- Let's talk about pain.

It's physical suffering or discomfort caused by illness or injury.

Chronic and acute pain are one of the most common reasons adults seek medical attention.

And, according to a study by the CDC, lower back pain is the most commonly-reported source of pain.

Managing pain treatments and coping mechanisms can vary, depending on one's socioeconomic background, access to care, and personal belief systems.

On this episode, we'll take a look at pain management, chronic back pain, and take a unique look at the Hispanic American pain experience.

Welcome to A Su Salud - Cheers to Good Health.

I'm your host, Genesis Ortega.

We're broadcasting from inside the PPL Public Media Center in Bethlehem, Pennsylvania.

My first guest is St. Luke's University Health Network pain management specialist, Dr. Farooq Qureshi.

Thank you, Doctor, for being with us today.

- Thank you, Genesis.

- Let's start here, I want to talk about your specialty.

Pain management seems like it can be a broad topic.

Can you break it down and tell us what pain management looks like?

- So, pain management is a specialty devoted to treating patients and people with chronic pain conditions.

So, the majority of patients that we see here are patients suffering from musculoskeletal conditions, including the spine and joints, as well as painful neuropathies.

Our goal in treating patients here is using a multimodal treatment approach involving interventions, medications, holistic and alternative treatments, including physical therapy, chiropractic manipulation and acupuncture.

The goal of pain management is to really take patients out of their chronic pain state and get them back into their life, get them rehabilitated.

- You lead me into my next question.

How serious is chronic pain?

- Well, it becomes serious when the pain starts to interfere with activities of daily living.

It starts decreasing your ability to do activities that you enjoy doing and starts leading to a disability state where you do this fear avoidance and stop doing activities because you're afraid of hurting.

When you get into that situation, what people do is they'll stop walking because it hurts to walk.

They become sedentary.

Then they'll start to gain weight.

Then, when they start to use their walk again, they'll start to hurt because they haven't been using those muscles.

So, it's really important to recognize that if you're in a pained state to kind of get an evaluation and figure out why you're experiencing that pain, and then, figure out a treatment regimen.

- It seems like it can be debilitating from a physical, emotional, and mental perspective.

- Absolutely, absolutely.

When you get into that situation where you're hurting and, let's say you like to go to the grocery store and pick out your own groceries, but the pain in your back is limiting, that you decide, "OK, I'm not going to do that.

"I'm going to let other people do it."

Then you start to get depressed because you're not able to do things that you normally could do for yourself.

So, it has a mental and physical component.

- So, Doctor, is there a difference in treatment methods when it comes to treating chronic and acute pain?

- Yes and no.

If you're experiencing a new onset pain condition, it's really important to see your family physician and get evaluated, because there's a lot of reasons people could be experiencing acute pain, new pain.

Let's say if it's in their back, it could be related to a compression fracture, or a muscle spasm would be a lighter indication of pain, a lighter diagnosis, but it could be cancer even.

You know, you really want to be checked out and make sure what the etiology of the pain is.

People who live with chronic pain have had arthritis, let's say, for a long time, and are dealing with something that they know is going on.

And so, the goal there is to kind of manage what's going on and start treating that.

- What are some of the techniques that you use for treatment therapies?

- So, we use a wide array of interventional treatments, including epidural cortisone injections, which are steroids delivered into the epidural space in the spine, which help with inflammation and pain.

They're particularly effective for people who have spinal stenosis or disc herniations where they're having pain, just not in the back, but also grating into their legs.

We do a treatment called radiofrequency ablation, which is a heating of pain nerves in the lower back, which heat the nerves that control pain from arthritis, and that allows them to move their back a little bit better, and then, increase their walking ability.

Some of the more advanced techniques include use of spinal cord stimulation, which is a pacemaker for the spine.

It sends electrical signals to the back of the spinal cord and interrupts the pain signals travel from the lower back and legs going up into the brain.

- Peripheral nerve stimulation.

Can you tell us more about that?

Are there any requirements that patients have to go under to get this type of treatment?

- Well, the patient's evaluated to see if they would be a candidate for it, so if you can identify a condition that's treated by the stimulation, that'll be the first indication.

So, that's an evaluation to see if they would actually be benefited from having the stimulation.

After that, there is a psychological component where a patient has to undergo a psychological exam just to make sure they wouldn't have an adverse reaction to having a nerve stimulator in their body.

And then, finally, they undergo a temporary trial.

So, we put a temporary device in, then they would have that week to kind of decide, is that helpful for their chronic pain condition?

- Now, you're St. Luke's online profile indicates that you take a holistic approach in some cases, as well as alternative therapies.

Can you elaborate more on that?

- Well, you know, every patient is different, and it's really important to include the patient's own beliefs and expectations on how they need to be treated and what options are available for them.

So, maybe an injection in the back isn't the most appropriate thing for them because they don't want any intervention in their spine, and they'd rather go through and try more conservative approaches, therapy, exercise, acupuncture, reiki, cupping.

There's a lot of different things.

And it's really important to have that conversation with the patient so we can determine what they feel most comfortable with.

- What do you hear from patients in your practice?

Are they receptive to that?

- Absolutely, absolutely.

I mean, I think the goal of most people is that they want to be able to live their life normal again, have some more autonomy and functioning.

And some patients prefer having an intervention, "just fix it and get me better," while others want to, you know, "Let's figure out the lifestyle modifications "I should be making so that I can help myself get better."

- Can you share a success story with us?

A patient suffering from chronic pain who was successfully treated?

- Yeah, actually, one comes to mind right now that that's kind of in the middle of treatment.

It's a gentleman, he's in his early 60s, and he's a type-one diabetic.

He's been having leg pain for a good 2-3 years related to neuropathy from the diabetes.

He's been maxed out on his neuropathic medications.

Coincidentally, he's also a kidney transplant recipient.

So, options are limited because of the history of the renal transplant, kidney transplant.

So, he has a son getting married next month, actually, and his number-one goal is to be able to dance at his son's wedding.

So, last month, we came up with a plan, because he wanted to be able to do that.

So, spinal cord stimulation was discussed with him, and he wanted to try it, so we did a temporary trial, and he had 80% relief with the device for the week that he had it.

He said he was walking with minimal pain, discomfort, he could feel his legs again.

And so, now he's getting the permanent implanted next week and should be recovered in time for his son's wedding.

- That's a great story.

Thanks for sharing that with us, Dr. Qureshi, I appreciate your insight and your time today.

Thank you very much, Genesis.

- As I stated earlier, back pain is the most common reason people seek out medical attention and is the cause for missed work and lower productivity.

My next guest is Dr. Michael Fishman, a board-certified anesthesiologist and interventional pain specialist.

Thank you, Doctor, for being with us today.

- Thanks for having me.

Let's start here.

Why don't you debrief us?

What parts of the body make up the back?

- You know, that's a great question, and when I think about what parts of the body make up different pieces of the puzzle, I usually want to think about what could cause pain in the back, because really, what we're here to talk about is back pain.

So, back pain can come from the muscles overlying your spine.

They can come from the spine joints themselves.

They could come from the discs in between your vertebrae, or from a combination of those factors.

That's not to forget that back pain sometimes can manifest as a result of things totally unrelated to your back, like a urinary tract infection, for example.

So, when we think about back pain clinically, it's really pain from the bottom of the ribs to the bottom of your butt cheeks.

- Now, how prevalent is back pain?

Now, back pain's probably the most common cause for anybody to go and see a doctor at least once in their life.

So, almost everybody will develop an episode of back pain, but chronic back pain that bothers people for more than three months, day in and day out, most of the time, you know, that and chronic pain affects like one in five Americans and causes a pretty significant amount of time, disability, and dysfunction to us and our fellow Americans.

- Now, you mentioned chronic back pain.

I want to take a step back.

What is the differences?

What are the differences between acute back pain and chronic back pain?

- So, most of us have had acute back pain, and humans in general are poorly suited to a lot of the things that we do, you know, that includes farming like heavy labor, it also includes sitting for long periods of time.

We're just not really meant to do those things, with respect to our anatomy.

So, we don't have a back that's optimized for the things that we do on a daily basis.

Acute back pain is the type of thing that almost everybody will experience in their lifetime.

An episode of pain in your back that's between your butt cheeks and your bottoms of your ribs, sometimes into your thighs that goes away on its own, or goes away with the types of things that people do to self-manage, like ice or heat, some stretching, ibuprofen, etc.

When pain doesn't go away, or when it's accompanied by numbness or tingling, or weakness, those are really the times when it's helpful to have a specialist help you understand what could be the cause underlying this symptom that is pain, because remember, pain is just a symptom, and back pain, unfortunately, though it represents a symptom in the way we talk about it, like, just talking about it as pain, it really is a complex disease.

Because when people have back pain day in and day out chronically, it affects the way they work, they sleep, they interact with their family and friends.

It becomes a really significant challenge.

And that can ultimately impact your self-esteem and your mood, as well.

- Definitely.

Now, when we're talking about diagnosing chronic back pain, what are some of the things that you look at as a specialist to make that diagnosis?

- You know, for me, I really break it down to simple things, so I want to know, was this something that kind of crept up on you, or did this happen one day after a specific incident?

And usually, that's going to help me understand which type we're dealing with.

Now, sometimes that will lead me to look deeper at X-rays or an MRI, but sometimes just based on physical examination, we can be pretty confident that people don't need more studies if they don't have any of the things that would suggest the need for those.

So, really, what my job is to make sure that there's nothing dangerous going on, that if somebody needs further imaging or workup, we can obtain it, and that people can get better in as quick as time frame as possible.

That's where I was going to go next with the million-dollar question is, can it be cured?

- Well, that's an interesting question.

So, unfortunately, when we talk about chronic low back pain, we really are starting to talk about a condition that needs to be managed and usually is not cured because of the...

The way I described it before, it affects every aspect of your life, it becomes much more than just where it hurts and how much.

Now, sometimes there are physical reasons for people to have back and/or leg pain that can be fixed.

And when I say fixed, usually that means a surgical fix.

Everything else is management.

Now, management is something that involves a two-way street between your doctor and the patient, and there's no one-size-fits-all approach, but sometimes it's a combination of exercises and medications.

Sometimes it's antidepressants, even.

Sometimes it's physical therapy and bracing, or sometimes it's surgery.

Sometimes we don't have a specific injection or procedure that can target a "cause" of the back pain.

Instead, we have an idea that it's coming from a region of the back, but we're not really sure exactly where.

We even have treatments for that.

But again, that's where specialists really need to come into play to help you understand what are you a candidate for, and what are your options?

- Now, I'm sure you've heard people probably come to you and say, "I threw out my back" because of the way that they lifted a box, and it really all just comes down to the way that you bend your knees.

But any other tips that you have for viewers to help prevent back injuries?

- I would say that there's this unfortunate forgetfulness about us grown-ups, that we all forgot that in high school gym class and high school sports, and as kids, we always warmed up and stretched before we did activities.

And, you know what's interesting, we learned that, everybody who ever went to school learned that.

And yet, adults don't practice that particular habit very often.

And I would say that we need it more than the kids do.

So, my best advice to anybody is a really good core-strengthening routine.

You do not need to go to a gym, but you need to spend 10-15 minutes a day on your back, on your floor doing some basic maneuvers.

And the American Academy of Orthopedic Surgery, AAOS, has some really wonderful spine exercises on their website that anybody can go and use.

- Great.

Now, Doctor, we're running out of time here.

But I'll end on this note.

Is there anything that you'd like to share for our viewers on this topic?

- Yeah.

You know, the reason I think I'm that so hopeful about the future of back pain is that, you know, we have had better success with minimally-invasive treatments.

One of them is a new treatment that we've done a lot of research on in our practice, and has recently done very well in the clinical space.

That's something called DTM spinal cord stimulation, and that's designed and developed by Medtronic, who I'm here on behalf of today.

But in general, I think the best and most important thing to understand is that whether it's spinal cord stimulation or spine surgery, or even injections or pills, having somebody help you understand your condition, to go through your MRI with you or your imaging, or your X-rays and really understand your case, that's paramount to understanding the treatment for you, because there is no one-size-fits-all treatment for back pain, or for chronic pain in general.

- Wonderful.

Thank you so much, Doctor, for being with us today.

- Thank you so much.

Have a great day.

- My next guest is Dr. Nicole Hollingshead from the Ohio State University Wexner Medical Center.

Dr. Hollingshead is an assistant professor and clinical psychologist.

Thank you, Doctor, for being with us today.

- Thank you for having me.

- Let's start here.

You published a critical review of literature that examines chronic pain of Hispanic Americans.

What prompted your interest in that area?

- Yeah, when I first started in the chronic pain lab at the IUPUI in Indianapolis, I was really interested in disparities in chronic pain.

And so, one of my first research projects was part of my master's thesis was looking at gender, male and female, and racial Black-white differences in chronic pain management and really interviewing medical providers about how they make decisions for this patient population.

And so, as part of my master's thesis, I interviewed health care providers, really trying to get information about how they use gender and race in their decisions for chronic pain.

And it was really interesting to me because, as though we were specifically asking about differences I noticed between Black and white patients with chronic pain, they were pretty hesitant to discuss that, but more open to talk about differences they noticed with their Hispanic-American patients.

So, I kind of went through the literature and found there wasn't a lot of information about the Hispanic-American teen experience, and especially with chronic pain in particular.

And so, that prompted me to sort of dive into the literature, see what's out there and build from that.

- And when we're talking about pain severity and sensitivity, what were your overall findings as they relate to the Hispanic community?

- Yeah, so it was very interesting with the Hispanic-American community, because we found there were lower rates of chronic pain conditions in this population.

But when it was present, Hispanic-Americans tended to report greater severity of pain and higher levels of disability.

And then, in experiments where somebody might predispose them to pain, they actually reported more sensitive pain experience than non-Hispanic white counterparts.

So, there was this interesting sort of mismatch between less likely to develop chronic pain, but then, when it's present, more severe pain and more sensitivity to pain.

You came across a variety of coping mechanisms that Hispanic-Americans utilize to deal with chronic pain.

Can you share that with us?

- Yeah, so when I looked at the literature, there were a lot of interviews with Hispanic-American patients who experienced chronic pain.

And some of the key coping mechanisms that we found across the country was, the first one being stoicism, sort of using the attitude that this is one's fate and sort of accepting it, and being able to move on with it.

So, not the strong reaction of "this is unfair, unjust" like we might see in other populations, just sort of accepting that this is what's happening and being able to move forward with that.

Another common coping mechanism was religious coping.

So, one of the ways that people can cope with chronic pain is sort of trying to find a way to make sense of it and make some meaning out of it.

And Hispanic-Americans in particular tended to use their faith as one way to sort of make sense of their pain experience.

So, sort of viewing it as, "This is a trial that God has put on me.

"It's God's will that I'm experiencing this," and then, finding a way to use prayer as a coping behavior to build up their resiliency and to maintain their functioning despite the chronic pain that might set them back.

So, those were two primary ones that we found across the literature in Hispanic-Americans.

- Now, you say that and it totally resonates with me.

It's something that I've definitely heard, especially the religious part of it growing up.

So, I'm sure our viewers will also resonate with that.

I'm going to quote your work here for a second.

"Compared with other racial and/or ethnic groups, "Hispanic-Americans disproportionately work "in blue collar and manual labor occupations with greater "safety risks that expose them to pain."

Can you elaborate a little more on that?

- Yeah, so when we look at sort of labor statistics, we found that Hispanic-Americans are more likely to work in occupations such as agriculture, factory work, the service industry, construction, all of those more occupations that require a lot of physically-demanding, manual labor-type work.

There also tend to be occupations where safety concerns are more prevalent.

And so, it's interesting, again, if we think about the broad literature of the Hispanic-American population, being less likely to report chronic pain, despite the fact that there's a higher level of being in these sort of manual labor jobs that require a lot of movement, a lot of manual manipulation and those sort of repetitive actions that we know can predispose someone to developing a chronic pain condition.

- Now, when it comes to pain management, what are some of the primary barriers that end up promoting a disparity in treatment?

- Yeah, so I think about disparities and barriers with three primary levels.

The first level, and more of a broader systems level, is really focused on insurance.

We know that within the Hispanic-American community, that this racial and ethnic group is less likely to have access to insurance, relative to any other racial or ethnic group across the country.

And that remained true even after the Affordable Care Act went into place.

So, just the basic need of, if you don't have insurance, you might not have access to care.

And many surveys have found that financial reasons is one of the reasons why patients might not seek care for chronic pain in the first place.

So, I think one of the primary barriers is at broad level is, of course, not having access to care because of insurance issues.

The second layer that I think about is patient-level barriers.

So, again, if you're working in an occupation that might not give you paid time off to attend medical appointments or give you access to health care, you're unlikely to seek care.

And we know that, with chronic pain in particular, it requires a lot of medical appointments, whether that's starting off with your primary care provider, maybe needing physical therapy, which requires multiple weekly or biweekly appointments, as well as potentially other specialists, working with maybe a spine center, getting injections, even working with a psychologist for mental health that's comorbid with chronic pain.

That's a lot of time and money, and resources that goes into taking care of yourself, which a lot of people don't have.

And so, it may be not being able to access the care, or a patient's willingness to seek valid care out.

And then, also within the Hispanic community broadly, when they've looked at willingness or openness to treatment, a lot of individuals have reported issues about pain medications and their comfort in taking pain meds, particularly opioids.

So, there was a lot of interviews that people had found.

Hispanic-Americans in particular were very concerned about the addiction potential or building tolerance to pain medications, especially opioids.

So, even if a patient is able to seek that care, it kind of goes back to their comfort and their willingness to use that care depending on what their attitudes might be.

And then, the third level that I have to think about is provider levels.

So, do patients have access to a provider who has things like a medical translator available, if the patient is primarily Spanish speaking?

It's really important that health care providers and health care centers use medical translators.

Particularly with chronic pain, there may not be objective evidence to know what exactly is going on, and so, objective evidence, what I mean is like an X-ray or an MRI, or lab work that helps the doctor to say, "Oh, this is what's going on with your pain."

So, it really relies on patients' reports.

And if a patient says something like "my pain is burning" versus "my pain is sharp", that signals to the provider different causes of pain, and that ultimately could signal different ways of managing that pain.

If you don't have a well-trained, competent medical provider or, I'm sorry, a medical translator who is able to communicate that, if you're just maybe using a family member or a support person who just kind of summarizes, that meaning can get lost and you might not receive the most effective care.

So, it's very important that health care providers and clinics have well-trained medical translators on staff, as well as Spanish-language consent forms and literature that can really help.

- I want to say I agree with you 100% on all of those points that you said.

Your research is super insightful.

But I think language and cultural competencies, when it comes to medicine overall, I should say, is super important, especially with dealing with the Hispanic community.

Doctor, I really appreciate your time with us today, and sharing your research and your insight.

Thank you.

- Thank you.

- I want to thank our St. Luke's University health network expert, Dr. Farooq A Qureshi, and our other guests, Dr. Michael Fishman and Dr. Nicole Hollingshead, for joining us today.

And thank you for tuning in.

We look forward to seeing you again soon.

If there's a medical subject you'd like for us to cover, send me a message on social media, you can find me on Facebook and Instagram.

Plus, you can tune in to hear more of my reporting on 91.3 FM WLVR News, your local NPR News source all day, every day.

I'm Genesis Ortega, and from all of us here at Lehigh Valley Public Media, stay safe, be healthy, and cheers to your health.