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Pain management.

When does it get bad enough?

When you have to seek other medical help other than just over-the-counter medication?

We've all heard about acupuncture, steroid shots, and also even surgery.

But have you ever heard about radiation medicine for chronic pain?

I haven't either, and I'm really looking forward to tonight's program.

This evening's program is underwritten by Rio Grande Cancer Specialists.

And we also want to say thank you to the El Paso County Medical Society for bringing this show to you.

I'm Kathrin Berg, and this is the El Paso Physician.

Neither the El Paso County Medical Society, its members nor PBS El Paso shall be responsible for the views, opinions or facts expressed by the panelists on this television program.

Please consult your doctor.

Thanks for joining us.

We're going to be talking about pain management.

All of us have felt pain in one way or the other.

And do we always take over-the-counter medications?

We talked about steroid shots.

We talked about acupuncture and then sometimes surgery.

But there is something new that I'm very excited to talk about.

Doctor Travis Mendel and I have talked through the years about just hints of what this is going to be all about, but with me this evening is Doctor Travis Mendel, who is the medical director of Rio Grande Cancer Specialists.

And also joining me is Brian Nabhan, who is the director of oncology at the Rio Grande Cancer Specialists as well.

So, Doctor Mendel, we've done several shows together, and I feel like every time you're on, there's like, what?

That's new and you're that guy.

So within tonight's discussion, what are we talking about with what you do all day, every day when it comes to pain management and radiation?

So I guess I can start by saying I'm a radiation oncologist.

So we typically use radiation therapy as a therapeutic for malignancies typically solid tumors.

And so my, my my De is I see patients who have majority of my patients have cancer diagnoses.

And we're we're working with the surgical, surgeon, surgical oncologist, the medical oncologist.

And we're as a team to kind of help these patients and hopefully cure these patients of their disease.

There's been a pretty big push in the US, more recently for more benign conditions.

And actually, radiation therapy has traditionally been used for, many benign conditions.

And so what we've been doing more treatments for is author osteoarthritis, stupid trans contractures, plantar fasciitis, these kind of inflammatory conditions that, many patients have and suffer from.

And so in that I, I'm again excited to talk about this because these are common everyday issues that the majority of us have as we start aging.

So thank you so much for being here.

And Brian, I want to say thank you for reaching out.

You reached out several months ago and said, hey, should we do a show about this?

I'm like, heck yeah, let's do so within your realm at Rio Grande Cancer Specialist, what is it that you do all day, every day?

So my role as the director of oncology, and I oversee the administrative and, and, clinical leadership for the group.

But I think the easiest way, for me to say what I do is I try to keep him as busy as possible.

Oh.

Lucky you.

He keeps me on line.

Yeah, it keeps you in line.

But he does like to take these vacations and go on these big hikes and everything.

So give him some room here and there and do that, right.

So I want to start off with.

And it seems so simple and it seems so benign, but when we talk about radiation therapy, it's the radiation therapy that we all know about about treating cancers.

Describe what physiologically radiation does the body treating cancers but then also pain management.

How how can you explain that to someone who's a layman and doesn't get it perfect?

Yeah.

So so radiation I mean, we use radiation and medicine, in many different ways.

I mean, we have Pet imaging, we have CT scans, we have X-ray scans.

I mean, we have all these scans.

We're using radiation to image patients.

We use radiation as the therapeutic and so the energy is much higher.

But you still you can't see it.

You can't feel it.

You're not going to be radioactive or anything like that.

You know, you really are.

You know, just receiving this therapy that's almost noninvasive.

Typically when we're using it to kill cancer, we're directing or focusing the radiation on the actual tumor.

It damages the DNA within those cells.

And tumors are really focused on replicating and growing.

They're not focused on repairing their DNA.

They kind of lose that ability as they become malignant.

And so the radiation when it does is a damage to the DNA.

The cells try to divide, but that's the roadmap you need to have.

Your your DNA is there to kind of guide the cell to make a new one, essentially.

And if it's damaged, the cell dies.

That's called apotheosis.

But with with with radiation in terms of, like benign conditions, it's specific specifically these inflammatory conditions, inflammatory cells are actually very sensitive to radiation.

The mechanism for how this works is still kind of gray, but the way I think about it is, you know, you have these inflammatory cells, they they they die almost immediately when they're exposed to radiation.

So if you have inflammation in one of your joints or your hands or your knees or whatever, and we treat you with very low doses of radiation, that it removes that inflammatory response inside the joint.

That's why these patients have relief, from from their pain.

So it sounds so, almost simple the way you're describing it.

And, Brian, I'd love for you to kind of hop in.

Is the director of the facility when you are describing the pain management with radiation to people who are coming in for the first time, or people who are being referred to your field for the first time, how is it that you are describing it to patients that are coming in, like the different options that they can, that they can have, right.

Well, you know, with with these patients, this is a relatively new service line for the group.

The patients that are coming in that are seeking, this type of treatment, they've probably been progressing through the health health care system where they started out taking over the counters.

Maybe even, got to, ortho and started getting injections or physical therapy.

It's an easy conversation to have with them.

When we tell them that this is noninvasive, it's not going to be a large interruption to their schedule.

It's also a short course of treatment.

For most patients, they're only looking at getting six fractions of radiation.

So expand a little bit on that.

Usually with, radiation for cancer treatment every day for, you know, I don't know, six, eight weeks.

And of course it's different with everything else.

So when you say it's short because again, I'm trying to think about what the laymen, what everybody at home is, is thinking about radiation and kind of changing the thought process of why and how this is different.

So when you're talking about a short course, when you say six treatments, is that within a couple of days?

Is that within a day, over a couple of weeks.

And I know everybody's different, but just in general, how does that how does that play out?

- Typically we're scheduling these patients twice a week for three weeks.

Okay.

It is a and and the treatment itself is also very brief.

Probably about ten minutes in the room.

Okay.

And so yes doctor.

So I was going to add so so we call this low dose radiation.

So for example, if I'm treating a prostate cancer I'm going to give it 70 units or 80 units of radiation.

This is a total of three over over six successions.

And so the dose is incredibly low.

And it's it's it's actually a comical one.

I remember before I started doing this, one of my friends out in East Texas set up a clinic similar to what we're we're establishing here.

And I thought it was a racket.

I was like, I was just like, this is no, it can't be easy.

And so I went and talked to and we were we're very close.

We were, in residency together.

And he, we were having a beer and he was just like, hey, man, let me show you this.

And he had this patient who was a painter, and the guy could barely open his hand and close it, you know, and he's in his 70s.

He's, you know, he's been a painter his whole life.

That's what he loves to do.

And he treated him.

And then the guy like, after treatments just like this.

Wow.

Ready to go?

So was he osteoarthritis?

Was that his his hands?

Yeah.

So he had his hands.

So he treated his entire his both of his hands.

And it doesn't last forever.

But you know the guy's going to get it probably a year or two of just like you get more mobility, less pain.

And he can do the things he loves versus just, you know, taking Tylenol and bearing, barely being able to hold the right brush.

Right.

And so once he told me that and I was like, I need to learn about this, really?

And on that note, I would like for you to kind of talk about you learning this specifically.

I mean, you're doing radiation oncology.

Yes.

But you you see this and you're thinking, wow, so talk about your training.

How do you obviously there's an interest there.

You want to dive in.

What's your training around this.

So it's it's really the techniques that we use to deliver the therapy are very basic.

It's like the the bit like the basic set ups that you learn in residency and things like that, just with extremely low doses.

And once, once I started kind of thinking, maybe this is something we should we should be offering the community.

I got radiation oncology is very like small community nationally.

There's not that many of us.

And so everyone knows each other.

And so I got in touch with Bobby Conroe, who's like the National leader in this.

And he, you know, he got on a phone call with me, went over.

He had a big, astro presentation maybe a year ago.

This is the National Radiation Oncology Group.

Within a week, he was on the phone with me on a, like, a virtual call for two hours, going over everything.

And then he has an ash.

Course that we all took.

Actually, there's probably eight of us that took it.

And they go over all the different conditions you can treat how to do it.

One dose to get the the biology behind it, things like that are or the, you know, expected biology behind it and things like that.

And so you get your little training certificate and things like that.

But it kind of it's, it's pretty basic, you know, it's it's not that difficult.

It's very safe.

And, you know, I have a couple of slides on this, but, you know, people are always worried about secondary malignancies and things like that.

And so we are, you know, very conscious of, of that risk.

And so usually we're offering this to patients that are over 40.

We definitely don't want to be doing this to like an 18 year old or something like that because they're at higher risk of developing can't they're going to live longer.

And so the risk is higher as they live longer.

But, but the, the, the secondary malignancy risk in terms of like treating your hand or your knee or your elbow or something like that is the same, almost the same as getting a CT scan of your abdomen and pelvis.

Yeah, I read that.

And I thought to myself, okay, how many times you get dental X-rays?

You know, just right.

Right.

And so the risk is extremely low to these different areas.

And the dose is very low.

And so to me that if there's if there's going to be a benefit for the patients and there's the risk of harming anyone is extremely low.

Right.

It's like, you know, done deal in my eyes.

Right.

So I want to get back to I'm going to ask Brian a question, but I do want to get back to osteoarthritis because I feel like of all the things that we have here, that's one of the biggest that all of us deal with.

I'm 58, as I said earlier, so I'm starting to feel a little things here and there.

And so like, what is it to like you too?

You guys are so young.

And Brian, when when Doctor Mendel was talking about the biology of all this.

So the biology of the radiation.

If you could break that down, I know you were talking about again, is trying.

It's inflammation.

You know, you're trying to break that down.

So with this radiation and you're learning about the biology of this radiation and how it affects physiologically, every person.

Is there something that stuck out to you when you were going through the trainings of, I didn't know that this could be this simple.

You know, that's a great question because I myself am also a radiation therapist.

So I, I've been treating, patients, on our, treatment equipment for almost 15 years now.

And when we started talking about the use of radiation for, benign conditions, it was scary for me because I know the, the biology of how radiation affects, you know, our cells.

But once we started doing the, the the training, and we had an opportunity to get a better understanding of, what dose ranges.

We were looking at the field set ups that we were, that we were going to be using.

It really alleviated a lot of that initial gut reaction to want to protect the patients.

And it, it became clear pretty quickly that this was going to be something that was really going to benefit our community.

And how long has this, therapy.

I know you said your radiation therapy.

How long is this type of pain management radiation therapy been around?

I know when you said you came across it, it's been around for decades.

Yes, yes.

Okay.

So that actually used to be more common.

But because of this, this push to kind of get rid of radiation, because it's dangerous, it kind of went by the wayside in the US.

However, in Europe, specifically in Germany, it is an extremely common treatment and actually almost half the patients receiving radiation therapy in Germany are receiving it for a benign condition.

And it's hilarious.

I have a there's a slide in there of Hussein Bolt.

He's that guy who's, who's sitting on like next to the, linear accelerator, but he's he's the world's fastest man.

You were editing later.

It's it's slide number seven, but.

Yeah.

Okay.

But he, he, you know, he in the real games won 3 or 4 gold medals.

And before it, before his race, he developed plants or fasciitis.

And so his, his trainer was German, knew about this therapy and put him in a plane, took him off, got him his treatments, came back.

The dude, the guy who won, you know, wow.

Many gold medals.

And he was suffering from plantar fasciitis, which I don't know if you've ever had before, but it is very--I haven't.

I know I talked about osteoarthritis, but let's let's go to to plantar fasciitis really quick cause I know a lot of people will have knock on wood.

I haven't.

That would be great to physiologically explain what is happening in your foot with plantar fasciitis.

So you're developing almost like a, like a chronic inflammation in the like the plant.

The bottom part that's called the plantar aspect of your foot.

And and it's it's very common in runners like I run quite a bit and it's almost everyone gets it but it goes away, you know, I get it, I get it pretty frequently.

And, you know, I'll get it.

I'll, freeze and I, water bottle and I'll put that on my foot and I'll just rub it out and, you know, it lasts for maybe like a week or so, and I'm sore, but I can still kind of run, you know, it's okay, but some people get it and it lasts for like 3 to 6 months.

And when it's bad, it really hurts.

It's you can't even you really can't put pain like a weight on your foot because of the pain.

And so I can't even fathom having that for six months.

I mean, you couldn't you there's no way you could train.

And mostly people that are getting this, they're they're athletes, right?

They're they're like, that's what they like to do is exercise and run.

And so you take that away from someone for 3 to 6 months.

It's it's messes with them.

Yeah.

Because you're, you're you're getting out of shape.

You can't do what you like to do.

You know, you're you're emotionally you're you're all a wreck because you're just like, stressed out all the time because you haven't been exercising.

Thats what happens to happens to me.

I don't exercise, I'm just like, yeah, can't, can't control myself.

That release.

But but basically this this is, you know, a, an option for patients, who, who have this kind of chronic plantar fasciitis and need and need it fixed, like, you know, the same bowl, right?

But, you know, they've studied this.

There's a, you know, there's a study in here where they compared the radiation therapy to actually steroid injections.

So these patient with these patients with plantar fasciitis, the radiation therapy was twice as effective, you know, just like nine day better.

And so in Europe this is this is like a common therapy here.

People just don't it doesn't even come to so the providers minds.

And the issue that we have is it's just it's really just education.

And so what we've been doing is going around and talking to some of the primary care doctors and things, the sports medicine, physicians, orthopedics, just to explain to them, hey, this is an option for your patients because I'm not going to see these patients, right?

I'm seeing you need to be referred to.

All right.

I have some patients that are like my hands hurt, like, you know, I heard I heard about this or whatever, and we help them, but it's really more of a community education, right?

Kind of situation where, like, where a lot of our, like, referring providers are now like family practice, physician, those that are sending their patients with arthritis or plantar fasciitis or dupuytren's and all these benign conditions that, you know, they had no clue about this, but the patients like it, you know?

Yeah, they get relief.

Some of the patients get relief, even like while reversing the treatments.

It's been like they've had like 2 or 3 treatments and they're like, my arm feels, my shoulder feels better.

It's all there.

It's all.

So I would like, Brian, if you could so explain for people who are completely unfamiliar with any kind of radiation treatment, therapy, etc., so let's say plantar fasciitis, and they're now in the room with the radiation machine.

Describe what it is that that happens to you.

If it's on your foot, do you just have the radiation machine over your foot?

Like just describe what was going on in the room while you're getting a treatment.

And you might want to bring up the CT simulation.

Sure.

Yeah.

Okay.

It's it's it actually starts well before going into the room for the treatment.

Okay.

You know, one of the, first steps in the process is to come in and have a CT scan performed, for whatever the treatment is.

And you'll come into the clinic, you'll, be escorted into the CT room, placed on to the table, into a position that's going to be conducive for your particular treatment.

Breasts, prostate or plantar fasciitis?

In, in that CT scan.

It we refer to it as a, as a CT simulation.

We're placing you into that actual treatment position that you would be in for your treatments.

You're scanned at that time.

That scan is used, by our physicist, physics department and our dosimetrist to plan out the geometric, the, the geometry for your, your treatment.

Okay.

And how the machine is going to deliver those little packets of radiation to your treatment area.

Okay.

And you don't feel anything, I think that's important for the audience to know that you don't feel it.

And that's, again, for people who are not familiar with it.

How does it feel?

You know, throw that out there if it feels boring.

Okay.

That's what I always tell patients That's a good thing that it feels boring because, so many people will, will work themselves up thinking that that they're going to to feel something or they'll hear from family members.

Oh, you're going to you'll you'll feel it burning you or you'll feel a tingling.

We leave the room.

We don't want to be in there when when the radiation is being delivered.

We want that all for our patients.

So we leave the room, we deliver the treatment, and we come back in.

And invariably, often patients will say, when are you going to start?

Oh, do we say we're done already?

Wow.

You know.

Beautiful.

Yeah.

Okay.

So let's go to our osteoarthritis now.

And let's go to hands because I feel like that's where a lot of people feel it.

So what I'd like to do first is kind of describe the symptoms that people come to you with.

Like, this is what I'm feeling.

Thumbs, fingers.

In general.

You were just talking about the pain.

I love case studies.

You know how I love case studies.

So there's this painter that comes in.

He is maybe through the years, unable to start moving a digit, 2 or 3 digits.

Talk about how that starts.

Then we get to a point where let's see if we can do some pain medication with radiation.

I mean, everyone's a little a little different.

I think some people sometimes have just like focal areas of arthritis, like in one joint or two.

Some people have it all over their entire hand.

You know, it's the patients will come in for a consultation and we'll kind of take a history and see what's what's been going on.

I mean, and if it's a patient that's just like, oh, my hand is a little bit sore.

And, you know, I, you know, maybe I'll take a Tylenol once a week and I'm fine.

That is not a patient that we're going to be treating.

This is a we're looking for patients that are like I've had, you know, multiple surgeries on my hand because I have this arthritis I'm taking, you know, narcotics or, you know, ibuprofen eight hundreds every day, which is not good for you.

And so those are the patients we're kind of targeting.

These are the, you know, the patients that are kind of like heading towards some type of, you know, much more invasive intervention.

Like a great example would be like, like a knee replacement or a hip replacement.

These kind of like, you know, pretty invasive procedures, which are 100% necessary in a lot of individuals.

But a lot of patients, you know, they'd rather just kind of like postpone it, or you have your guy who's 80 years old and he doesn't want to have a huge surgery, you know, so these kind of, these kind of things are, you know, we're offering this to the patients so that they can kind of kick the can down the road, maybe avoid it, if possible.

But, you know, to go back to your question, you know, we evaluate the patients.

Typically we want to make sure that they've had some type of intervention.

You know, whether it's just been like, they've been on Tylenol.

That's fine.

But we don't want patients taking, you know, pain medication every single day because of their arthritis.

And I know a lot of people who do.

Oh, yeah.

Like I said, it's not it's not good for the system.

And I'm the first one if I have like a sore muscle or like my knee hurts from running or something, I'm like Tylenol, ibuprofen.

I'm like, let's go, but I don't I, I would do it for like a week tops.

If it's more than that.

It's not like ibuprofen particularly is not good for your stomach.

It's not good for your kidneys.

And especially as you get older, these these effects are much more substantial than, you know, a guy in his 30s.

So, so we start the treatment now on this person has a hand.

You were talking about each joint is different.

Is radiation then given to like is it pinpointed where.

A little bit to this joint a little bit to this joint.

You talked about low dose.

So I don't know if that's something that goes everywhere.

Yeah.

So typically what we do the main thing I'm worried about is people losing their fingernails.

And so what we do when we set them up for a CT or CT simulation, we put some wires on their nails so we know exactly where their nails are.

And we can avoid them.

So to help prevent that from happening, I've never seen it happen, but theoretically it could some people would treat the individual joints in my eyes, the dose is so incredibly low that I just treat the whole hand like if they have, you know, pain here, some pain here.

I'll just treat the entire way.

Everything gets hand.

Yeah.

Everything gets the love.

Yeah.

Okay.

Yeah.

And the dose, it's just incredibly low.

There's like absolutely no way of, like harming someone or like, you know, preventing them from having some type of, like, surgery in the future or anything like that.

And so I just treat the whole hand and you can do this several times.

So, so say the patient responds or they have a partial response or something like that.

At three months after the treatment, we'll treat them again and hopefully give them more pain relief.

Or say this patient their-have their their arthritis has been good for two years after their treatment.

Now they're back saying it's coming back.

Then you treat them again you know and the dose the dose that you're giving is is is honestly it's the it's--in one treatment that I give for like regular cancers, like one of the fractions over the course of like 1 to 2 months.

That's what you're getting in six treatments.

Oh wow.

It's the doses just like so it is low love.

Yeah.

And that's something I really want to to get across today because I think just the word radiation, for the lack of a better word, kind of scares people.

So if we can do talk about and you said again, it's like doing one scan or again, I look at dental X-rays.

I mean, if you go to the dentist regularly, you get one every year.

And that that is radiation, you know, give me cancer.

Yeah.

none even ask--my brother's a pilot, you know, and I'm thinking, okay, he talks about radiation that you get when you're an airplane.

People talk about that kind of radiation.

So it just in the idea of, putting it into perspective for people of, okay, when you take an airplane ride, you get so much radiation anyway.

People don't think about that.

So coming into this type of a specific area of not feeling the fear, so to speak.

So I know I have a lot of your slides here, and I don't know if you're able to pull them up on there, but I would love for you to kind of go through the slides that you think are the most important slides, to touch base on.

I know we talked a little bit about plantar fasciitis.

Osteoarthritis, humeral epicond--dee-la-lapothy So that's that's yeah, that's great for a team that's, golfer tennis elbow.

Oh there.

So why not just say tennis elbow okay.

Tennis or golf elbow.

Oh my gosh.

So that's a big one too.

Yeah.

So we have a lot of golfers in my practice and there they come and want us to treat their elbow or whatever.

And right can keep playing.

So that's another thing too when someone gets tennis elbow.

And I know we've been talking about inflammation right.

What exactly is it.

Overuse obviously hit why is it getting inflamed.

It's just it's it's just the like having a, like, chronically and inflamed joint or tendon that's there and usually like with golf golf or tennis elbow if you, if you just kind of rest and ice it it goes away.

Right.

I've had I play golf and I've played a little tennis but I've gotten, I've gotten is these like I got a golf elbow before and it goes away after a week.

But these are the patients we're treating or the patients that it's it's been there for months and it's not going away.

And so, you know, the patients that are like, just out, you know, shagging balls right now and my, my elbow hurts.

That's not the patient you want to treat.

You want to treat these guys.

I was like, I haven't been able to play golf for six months.

And it's like, that's the only thing I like to do in my life right now, you know?

And so.

So those are the patients you you want to you want to treat.

And the guys that have been, you know, been in pain for maybe a week or two, you know, just have them take some Tylenol.

ice it, rest and then it usually your body will heal on its own.

So in the opening of this show, I was thinking, when do you know it's time to have true intervention?

Yeah.

So a week or two?

No.

But if someone has been feeling it for months.

Yeah, months is kind of the deal.

And here, you know they kind of talk about like what are we who are we targeting.

You know, who's a candidate.

And it's like arthritis in the knee.

There's a there's a good slide here where you have physical therapy, weight loss, topical therapies, maybe some NSAIDs.

But once you're starting NSAIDs or like ibuprofen, naproxen, these kind of medications that you can get over the counter once you start getting into narcotic pain medication, steroid injections, hyaluronic acid injections, like surgical interventions, whether it's, you know, cleaning out your joint or going in and doing a total like a total knee replacement, those we're trying to capture the patients from the taking a like a little bit of medications versus full on surgery.

We want to capture them right here in the middle to help prevent them from having to go through these like more invasive procedures.

And just like everything, it doesn't work forever.

And that's, I don't know if you've ever had, like, steroid injections before, but they really only last for, you know, 4 to 6 months, and then you have to get another injection and then they become as you get more injections, they become less and less responsive.

And your, you know, your arthritis comes back.

Now it's, you know, you've had three injections, now it's coming back at three months, these kind of things.

And I'm assuming that's probably the same with the radiation is it's just like your joints getting a little bit more beat up over the years.

And now you're having more arthritis.

Right.

But it's just that chronic the chronic inflammation.

And you know, the picture here is kind of shows you, you know, you have your normal joint.

It you know yeah looks smooth, healthy.

But you start getting chronic inflammation.

And the inflammatory effects just kind of damage the interior of the joint to where it gets becomes so damaged that it cannot, you know, function or repair itself.

And those are the patients I go on to get total knee replacements okay.

Yeah.

Gotcha I have yes, Brian, I was just going to say, I think one of the best ways to look at it is this is not a first line therapy for for the treatment of these conditions.

This is when you, you, have is, as we said, a couple of times, chronic, chronic and acute pain.

That is not going to be controlled with over-the-counter medication or even physical therapy anymore, where you've got to start looking at that next step.

Yeah, I'm trying to see it almost like the middle stage.

Right.

It's not in the very beginning.

You're hurting for several months before we even consider surgery.

Maybe give this a shot.

And you were saying earlier, and I was reading my paper as you were talking, but you were saying that you can't get a full treatment.

You know, there's the three weeks or whatever you need to do.

It lasts a year or two years, maybe another treatment.

So that's that's also something that's an option.

Like you were talking about this painter.

You said this is probably going to last for about two years.

And he's almost 80.

Would he then would the option be then for him to get radiation again.

Sure.

And would there be a certain stopping point or so.

So everyone has their limit.

Right.

Right.

Okay.

So the tissue, you know, the tissue every tissue has it's kind of like life long exposure, maximum to radiation.

You know, I think for me, you know, if it's if the patients come like 5 or 6 times, I'm probably where I'm going to say, yeah, this isn't really working that well for you.

You don't want to keep doing it.

But, you know, if it's the second or third time and it's very common to come back at three months and you've had a partial response.

So, so the statistics on it are, at least at least 70 to 80% of patients will have some pain response.

So the majority of patients will will respond.

But what we're looking for is a complete response in the pain.

And so they typically they come back at three months.

Half of the patients that that have had a response will most likely require another treatment because they've only just had a partial response.

They feel better and they're like, man, it's so much better now.

But I still have it right.

We hit them again so they can we can hopefully get them to a complete response in the pain so they don't have to take anything for it.

So I'm just trying to understand and say this out loud.

So what we're looking at doing is decreasing inflammation.

And I am going to ask a selfish question.

I again, I'm 58 so I have adhesive capsulitis of my shoulder.

And it's supposed to take about two years to go away unless you do something with it.

Is this something that could be an option as well?

And maybe we can Frozen's frozen shoulder is what a lot of people call it.

You know, if somebody call the 40 year old shoulder and they're frozen shoulder.

So and I figured I thought, what did I do to my shoulder?

And it was just hurting for months.

And I finally went to an orthopedic and he said, yeah, you got typical frozen shoulder.

Just stretch it, do exercises.

But it hurts.

Is this something that could be an option for that?

Because I know that we're looking at joints.

So it's it's probably has not been studied okay.

That specific condition okay.

And I think it's probably less likely to respond than like arthritis in your shoulder because it's not a joint.

Yeah.

Right.

Is that well it's a joint.

But I think, you know, when you're talking about frozen shoulder it's more of you have like the the scar tissues in there.

It's already formed.

Kind of like that picture I showed you.

It's already in there.

And it's just, like, sticking to itself, and then it can't move.

You know, whether or not the radiation would help prevent that, you know, that from freezing up again.

I'm not sure.

I've treated quite a few shoulders at this point.

And it's been it's been, kind of fascinating to see the responses because some of the guys, one of the guys I have that has a he's like frozen shoulder, he can't really move it.

It didn't really do much for him.

Okay.

To be honest.

Okay.

You know, and I have another guy that just have arthritis to the point where he couldn't even lay on his shoulder at night.

And by his last treatment, he's, like, moving his arm to me.

I can't lay on my shoulder at all.

Yeah.

So it's the same same thing with this guy.

So he, you know, after his last treatment he's laying on, it's sleeping on the shoulder.

He's fine, he's happy.

He's like, look at my arm.

I can move it.

He's all happy.

So this is a perfect transition is what shoulder issues can be treated with this.

So we were talking about rotator cuff earlier right.

Rotator cuff syndrome.

And I know we have slide 15 in here that that talks about that.

So with that and treating it how maybe let's talk about the rotator cuff again physiologically for people that don't know what is going on in the rotator cuff when that syndrome is affecting a person, I mean, I think you know, any, any condition that's like inflammatory in nature, I think would would be a candidate for at least trying it.

You know, your, your, your shoulder is, is your most like mobile joint.

Right.

And so that's why there's, I've had so many sort short shoulder injuries just because like playing football right.

You know golfing and all these things.

So so it's like this joint that that is susceptible to kind of damage because it's just so mobile.

You know, it can you can you can pop your socket out.

Right.

So so I think anything that's like kind of associated with inflammation, I think has a chance of working.

And I, you know, we've had patients where it's not kind of like the standard thing.

You would, you would think of like arthritis of the shoulder, but where like my shoulder hurts all the time and we treat them and you know, some of them have a response and some don't.

And to me, you know, especially a guy that's like seventy years old, there's really no harm in giving it a shot, right?

You know, like they don't really have any other option.

They're kind of just miserable, you know, like, we'll get we'll give it a shot.

You know, it's not going to hurt you.

It's, you know, it might work.

It might not.

And and most of them are like, go for it.

Exactly.

And Brian, I'll ask you how how how is the evaluation done.

So somebody comes in and says my shoulder hurts all the time.

What is it that you all do to, for the lack of a better word, diagnose it.

You know, whether it's isolated capsulitis is it.

Rotator cuff issues.

Is it just joints messing up?

How is it that you go in.

What imaging do you use to diagnose what's going on to see what the treatment will be going forward?

We need Beth here for this.

So so we have a first vest.

Yeah.

So we, my pa, she's, is probably the most meticulous person I've ever met.

So she has with all these diagnoses, all the criteria that meet that diagnosis.

On her note, and so she'll, majority of time, she actually meets the patient in consultation.

And we'll go over their diagnosis, their history.

And then she has in her note all the criteria to make that diagnosis.

And most of these are clinical, like you can like with plants or fasciitis, you can get an MRI or a CT scan and see the little bone spur and stuff like that.

But it's most of this is clinical where you're just kind of ticking off the box of, you know, how long has it been and what have you done for it?

You know, yeah.

You know, there's is it swollen?

There's all these different criteria, that will allow you to meet that diagnosis.

And a lot of the patients come in with that diagnosis already because they've been seeing their PCP or their orthopedic, you know, physician.

And they've they've already came with that diagnosis.

And so we already know they have that.

So we just, you know, manage it that way okay.

But it's definitely you know, most of this is clinical as it's sitting down with the patient for 30 minutes and trying to like decipher what's been going on and why they have this pain.

Especially if it's a new diagnosis.

Right.

And with diagnosis.

And this is always the ugly question to ask doctors, but with a diagnosis is insurance and medically necessary, etc., etc.. And it's an ugly question, but people always want to know.

So if it's pain management or you were talking about benign and the word benign to me with insurance like, well, it's benign how in general.

And I know you have someone at your office that deals with this, and I know it's an ugly question and would have spent a long time on it, but in general, how does that how does that fit Brian, for this?

Brian, you're the guy because you're the director.

Yes.

After all, surprisingly, we have had little to no, kickback from the insurance companies.

Very nice.

It is a service that's covered by almost all insurances.

The patients generally, if they, have a deductible or a co-payment that goes with their with their insurance.

This kind of goes along with that.

Okay.

You know, this falls into there I like that.

But yeah it is a service that is covered by the majority of insurances.

And that was my first question when this was brought up.

Like, are the patients having to pay for this?

or is this by the insurance?

Yeah.

And even the insurers that are notorious or just being a huge pain in the butt.

Right.

They've been covering it and it's in their guidelines okay.

Yeah.

So so I mean yeah I mean we've we've had a couple of issues with the image guidance.

And so we, we typically take images before we deliver therapy to, to assure that we're, we're treating the right area.

We basically we use the CT simulation and we match up the current position of the patient to the CT scan.

So we know we're delivering it directly how we had planned it.

We've had some issues with that, which is not a big deal.

We're just like whatever.

But but that's really been the only thing, right?

Which to me doesn't seem like a lot at all.

You know, I'm dealing with some stuff with my son and, you know, surgeries.

Right.

Well, it's not necessary.

And so, yeah, it's just it's just hard for people who, again, diagnosis.

Where do you go from there?

And I want to say this out loud again to in case somebody wants to come, that this is something for the most part, is covered with insurances.

Yes.

You were talking about I'm not going to try to pronounce this dupuytren's contractures.

So that's when you patients will develop this kind of scar, scar tissue, these little nodules that I don't know if you've ever seen people with like a trigger.

So.

Yes, just it just goes like that.

And Steve very familiar with that.

Yes.

So this what we do with radiation as well as that's happening, you know, this is something that happens over the course of like, you know, months to years, right, where you just develop this, these little nodules and your fingers just start kind of going like that.

And to fix this, like a fully contracted finger, they have to slice open your hand and then relieve all those cords and tendons that are, that are kind of bunched up.

Yeah.

Contracted in your hand.

And there's a great picture of what your hand looks like.

You know what I mean?

It too is I feel like that.

And that doesn't look very pleasant to me at all.

Right.

And so what we do is, as this is forming and we're in the process of going to talk to some of the hand surgeons is when, when this, this is happening and you can see you, you can feel the nodules and things like that, that's the perfect time to do the radiation because it stops the for the formation of those nodules and the contraction in the hands.

And it's actually like quite successful.

I mean, it's probably like 70, 80% of the patients will have like a complete like like wow, remission or it just kind of stops.

It usually doesn't like the if the fingers say the fingers like this and we treated them, it won't it won't go back to normal, but it'll prevent it from getting from getting a full contracture.

Okay, essentially.

And the pain that is associated with that too is phenomenal.

I mean, just like, well, you just can't like, you just can't open your hand.

And of course, I mean, we use our hands for everything.

And I, I don't know if you've ever, like, hurt your finger and you didn't realize, like, man, I use my little finger so much.

It's like everyday, all day long, specially for the teeth, you know.

So I can imagine if your hands are just, like, closed and you just can't, like.

Yeah, you know, what do you do.

Yeah.

Right.

Especially when you're older.

So, so I think this is a this is a cool cool therapy.

It's definitely something that we need to spend more time, you know discussing with the hand surgeons and things like that.

And so when people see this on this screen you're talking about covering the finger the tips of the fingers here.

And so with radiation again you are radiating the entire hand with low dose so that it kind of spreads everywhere and try to help.

Is that correct?

Yeah.

So the technique for this, this one specifically we actually use higher doses for the dupuytren's contractures.

And we use typically a technique called electron therapy.

So we, we fire electrons at the, at the hand.

And they only they only penetrate superficially.

They don't go all the way through your hand like an x ray would.

And so we usually put, a material.

It's like fake skin on your hand.

And then we treat, we treat kind of the, the, the, maybe have half the depth of your hand or something like that.

In order, in order to kind of disrupt these inflammatory and, like, scar tissue formation in there, there's another there's another, process called Peyronie's disease, where men, when they, have an erection, they have a very similar type of scar tissue that forms, on the shaft of the penis.

And it causes it's a curve when they have an erection, and we do radiation for that.

Okay.

And it's it's fascinating because we we're able to prevent this from actually the actual plaque from forming in these patients again, physiologically, just so I understand it.

So you're looking at you have plaque in there.

You have the curvature.

Whatever is the radiation breaking up.

It's that tissue.

It's preventing further for like formation of the plaque.

And so the plaque forms.

And just like a scar like it'll it'll contract and it gets firm, it'll pull the skin.

And you always see everything's tight.

It's the same thing internally with these conditions.

And we're preventing the scar from forming.

And the issue is that the treatments that we give for patients now, we wait for the scar, like the was a there's an injection that we can give to help the surgery and things like that.

They wait until the scars completely formed before they do any type of intervention like this.

And so we're at the part where we're like, well, why don't we try this first?

And then if they, they need the injection or whatever the surgery afterwards, do the surgery or give the injection, it's not going to prevent them from having that.

But at least we're able to, to, to hopefully prevent it from happening.

In you know majority of patients.

Right.

It's just no one knows about it.

Yeah.

All right.

So yeah we have to go out and educate and and that's Brian's job right.

He's out here telling people about it.

And I love everything about that.

Parkinson's tremor.

Again, I'm just trying to think of things that people are familiar with because we know a lot of people that they have a tremor.

It goes away, it comes back.

How can radiation, benign radiation therapy help with that?

So some some of these are are more novel and they're being explored.

Parkinson's is one of those that's being explored.

Alzheimer's is being explored.

And these are these are things that we think are going to be become more prominent in the future because people are kind of studying it.

The Alzheimer's specifically, that study was, was on a like 20 patients, but 60% of them had a, you know, reduction in their in their, Alzheimer's and like diminished, formation of other symptoms.

And so they think that, you know, the interaction with the radiation is in the brain is helping prevent, prevent the preventing that disease process.

Wow.

But but all these all these things, they're all they're kind of associated with, you know, like it's they're very different.

Right?

So like the Aboriginal neuralgia that you're actually damaging the, the, the nerve root that's like, that's causing all the pain for these patients.

And you're giving it a massive dose of radiation.

But it's pinpoint right on the nerve.

Right.

And it it works very well.

It doesn't work forever, but it works for several years because you're actually damaging the nerve in these cases.

You know, in Alzheimer's you're giving a lower dose to, to help like, like, disrupt the actual process for the disease, not damage the brain tissue.

And all of these are like, all different, like gynecomastia formation we have that's like developing breasts and men, which, you know, can be quite painful.

And so we have guys that are on androgen deprivation therapy for prostate cancer, and they start developing breast buds.

And it's very it's extremely painful.

They can't have shirts on and they're like, oh it's terrible.

And we just treat that with with actually two high doses of radiation.

They have like a little sunburn in a circle.

So don't go swimming after that.

But but you know, it's, it just freezes the formation of the breast tissue.

And so they have a reduction in pain.

They don't develop, you know, more breast tissue, which of course, the guys are all stressed about when they discuss these things.

So.

And so that would be going on during treatment for prostate cancer.

So after they're done treating prostate cancer then that's not an issue anymore.

So it's like a one time treatment for something like that.

Yeah.

Yeah.

Typically what ends up happening is the patients like if you have high risk cancer you're on the hormone suppression for sometimes years.

And and nowadays it's not as common as it was before.

But now with these novel hormonal agents that we have, we're able to, to, that have less side effects, but they have more risk of developing gynecomastia.

And the rates are like 70 to 80% of the patients that are receiving these things.

So we do this very frequently where they come in and they're like, what is going on?

And we just fix it.

You just fix it.

Yeah.

I've just been given the ten minute mark.

And so what I usually do at this point and Brian, I need to get you to, to do some more talking.

That's my bad.

Sorry.

No.

No.

Yeah.

Stop.

I like listening to.

What are you excited about?

When I say that, it's.

I try to use the end of the show, usually of what is coming up like this to me.

So it's been going on for decades.

Kind of went away for a while because the scary word of radiation coming back into play, what do you see 5 to 10 years from now in this space?

I see it, you know, educating people, people coming to try it out anytime you try something out.

There's more research on that, which I think is always a good thing.

It's not clinical studies.

This is real, ongoing treatment that you all are doing.

But in general, in your role, what do you see in this space?

5 to 10 years from now?

I see this continuing to grow.

I mean, you've got a great list of, of, conditions there.

That, some are currently being treated some are still in that, exploratory phase.

I see that list continuing to get larger and larger as more, research is done on different conditions that can be treated as it becomes more mainstream.

You know, as Doctor Mendel mentioned, this has been, very common in a lot of European countries, Germany, for sure.

For a very long time as it starts to become, or as it starts to get adapted into the, the American landscape of, of treatment.

It'll be very interesting to see the, the research that's done.

It's exciting because this is something that, you know, our community here in El Paso, we're usually not on the the cutting edge.

You know, we we wait to see is a good one.

Like this guy.

Yeah, but we wait a good 5 or 8 years typically to, to start doing things in El Paso that are, that are common in other areas.

This is one of those cases where we're ahead of the curve here.

And I want to reiterate that you said that insurances, for the most part are picking it up.

And and the way I look at too is research is once an insurance company covers something, then there's more ability for things to move forward.

So I want to re say that, that this is something that that can be open and going forward.

And there's something more you think about.

Let me know.

You always have like a laundry list of things that are coming up.

Oh yeah.

In this space, what do you see the next five, ten years, even 20 years?

Well, I really think that, people are really exploring more of these benign conditions and just, you know, kind of experimenting with it.

But a lot of times, the one, the one thing that comes to mind right now is, is, refractory ventricular tachycardia.

So these are patients.

Can you say that slowly.

So we're looking at heart tachycardia.

Okay.

Like your heart rate going very fast.

And you're not able to stop it in these patients.

I mean, it's just basically a death sentence, and they have, there's a there's a study that was published probably 5 or 10 years ago now, where they did high dose focused radiation treatments to the heart.

And these these patients responded.

And they had they had a massive reduction in the, these episodes that they have a tachycardia.

And this, these, these patients are like in the ICU, you know, and they're on their all kinds of medications.

And what, what we've been doing before is essentially your heart's like a circuit.

So you have like electrical pulses that go through.

And that's what that's how how your heart pumps.

And you can develop a little scar tissue or, you know, an area schema, something like that, to where the circuit just goes in a circle and keeps, you know, keeps sending off the signals for your heart to beat, essentially.

And so it just it goes around and your heart starts beating very fast, but it doesn't effectively pump blood because it's been way too fast.

Right.

And so what they'll do is they'll go in there and they'll try to disrupt that area of, of the circuit, and they'll go in there and burn it or whatever.

And we we've discovered that you can actually use radiation to go in there and target that area and then reduce, reduce the circuit by damaging the cardiac tissue there.

And so there's a lot of when you're saying all this, I'm thinking almost like an ablation when you go in there.

Okay.

All right.

And when we sbrt stands for stereotactic body radiotherapy.

Okay.

One of my mentors who's very big in the field, he used to call it saber, and he'd always have his, his, his PowerPoints presentation.

And he's a he's a farmer.

And so you'd have cows and stuff like that.

And he lives in Fort Worth, but he'd always have himself on there holding a light saber.

And is it standing It was standing for ablation therapy.

This is for ablation.

And so we're these high doses of radiation.

Instead of thinking, oh, we're, we're damaging the DNA in the cells.

The dose is so high, we're essentially a ablating the cancer.

And so we do these techniques very frequently for, you know, metastatic disease, things like that.

Brain tumors.

But this, these benign conditions that, you know, no one would have thought in a million years that this would be something that would be beneficial for these patients.

But we're starting to see, well, maybe, maybe it does help.

You know, one of the other ones that that I was, listening to a talk on were patients with sciatica or they're going in and they're, they're just locally treating the nerve root that's causing the pain.

Wow.

And it's okay.

That's the patients are having, like, significant improvements in their sciatica because that is very, very specific.

Okay.

Yeah.

So you're just damaging the nerve root with radiation.

Nothing else.

Just the nerve root and you're relieving the pain just like you would with trigeminal neuralgia or any kind of other, you know like nerve related pain.

And so people have a lot of very strange nerve conditions that can be like completely debilitating.

I trigeminal neuralgia can be, can be terrible.

Tell people what that is.

So it's basically when you have severe like this constant horrible pain in your from your trigeminal nerve, which innervates your entire like half your face.

And so they'll have, they'll, they'll just have this, this excruciating pain that's just completely debilitating.

They can't do anything.

And they'll take all kinds of these, like, neuroleptics and different medications to try to help, and it typically doesn't.

And we very, very commonly do radiation to this, typically with a gamma knife or some type of, boutique machine.

And it works very well.

And they, you know, it's, it's just a, it's a very it's a very well known in the neuro like neurosurgical realm, treatment for this disorder.

But they're exploring these other nerve disorders, like, you can have, like a glass of pharyngeal nerve pain.

You can have you know, sciatica.

These kind of these are all nerve related pains.

And so they're kind of looking in, to see how, you know, if we can treat that nerve in the same.

It's the same thing is doing in the trigeminal neuralgia that's just in a different site.

And then these patients, you know, potentially would have tremendous pain relief without having to, you know, do injections and surgery, right?

Depression surgeries and all these things that, that we do.

And so you were talking about I'm going back to programs like trauma programs where somebody like putting together some of these hand again and then reconnecting nerves that nerves have a way of do they regenerate.

And so when you're talking about that addressing a nerve situation, and then the nerve tries to heal itself after you're trying.

So that's when maybe the the next treatment might come.

I'm just trying to again physiologically figure out how how that works.

So for trigeminal neuralgia, I, I spend a lot of time on the gamma knife in Dallas, but, but basically you'll you'll treat it and the patients will sometimes have, like, paresthesia like, it'll get numb and things like that because you just killed the nerve, but it comes back and the nerve grows, and then it can it can, you know, the trigeminal neuralgia can come back, but at least they had relief for a year or two.

And patients like these patients are miserable, like they are begging for anything because they just can't function.

It's just terrible pain.

And it's the same thing with back pain.

I mean, you're like, you know, my back hurts and I complain about it, but I can't even imagine what I'm going to be.

I'm in my head as you guys are talking.

I'm like, I got this, I got this, I got this.

Oh, yeah, no kidding.

And then you see all these people kind of one thing around and stuff and I'm like, well, that's problem.

There's hope for us.

Yeah.

Right.

Yeah.

Just radiate half my body and I'll be okay.

Right.

Well we were talking about like osteoarthritis which may not always be osteoarthritis.

Right.

But who does not have knee pain.

Shoulder pain.

Even ankle pain.

Just as we get older, whether it's arthritis or not, it's wear and tear.

It is.

You were talking about being an athlete.

We've done a lot of things that kind of beat ourselves up.

And I'm saying that too.

And Brian, I will give this to you when people are listening to this program and they're thinking, okay, can I just call you guys outright?

Do you need to be referred by a physician to come see you guys?

How does that how does that work with people who are who are around and listening to this?

Yeah, our our end goal is to help these people.

Right.

We would love to have a primary doctor, who's involved with their current care, for the issue, refer that patient over.

But anyone is welcome to refer Self-refer.

Okay.

Get on to our website.

They can reach out to us RGCSHope.com.

There you go.

I was going to say this is the Rio Grande cancer specialist.

We are out of time.

But man I could do this topic 12 different times and still learn stuff.

Again, we've had Doctor Travis Mendel with us.

We've had Brian Nabhan with us.

And this has been: "No Scalpels Needed".

I kind of love the title Radiation Medicine for Chronic Pain.

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Thank you so much for joining us.

We are, taping in the beautiful Turner Home of the El Paso County Medical Society.

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This is the El Paso physician.

I'm Kathrin Berg.

Good night.

The El Paso County Medical Society is a nonprofit organization established in 1898 that unites physicians to elevate the health of the El Paso community.

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