for those with renal, gastrointestinal, or cardiovascular disease Dr. Rosenblum considers the potential of using Ketorolac injections directly at pain sites rather than intramuscularly Upcoming Courses and Conferences Ultrasound courses in New York and Costa Rica (check unwrappedpain.org) Private ultrasound sessions available Dr. Rosenblum will be speaking at Pain Week about ultrasound in pain practice and PRP Presenting at a primary care conference in London Teaching ultrasound at ISPN LAPSES conference in Chile (Dr. Rosenblum won't attend this year)Ketorolac Injections: An Effective Alternative for Musculoskeletal Pain Management
Musculoskeletal conditions such as bursitis, adhesive capsulitis, and osteoarthritis affect millions and often require injectable therapies to reduce pain and inflammation. Traditionally, corticosteroid injections have been the mainstay treatment. However, concerns over side effects like tendon rupture, cartilage damage, and systemic hyperglycemia have prompted exploration of alternatives. A recent narrative review by Kiel et al. (2024) highlights ketorolac—a parenteral nonsteroidal anti-inflammatory drug (NSAID)—as a promising substitute for corticosteroids in musculoskeletal injections.
Warning: OFF Label use of Ketorolac discussed. Please consult your physician.
See full article for details.
Subacromial Ketorolac Injections for Shoulder PainSubacromial bursitis and impingement syndrome are common causes of shoulder pain and disability. Several randomized controlled trials have shown that subacromial ketorolac injections provide pain relief and functional improvement comparable to corticosteroids:
Goyal et al. demonstrated significant reductions in pain scores after subacromial injection of 60 mg ketorolac versus 40 mg methylprednisolone, with no difference in outcomes between groups. Taheri et al. found similar short-term pain relief at 1 and 3 months with either ketorolac or corticosteroid subacromial injections. Kim et al. reported equivalent clinical improvement in rotator cuff syndrome patients receiving ketorolac or triamcinolone injections. Min et al. noted ketorolac led to better forward flexion and patient satisfaction at 4 weeks compared to corticosteroids.These studies support ketorolac as an effective agent for subacromial injection, offering an alternative for patients where corticosteroid use is limited.
Intra-articular Ketorolac Injections for Adhesive Capsulitis and OsteoarthritisAdhesive capsulitis (frozen shoulder) and osteoarthritis of the hip, knee, and carpometacarpal joint are often treated with intra-articular corticosteroids. Ketorolac injections have shown comparable efficacy in these conditions:
Akhtar et al. found intra-articular ketorolac significantly reduced shoulder pain at 4 weeks in adhesive capsulitis compared to hyaluronic acid. Ahn et al. reported similar pain relief between intra-articular ketorolac and corticosteroid injections in adhesive capsulitis, with ketorolac providing superior shoulder mobility at 3 and 6 months. Koh et al. showed that adding ketorolac to hyaluronic acid injections in carpometacarpal osteoarthritis resulted in faster onset of pain relief compared to hyaluronic acid alone. Park et al. observed equivalent functional improvements with intra-articular ketorolac or corticosteroids in hip osteoarthritis. Jurgensmeier et al. demonstrated similar symptom improvement at 1 and 3 months post-injection for ketorolac and triamcinolone in hip and knee osteoarthritis. Xu et al. and Bellamy et al. confirmed ketorolac's comparable pain relief and functional benefits to corticosteroids for knee osteoarthritis, with ketorolac being more cost-effective. Lee et al. noted quicker pain reduction with intra-articular ketorolac combined with hyaluronic acid versus hyaluronic acid alone in knee osteoarthritis. aSafety and Pharmacologic ConsiderationsKetorolac's anti-inflammatory action stems from cyclooxygenase inhibition, reducing prostaglandin synthesis. Its half-life is approximately 5.2–5.6 hours, and it is metabolized in the liver. Unlike corticosteroids, ketorolac avoids systemic hyperglycemia and cartilage damage risks. Animal and in vitro studies suggest ketorolac may protect cartilage by inhibiting inflammatory cytokines.
While gastrointestinal, renal, and cardiovascular risks associated with NSAIDs remain considerations, localized intra-articular and subacromial ketorolac injections may limit systemic exposure and adverse effects. Mild, transient post-injection pain has been reported but resolves without intervention.
ConclusionKetorolac injections, administered intra-articularly or subacromially, are a safe, effective, and economical alternative to corticosteroids for managing common musculoskeletal conditions. Their comparable efficacy in reducing pain and improving function, combined with a more favorable side effect profile, makes ketorolac an appealing option for clinicians and patients alike. Further research is warranted to fully elucidate long-term safety and optimal dosing strategies.
FAQS
Ketorolac Injections for Musculoskeletal Conditions: Frequently Asked Questions
Musculoskeletal pain from conditions like bursitis, adhesive capsulitis, and osteoarthritis often requires injectable treatments. Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is emerging as a promising alternative to corticosteroids. Below are common questions and answers based on a recent narrative review by Kiel et al. (2024).
1. What is ketorolac and how does it work?Ketorolac is a parenteral NSAID that reduces pain and inflammation by inhibiting cyclooxygenase enzymes, which decreases prostaglandin synthesis. It can be administered orally, intramuscularly, intravenously, or by injection directly into joints or around bursae.
2. How effective is ketorolac for musculoskeletal conditions?Studies show ketorolac injections provide significant pain relief and functional improvement comparable to corticosteroids in conditions like:
Subacromial bursitis and shoulder impingement (subacromial injections) Adhesive capsulitis (frozen shoulder) (intra-articular injections) Osteoarthritis of the hip, knee, and thumb carpometacarpal joint (intra-articular injections) 3. What evidence supports subacromial ketorolac injections?Randomized controlled trials found:
Goyal et al. and Taheri et al. reported similar pain reduction and functional outcomes between ketorolac and corticosteroids for subacromial injections. Kim et al. and Min et al. observed comparable or better patient satisfaction and shoulder mobility with ketorolac versus corticosteroids. 4. How does intra-articular ketorolac compare to corticosteroids for adhesive capsulitis? Akhtar et al. showed ketorolac reduced shoulder pain more than hyaluronic acid. Ahn et al. found ketorolac and corticosteroids equally effective for pain relief, with ketorolac providing better shoulder mobility at 3 and 6 months. 5. What about ketorolac for osteoarthritis? Ketorolac combined with hyaluronic acid provided faster pain relief than hyaluronic acid alone in thumb carpometacarpal joint osteoarthritis (Koh et al.). Intra-articular ketorolac had similar efficacy to corticosteroids in hip (Park et al., Jurgensmeier et al.) and knee osteoarthritis (Bellamy et al., Xu et al.). Ketorolac injections were more cost-effective compared to corticosteroids (Bellamy et al.). 6. Are ketorolac injections safe?Ketorolac's side effects are similar to other NSAIDs, mainly involving gastrointestinal, renal, and cardiovascular risks. However, localized intra-articular and subacromial injections may reduce systemic exposure. Animal studies suggest ketorolac does not harm cartilage and may protect against inflammatory damage. Mild, transient local pain post-injection is possible but usually resolves without treatment.
7. What are the limitations of ketorolac use?Ketorolac is not suitable for patients with:
Renal impairment Gastrointestinal ulcers or bleeding risk Cardiovascular disease or hypertension NSAID hypersensitivity, especially in asthma or chronic urticaria patientsClinicians should assess individual risks before choosing ketorolac injections.
8. How does ketorolac's pharmacokinetics affect its use?Ketorolac has a plasma half-life of about 5.2 to 5.6 hours and is metabolized in the liver. Pharmacokinetics for subcutaneous or intra-articular administration are less defined but systemic absorption occurs. Its relatively short half-life supports repeated dosing if needed.
9. Why consider ketorolac over corticosteroids?Ketorolac avoids corticosteroid-associated risks such as tendon rupture, cartilage damage, and steroid-induced hyperglycemia. It is also more cost-effective, making it a favorable option for patients and healthcare systems.
10. What further research is needed?More large-scale, long-term studies are needed to fully understand ketorolac's intra-articular effects, optimal dosing, and safety profile compared to corticosteroids and other treatments.
Summary:
Ketorolac injections, whether intra-articular or subacromial, offer a safe, effective, and economical alternative to corticosteroids for managing various musculoskeletal conditions. This makes ketorolac an important option in pain management and inflammation control.Reference:
Kiel J, Applewhite AI, Bertasi TGO, Bertasi RAO, Seemann LL, Costa LMC, Helmi H, Pujalte GGA. Ketorolac Injections for Musculoskeletal Conditions: A Narrative Review. Clinical Medicine & Research. 2024;22(1):19-27. DOI: https://doi.org/10.3121/cmr.2024.1847
Disclaimer: This Podcast, website and any content from NRAP Academy (PMRexam.com) otherwise known as Qbazaar.com, LLC is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user's own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.
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Summary
In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures.
Chapters Introduction to the Pain Exam Podcast and Topic OverviewDr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease.
Upcoming Conferences and Educational OpportunitiesDr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities.
Overview of Postherpetic NeuralgiaDr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life.
Treatment Options OverviewDr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics.
Phases of Herpes Zoster and DefinitionsDr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash.
Incidence and Risk FactorsDr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia.
Impact on Quality of LifeDr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia.
Literature Review and PathophysiologyDr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia.
Central Sensitization and Nerve DamageDr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome.
Different Phenotypes and ClassificationDr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration.
Deafferentation PhenotypeDr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial.
Diagnosis and Physical ExaminationDr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients.
Sensory Testing and AssessmentDr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons.
Prevention Through VaccinationDr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions.
Treatment ObjectivesDr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation.
Antiviral MedicationsDr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised.
Benefits of Antiviral TherapyDr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible.
Corticosteroids and OpioidsDr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction.
Methadone and AntidepressantsDr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction.
Antiepileptics and Pharmacological Treatment SummaryDr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011.
Topical AgentsDr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group.
Intracutaneous InjectionsDr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study.
Summary of Local AnestheticsDr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy.
Interventional Treatments: Epidural and Paravertebral InjectionsDr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster.
Comparative Studies on Injection ApproachesDr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster.
Timing of Interventions and Continuous Epidural BlockadeDr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality.
Interventions for Postherpetic NeuralgiaDr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence.
Summary of Epidural and Paravertebral InjectionsDr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy.
Pulsed Radiofrequency (PRF) EvidenceDr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy.
PRF Studies for Acute Herpes ZosterDr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group.
PRF for Trigeminal NeuralgiaDr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group.
PRF Compared to Other InterventionsDr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate.
Summary of PRF and Final RecommendationsDr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature.
Sympathetic Blocks and ConclusionDr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia.
Personal Clinical Approach and ClosingDr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast.
Q&ANo Q&A session in this lecture
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HighlightsDavid Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.
Awards
New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025
Schneps Media: 2015, 2016, 2017, 2019, 2020
Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025
Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023
Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!
Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.
Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators.
He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call
Brooklyn 718 436 7246
Reference
Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.
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Summary
In this Pain Exam Podcast episode, Dr. David Rosenblum discusses a journal club article on low volume neurolytic retrocrural celiac plexus blocks for visceral cancer pain. The study reviewed 507 patients with severe malignancy-related abdominal pain, with data retained for 455 patients at the 5-month mark. Dr. Rosenblum explains that the procedure involves injecting 3-5ml of 6% aqueous phenol at the T12-L1 level under fluoroscopic guidance, with an average procedure time of 16.3 minutes. The study found significant pain relief lasting up to six months, reduced opioid consumption, and improved quality of life for patients with primary abdominal cancer or metastatic disease. Dr. Rosenblum shares his personal experience with celiac plexus blocks, including the trans-aortic approach he trained on, and mentions his interest in ultrasound-guided approaches. He also announces upcoming teaching engagements at ASPN, Pain Week, and other conferences, as well as CME ultrasound courses available through nrappain.org. Additionally, he mentions a new community page on the website where users can share board preparation information, though he emphasizes that remembered board questions should not be posted as he is a board question writer himself.
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Highlights Introduction and Upcoming EventsDr. David Rosenblum introduces the Pain Exam Podcast and shares information about upcoming events. He mentions teaching ultrasound at ASPN in July, attending Pain Week in September, and participating in the Latin American Pain Society conference. Dr. Rosenblum also promotes his CME ultrasound courses available at nrappain.org and mentions he's considering organizing another regenerative medicine course in fall or winter. He offers private training for those wanting more intensive ultrasound instruction.
Board Prep Community AnnouncementDr. Rosenblum announces a new community page on the nrappain.org website for board preparation. He explains that registered users can access free information and keywords relevant to board exams. He emphasizes that users should not post remembered questions as this would be inappropriate, noting that he himself is a board question writer for various pain boards. Dr. Rosenblum mentions that a post about phenol in this community inspired today's podcast topic.
Journal Article Overview on Celiac Plexus BlockDr. Rosenblum introduces a journal article on low volume neurolytic retrocrural celiac plexus block for visceral cancer pain, a retrospective review of 507 patients with severe malignancy-related abdominal pain. He explains that the study assessed pain relief provided by this procedure, its duration, reduction in daily opioid consumption, and quality of life improvements. The patients received neurolytic blocks without previous diagnostic blocks due to multiple comorbidities, which Dr. Rosenblum acknowledges is sometimes necessary with very sick patients despite the typical preference for diagnostic blocks before neurolysis.
Dr. Rosenblum's Personal Experience with Celiac Plexus BlocksDr. Rosenblum shares his personal training experience with trans-aortic celiac plexus blocks, where a needle is inserted through the aorta after confirming no plaques or aneurysms are present. He describes it as a safe and effective procedure despite sounding intimidating. He mentions he's only performed a handful of these procedures and doesn't do many now as an outpatient pain doctor.
Study Methods and ResultsDr. Rosenblum details the study methods, noting that of 507 patients studied, data for 455 was retained at the end of the review. Patients were evaluated before and after the neurolytic retrocrural celiac plexus block under fluoroscopic guidance. Assessment included procedure duration, pain scores (0-10 scale), daily opioid consumption, and quality of life improvement. Follow-up was completed six months after the procedure, showing improved pain scores, reduced opioid consumption, and better quality of life throughout the study period. Some pain returned during months 4-6 due to disease progression and the anticipated duration of the neurolytic agent. The study noted a 6.7% initial vascular contrast uptake during the procedure while using digital subtraction angiography with fluoroscopy.
Study Limitations and ConclusionsDr. Rosenblum discusses the study's limitations, including the need for a larger sample size and a prospective trial with a control group, though he acknowledges this is unrealistic given the patient population. He mentions that a proven quality of life questionnaire would be beneficial, and that comparing alcohol, phenol, and RF thermocoagulation would be interesting to evaluate duration effects and side effects. The study concluded that low volume neurolytic retrocrural celiac plexus block with phenol is safe, providing up to six months of pain relief for abdominal pain due to primary malignancy or metastatic spread.
Detailed Procedure TechniqueDr. Rosenblum explains the detailed procedure technique used in the study. The retrocrural celiac plexus was targeted at L1 level with aim towards T12. Anterior and posterior radiographic imaging aligning the spinous process of T12-L1 junction was used with 15-20 degree oblique rotation. Local anesthetic (1% lidocaine with sodium bicarbonate) was infiltrated along the injection path. A 22 or 25 gauge 3.5-7 inch curved spinal needle was used depending on patient body habitus. Dr. Rosenblum notes he typically uses a 6-inch Chiba needle or 25 gauge spinal needle for such procedures.
Procedure Execution and MonitoringDr. Rosenblum continues describing the procedure, noting that the needle was advanced to the anterior border of T12-L1 under multiple imaging views. Contrast dye studies verified spread and location, with digital subtraction angiography used to check for intravascular uptake. A test dose of 1ml of 0.5% bupivacaine with epinephrine per site was administered, which Dr. Rosenblum finds interesting as he typically doesn't mix bupivacaine with epinephrine. After confirming no vascular uptake, 3-5ml of 6% aqueous phenol was injected in 1ml aliquots while communicating with the patient. The average procedure time was 16.3 minutes with minimal or no sedation. Patients remained prone for 30 minutes afterward to avoid neuroforaminal spread, as phenol is heavier and more viscous than alcohol.
Post-Procedure Care and Study EvaluationDr. Rosenblum explains that patients were monitored in recovery for one hour for adverse events and their ability to eat and void easily. They were discharged once hospital post-anesthetic criteria were met and received a follow-up call 24 hours later. Dr. Rosenblum praises the study and notes that the procedure looks similar to a lumbar sympathetic plexus block, which is also a sympathetic block.
Ultrasound Considerations and Alternative ApproachesDr. Rosenblum shares his interest in ultrasound-guided celiac plexus blocks but acknowledges concerns about bowel perforation. He mentions a conversation with an interventional radiology colleague who suggested a transhepatic approach. Dr. Rosenblum recalls scanning a very thin patient where the aorta was easily visible and close to the anterior abdominal wall, making the celiac plexus potentially accessible if bowel perforation, liver bleeding, or gallbladder perforation could be avoided. He shares an experience with a patient suffering from severe pancreatitis pain who received temporary relief from a paravertebral thoracic nerve block at T8-T10, noting that paravertebral blocks provide some sympathetic spread.
Conclusion and Community Resource ReminderDr. Rosenblum concludes by recommending the article, noting its well-written analysis and graphs showing morphine consumption dropping over months following the procedure. He suggests neurolytic procedures are underutilized because they sound intimidating. He again encourages listeners to check out the community he created with separate chat rooms for regenerative medicine, regional anesthesia, and pain boards, where users can share keywords but not specific board questions. Dr. Rosenblum reminds listeners about upcoming courses and his website resources, mentions an upcoming PRP lecture, and asks for five-star reviews if listeners enjoy the podcast. The episode ends with a standard medical disclaimer.
Reference
https://www.painphysicianjournal.com/current/pdf?article=NTQwOA%3D%3D&journal=113
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PRP in the Epidural Space for Radiculopathy
Brooklyn Based Pain Physician, David Rosenblum, MD known for his work publishing and teaching Regenerative Pain Medicine and Ultrasound Guided Pain Procedures hosts this podcast covering the latest and most advanced concepts in Pain Medicine.
SummaryDr. David Rosenblum delivered a comprehensive lecture covering several key topics in pain management. He discussed his upcoming speaking engagements at PainWeek, ASPN and great upcoming meetings like the Latin American Pain Society, and other conferences. Dr. Rosenblum shared his extensive experience with PRP (Platelet-Rich Plasma) epidural injections, reviewing multiple research studies that support their efficacy. He highlighted three significant studies: a randomized control trial comparing PRP epidural injections to traditional treatments, a CT-guided epidural PRP study, and a 2025 meta-analysis comparing PRP to steroids. Dr. Rosenblum emphasized that PRP treatments are showing comparable or better results than traditional steroid injections, with potentially fewer required treatments and longer-lasting relief. He noted that while PRP is currently not covered by insurance, it represents a growing trend in 'natural' treatment approaches that patients increasingly prefer.
Chapters Introduction and Upcoming EventsDr. Rosenblum announced his upcoming lectures at Pain Week focusing on ultrasound and regenerative medicine, followed by presentations at the Latin American Pain Society in Chile and the New York, New Jersey Pain Conference. He mentioned the SoMeDocs online pain conference accessible through nrappain.org, and upcoming ultrasound training sessions in New York City.
PRP Epidural Research ReviewDr. Rosenblum discussed a randomized control trial involving 30 patients receiving transforaminal epidural injections. The study showed that PRP patients demonstrated significant improvements in leg pain scores at 6, 12, and 24 weeks. He noted that while the study didn't use contrast, he personally prefers using contrast diluted with saline for better visualization.
CT-Guided Epidural Study AnalysisDr. Rosenblum reviewed a study comparing CT-guided epidural PRP versus steroid injections, questioning the necessity of CT guidance. The study included 60 patients and showed similar results between PRP and steroid groups at six weeks, though he criticized the short follow-up period, noting that PRP typically takes months to show full effects.
Meta-Analysis DiscussionDr. Rosenblum presented a 2025 meta-analysis comparing PRP to steroids in epidural injections. The analysis included 310 patients across five RCTs, demonstrating comparable efficacy between PRP and steroid injections without increased adverse events. He emphasized that his clinical experience shows patients typically require fewer PRP injections compared to steroid treatments.
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References
Wongjarupong, Asarn, et al. ""Platelet-Rich Plasma" epidural injection an emerging strategy in lumbar disc herniation: a Randomized Controlled Trial." BMC Musculoskeletal Disorders 24.1 (2023): 335.
Bise, Sylvain, et al. "Comparison of interlaminar CT-guided epidural platelet-rich plasma versus steroid injection in patients with lumbar radicular pain." European radiology 30 (2020): 3152-3160.
Muthu S, Viswanathan VK, Gangadaran P. Is platelet-rich plasma better than steroids as epidural drug of choice in lumbar disc disease with radiculopathy? Meta-analysis of randomized controlled trials. Exp Biol Med (Maywood). 2025 Feb 4;250:10390. doi: 10.3389/ebm.2025.10390. PMID: 39968415; PMCID: PMC11832311.
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