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Interviewer: Hello everybody. Welcome to this episode of the Oklahoma Pain and Wellness podcast. Your home for Tulsa pain management. I am joined today with a very, very special guest. Michelle Loeber, nurse practitioner. Michelle, welcome to the show.

Michelle: Thank you. I appreciate you having me.

Interviewer: Absolutely. You work with Oklahoma Pain and Wellness and you, I understand, are like a superstar– the superstar in the office.

Michelle: I don’t look at myself as that at all. I’m just part of the team.

Interviewer: Yes. You help the clinic run though and you have a variety of different capacities and responsibilities. Why don’t you just introduce yourself and tell us a little bit more about you.

Michelle: Okay. Well, like you said, my name is Michelle Loeber. I’m a nurse practitioner. Originally, I’m from the state of Maine, way up North, North East. Beautiful country, if I might add. I’ve lived in Tulsa, though, for 22 years. I’ve been married 30 years. I have two kids, both are married. And then I have three of the cutest granddaughters that you’ve ever seen and they really have me wrapped around their fingers. As far as my medical background goes, I actually started way back in school a long time ago, I want to say that. I got my RN through TCC. I got my bachelor’s through OU and I got my master’s of Nursing for my advance practice RN. Basically, it translates to a certified nurse practitioner through Saint Louise University. They have a really rigorous program. I don’t remember those three years of my life. I’ve been in the medically [sic] here in Tulsa, practicing for about 15 years in the medical field.

Interviewer: So, 15 years and you’ve seen the growth of Tulsa and all the practices in Tulsa.

Michelle: Oh, yes and the huge change in healthcare and what that’s done. I’ve always wanted to be a nurse since I was — I was actually a candy striper. Since I was like 10 years old, I knew that I was going to be a nurse. It just took me a little longer. I have my kids, stayed home, and then went back to school later. Finished it all out and worked my way up. I started out working with cardiology. I loved it. I did a stint in wound care while I was going back to get my bachelor’s. Schedule wise, that worked out better. I went back to cardiology and then when I was getting my master’s, I worked in oncology for a while. After that, I did internal medicine, I got really immersed in the fire of learning a lot about everything. I feel very comfortable treating patients.

During that internal medicine, I actually took care of nursing home patients, I go to different nursing home every day, took care of a variety of ailments, including pain. Then a friend of mine called and said, “Hey, we have an opening. I’d loved for you to come.” I thought, I was on call basically 24/7. I was like, “I need a break.” I wanted to spend more time with my family. Fortunately, for me, Dr. Patel over at Oklahoma Pain and Wellness had an opening for a part-time and I worked three days a week. That’s how I got into Tulsa pain management.

Interviewer: Oklahoma Pain and Wellness, they do Tulsa pain management?

Michelle: Yes.

Interviewer: For you, why do you feel like you’ve always gravitated towards becoming a nurse practitioner? What about it do you really like? That’s the first question. The second question is, “Why do you like Tulsa ┬ápain management?

Michelle: As far as becoming a nurse practitioner, I probably see myself sometimes more as taking on a leadership role. It’s like I’ve always gravitated to that. I felt that the capacity that I wanted to provide the type of care that was the best avenue for me to go. I loved nursing. I just wanted to expand my role in it, basically. With Tulsa pain management, it really was not something on my radar. I really didn’t know a whole lot about it because I’ve always managed acute pain of patients throughout my nursing career. I thought that was just part of my everyday. Then with internal medicine and working with nursing home patients, I got more of a taste of the chronic pain world. I felt like, for me, it was a way that you can really make a difference in someone’s life.

I didn’t realize to the extent until I really started working with Oklahoma Pain and Wellness. After starting to work there, I’ve had some pretty unique experiences. I feel like sometimes that population is — How do you say it? — May be cast aside because of the negative connotation associated with chronic pain and because of the whole drug crisis in our country that automatically, if someone is a chronic pain patient sometimes they get the negative association of, “Oh you’re an addict.” This has enabled me to really be able to come and bring those patients. I try, anyways, to give them more of, “You’re normal”, “There’s nothing wrong with you other than you do have a disease which is chronic pain”, and “How can we best take care of you?”

Interviewer: You deal with patients that have a variety of diseases or ailments or pain-

Michelle: Yes.

Interviewer: – existing pain, chronic pain. Let me ask you. For you, do you go into the office knowing what your typical day is going to look like everyday or does that change quite a bit?

Michelle: For me, it does not change so much. In other words, I usually have a full load of patients I can see. I start at eight in the morning and I’m pretty much not done till five. Normally, I see patients pretty much — boom, boom, boom — but the reason I see them is different for everybody because there is no one that is alike. I can have the patient who has migraines for years, to a patient who has had 11 back surgeries and they failed, to a patient who had a crushing leg injury from a fall. It’s like every injury is unique and every injury to that patient is unique and their pain is what they say it is. I think a lot of medical professionals sometimes tend to judge, “Well, that shouldn’t hurt you because I’ve had that done before”, “I know somebody who lives with it.” Perception of pain is different for every person, you’ve got to look at it like, “This is an individual and how they say they hurt is how they hurt.”

Interviewer: Sure. In understanding that, that is something that some of the other physicians that we’ve talked about on the podcast have mentioned as well. Pain is very relative to the patient.

Michelle: Exactly.

Interviewer: In terms of the procedures and how you help patients, the first question that I want to ask you is, “In terms of dealing with Tulsa pain management, do the procedures hurt? Is there pain associated with the procedures that you’re doing to alleviate the pain?”

Michelle: I think there can be some sort of uncomfortable. I won’t say that it’s pain that’s going to last for 20 days or so. It’s like when you get your flu shot sometimes that doesn’t feel good. Right? There are ways that we can help alleviate the pain. I hate to say that, “Oh no, there’s no pain.” I think that would be a false statement. There might be some uncomfortableness [sic] but you have to understand — You have to go — No pain, no gain kind of thing. If you can tolerate a shot and then in knowing in maybe five minutes, “Oh my gosh, it’s going to feel so much better” you’ll be much more well off. I think too, we try to do things to help alleviate the discomfort during a procedure. Like we can sedate a patient, which means it helps relax them and there’s medication that you can give them that combats any discomfort and also even takes away the thought of the pain.

They can numb the area where they’re going to go in. If a patient is very vocal, you have to be your own advocate. That’s what I always tell my patient. If you know that you need more numbing medicine than the normal patient, you just tell the doctor, “Last time I had this type of procedure done, it hurt me so bad. Can you really numb it more?” I think I try to educate my patients on things that they can do to help and that it’s better to communicate with the provider as well. If they can come with the mindset of trying to be relaxed and calm which is really hard sometimes because you’re nervous. I have a lot of patients that have a fear of needles and to just say, “Don’t look at it.” Oftentimes, you can talk them through it and then make them comfortable with sedation and then numb it. That’s the true way to help alleviate some of those fears and discomfort.

Interviewer: How do you decide what procedures that you’re going to do? What treatments you’re going to do for the patient?

Michelle: As far as trying to figure out which procedure works best for which patient, it all depends on what type of pain they are having, their symptoms. You go through an extensive history. Have a physical. Then you look at any type of test that have been done whether it be MRI imaging, CTs, X-rays, ultrasounds, they may even have checked their nerve test. We do muscle to see how well they call, myelograms, and see how things are working. There are different things that you do and then, to me, I always look at what is the patient saying, where are they hurting, and if a patient says to me, “Okay, my low back hurts, right around my coccyx area, like when I sit down I can hardly sit down for more two minutes at a time. It just kills me.” Then the more you talk to them about it, well, “Does it go down into your legs? Does it?” There are different ways and by going into depth about how their pain affects them or where their pain is and the associated symptoms with that pain, that enables us to figure out which procedure would be hopefully best at combating that pain. I always tell patients because we have patients that come in and they’re like, “I’ve tried an epidural before and it didn’t work. I don’t want to have any needles in my back, period.”

Then I tried to educate them and say “Okay, I understand that this didn’t work for you but try to think of it as a recipe. There are so many chocolate cake recipes. How do you don’t know which recipe you like best until you try it.” So I said, “You have to give us a chance. Your chronic pain didn’t happen overnight. If you give us a chance to say, maybe this epidural doesn’t work for you but maybe a selective nerve root block would work for you. Or maybe a medial branch block would work for you, or radio frequency, but there are so many different types and there are so many different locations. If we really can try to narrow your symptoms, or your pain, the ideology of your pain source, then maybe we can provide you with a better recipe that can help alleviate those pain symptoms.”

Interviewer: When you talk about these different procedures, I’ll be honest, I don’t have a great understanding of them. I want to go through and maybe understand some of them better, okay. If you’ll bear with me in explaining them, why don’t you get into epidural injections, you mentioned that, what are those epidural injections?

Michelle: Well, an epidural injection is basically an injection. It’s one injection and it goes into the spine area and depending on where your pain is located, depends on where they’re going to inject you. If you will come into me and say, “Oh my gosh, I have a really bad back pain” and I’ll say to you, “Tell me about it. Does it go down into your legs? Does it go into your hips? Does it go all the way to your toes?” you say, “Oh, it hurts so much. I can feel the pain rating down into my toes.” Well, that tells me because these nerves innervate different functions or different sensory that we know that the low back sensory is all the way down to the toes. I would say that’s L5 which is the bottom. L5 S1, lumbar number one, sacral one.

They will go into that, when I order- I don’t do these procedures personally but I ordered them, I refer them to the physicians that we work with- and I would actually say, “Let’s schedule him for lumbar epidural L5 S1.” What that means to me is, when they insert that needle, the medication is going to cover that area. Normally, when they’ve had these symptoms for a while, there’s a lot of inflammation. They will use a steroid and a numbing medication. Right away you should feel some sort of relief because the numbing medication is going in. The steroid takes a little more time. 42 to 72 hours I would say, and then you should have some reduction in that type of pain.

Will it go away completely? Absolutely not and usually not the first time. With the epidurals, I always tell, you have to do understand this didn’t happen overnight, it’s not going to go away overnight. These epidurals have a cumulative effect. We do it the first time, you may have a significant improvement for a week and then slowly your symptoms return. Then I say, “Okay, in eight to twelve weeks we’re going to do it again and then you’ll have more of a longer sustained result.” But it’s always that third injection that’s the magical one because I have patients that after they’ve had their third epidural can have no pain, significantly reduction in their pain or they’ll have from anywhere from three months to 18 months of like, “Oh, my Gosh, I can move again and do with my life”, because you’ve given your back a chance to have that reduction in the inflammation. The bulging maybe reduced, if there’s a bulging disc, any pressure on those nerves, you know with that reduction of inflammation. I try to really reinforce that, give us time and work with us, let’s work together as a team and hopefully that will give you the sustained relief that we’re looking for.

Interviewer: Among the epidural injections that you do, what are some of these other procedures that, maybe, Oklahoma Pain and Wellness, remember the they’re dealing with Tulsa pain management, but what about like Botox for headaches and migraines.

Michelle: Okay, epidurals are totally different than Botox. You were saying about, there’s different areas, epidural normally do the cervical which is your neck, the thoracic is the chest area and mid back and then lumbar is low. Going to Botox is a totally different animal. Botox paralyzes the muscles, right. It reduces spasticity. I’ve had patients that have had chronic migraines, probably till in their early teens to even preteens and after starting Botox therapy they actually have either no migraines or headaches or such a significant reduction in their headaches, it totally changes their life and these are people who have had headaches for over maybe 30 years.

I had one lady who had headaches every day of her life since she was probably 12 or 13. She started Botox therapy her headaches gone away completely. She started hiking, camping, kayaking, doing biking and her husband was like, “What is wrong with you?” because he’s never seen her so active and full of life and she’s like, “I don’t have headaches anymore.” And I think people don’t realize sometimes migraines are debilitating. You want to be in a dark room, no noise, you just want to sleep it off. And a lot of times Botox is an imminent improvement, like she had 15 or more headaches in the three-month period. 15 or more headaches, that’s what, five a month in three months and these people normally have lived with headaches almost on a daily basis. They’re able to produce more work, they are able to function at home, participate in social and recreational activities, it literally changes their life.

Interviewer: Botox for headaches is a game changer.

Michelle: Yes, absolutely.

Interviewer: What about facet joint injections?

Michelle: Facet joint injections also, that’s more, when you can point to me and say, “Okay, right this area in my back is killing me.” What we call that it’s literally localized pain in your back. It doesn’t radiate down, it doesn’t really go anyplace but you can be sitting there all day and your back is just killing you in this one area. A lot of times we’ll do what they call a facet joint injection because that’s saying it’s right in that area of the back. They go in you probably have, a lot of this is inflammation, the steroids help reduce that inflammation. Steroids, you inject into the back with the numbing medication and they will have relief sometimes from one to two weeks and that just might be enough to help reduce inflammation and the pain won’t return. If the pain should happen to return but they did have relief for one to two weeks and they come back and say, “Oh, my Gosh, that was great, I had relief”, Then we can offer them what they call radio-frequency ablation because that says, “Okay, you had relief in that area for a week or maybe three days, five days, whatever it is then we know that if we go in and we ease up the nerve or burn the nerve, it basically will kill the nerve and then you’ll have relief for basically how long it takes for that nerve to rejuvenate or re come back whatever.

Interviewer: Sure.

Michelle: That nerve in and of itself is gone and normally it takes about three months for a nerve to come back. What some patients will report is because they haven’t aggravated it again. I can have patients that will come back in three months in the another ablation or maybe six months, nine months, a year, before they even think that they need to do it again. Depends on how much you aggravate, or how much trauma damage there is in the back, but when you have the facet or medial branch block injections, followed by the radio frequency, you can really have a longer and sustained relief. I have patients that on the clock every three months, “Okay,I need ablation.” because they know it’s going to–

Interviewer: Tell me, how does that relate to the sacroiliac joint injection and the ablation of the sacral lateral branch nerves?

Michelle: It’s just the location, it’s the sacroiliac joint is down and in the mid buttock area you would say, and it does basically essentially the same thing. If you go in and we do an injection there and you have relief for a while and then it comes back, we can go ablate those nerves and offer you longer more sustained relief. It’s basically the same thing just a different area.

Interviewer: What about peripheral nerve injections?

Michelle: Let’s just say you have different areas in your body where you have chronic pain. Lets say you have- the intercostal nerve, that’s around your rib cage area and for some reason you may have it out of trauma, you may have been in a car accident where broke ribs, or had to have surgery for whatever reason, you have chronic pain in your rib area. During whatever trauma they may have damaged those nerves so you just have that pain that does not go away. They can go in, essentially, do a nerve block. Go in reduce the inflammation around there, do some numbing area and then hopefully coming down to where you have sustained relief.

Interviewer: We’re talking about peripheral nerve injections and we said the intercostal nerve, now there’s some other listed here that I understand that may just relate to different points in the body?

Michelle: Correct.

Interviewer: But where might be the lateral femoral cutaneous nerve? Where might that be?

Michelle: That’s around the groin area on the femoral artery. It could be anywhere around in the inner thigh hip area. It depends on how a patient would explain where the pain is. We just do a physical exam and if they are having pain there, they’ll tell you.

Interviewer: What about the Ilioinguinal?

Michelle: Just where like the Ilioinguinal nerve, that’s the Ilioinguinal area as well. It’s just the location.

Interviewer: There is this next one that I don’t even know if I can pronounce it, but I’m going to try. The stellate ganglion and lumbar sympathetic block and the celiac plexus block and the splash neck nerve block, tell me about those.

Michelle: The stellate ganglion block is one that if a patient has eccessive hyperhidrosis or what I would say is, you sweat all the time, they can actually do a block that would help reduce the amount of sweating that you have. It’s a cool thing. Lumbar sympathetic block, it’s actually the same thing, it’s low back but it treats leg pain and low back pain. It reduces the symptoms, if somebody could have a crushing led injury or even have an ankle that has bothered them for a while or knee problem and sometimes, it’s just by doing a block to that area. In fact, one of the physicians, we had a patient who had a really bad– she had a bad knee and had a to have a knee replacement. Because of the pain, she wasn’t even able to participate in physical therapy. She would come see our physician every week and he would do a verve block so that she could actually participate in therapy. Those don’t last as long, they last about three days, but it got her moving so that it would’nt affect her physical therapy, it would actually improve her recovery. He did that for three or four week while she was really active. It allowed her time to heal because the damage had been so severe, her pain was more acute probably than most people following a knee replacement but the fact that he was able to provide her with significant reduction in pain, she was able to participate in therapy better.

Interviewer: You mentioned that doing this particular block for the stellate ganglion, it can actually reduce sweating. Most people might not understand sweating related to the nerves, but those two things are connected?

Michelle: Yes. Our nerves are what produce most of our bodily functions, they coordinate everything. Sweating itself some people–I don’t have hyperhidrosis, I sweat a little bit when it’s hot. If I work out I might–I’m not a big sweater, I can’t produce a huge sweat. I know people who their hands are just sweaty all the time or just always sweaty. Those are the type of people that you can provide more controlled sweating or decrease the amount of sweating that they have, to have more of a normal life. Some people have embarrassment or they don’t want to hold someone’s hand or something because of that. It enables them to feel better about themselves.

Interviewer: As it relates to Tulsa pain management, tell me about the celiac plexus block and the splanchnic nerves block.

Michelle: The celiac plexus block, that’s more for abdominal pain, patients that may have had a cancer or have cancer or had cancer and had radiation or chemo treatment, it can actually cause damage to the nerves. Also patients who have chronic pancreatitis for whatever reason. These are like a bundle of nerves in the abdomen that they can go in and block and help reduce that. It’s pretty intense pain, it can help reduce that pain for the patient.

Interviewer: This next one that I want you to walk me through it sounds crazy but when we were talking with, I believe is Dr. Chan, he was explaining this to us, but tell me about the spinal cord stimulator lead placement and the pulse generator.

Michelle: For a spinal cord stimulator the way I wrap it in my head is, the first of all it looks the little box that’s the generator that controls the whole program for reducing the amount of pain that a person has, is about the size of a pacemaker. I don’t know if you’ve ever seen a pacemaker goes into the chest wall and right or left depending on a patient, but you can usually see a little bit of it. A spinal cord stimulator is used for when patients either, a, they want to get off their medications, they’re tired of taking medications, the medications don’t work the way they should work, the patients are unable to actively participate in their life because medication side effects, or the pain is so severe that even with medications it doesn’t work.

What a spinal cord stimulator does, depending on the location, so let’s just say someone has low back or leg pain, will talk about it this way. They place the lids above the area of injury. It’s like three tiny wires that they’ll go above the area of injury in that spinal cord area. If it’s in the lumbar they go upper thoracic and they’ll place three lead. Normally, it’s three leads. What it does is when you’re hurting your spinal cord or those nerves are sending messages to the brain, where those leads are above the area of injury they stop that message from going to the brain. Iinstead it translates or changes that message into something different. So rather than feeling pain, you either feel nothing, or you’ll feel some tingling, but it’s not a painful tingling.

I don’t know if you know what a tens unit is, it’s a type of device that you can put on your back that sends electrical impulses that takes away the pain basically. It’s on that same premise that you’ll feel tingling, so I have patients that after they’ve had their spinal cord stimulator they are like,”Oh my Gosh, I have my life back, I can walk, I can participate in activities.”

We had an older lady who had been on a boat load of medications for pain, and Dr. Patel actually placed a spinal cord stimulator, she got off all her medications, and she’s like in her 60″ or early 70.” She’s able to do dishes, walk to the mailbox, she’s able to go shopping, she’s able to play with her grandchildren, all because of her spinal cord stimulator, and she says,” If I didn’t have that I can’t imagine what my life would be.” And patients that have spinal cord stimulators, that’s what they say, “I can’t imagine my life without it.” Now does it take away everybody’s all pain, the whole, not necessarily, and that all depends on the type of pain you have, and where it’s located, but there are basically two on the market, one does cause this tingling, there is a newer brand that has absolutely no side effects. It’s, of course, more costly. It’s covered by insurances, but there’s a bigger copay. The way it works is at a higher frequency so you don’t have that tingling. 80% of patients say they don’t feel anything, so they go from having extreme pain to no pain.

Interviewer: And it’s all responsible from this generator, from this lead wires?

Michelle: Correct. Exactly. It’s like a pacemaker for

Interviewer: That’s cool.

Michelle: It’s the way look at it. I say to patients, “If you had to have a pacemaker-“, because a lot of them will say, “I don’t want anything foreign in my body.” or “I don’t want to put anything else in my back.” It’s very minimally invasive. We are not restructuring anything. We’re not removing discs, we’re not cleaning out an area. We’re literally placing these on top, and they become part of you. It’s not like we’re changing anything of you. They can be unhooked and they can be left there and it won’t affect anything.

What it does, is it just helps to provide patients with reduced pain in their life. It’s like when is a can- when is a patient a candidate for this, I always say, “Depends how–” I think patients sometimes– automatically there are patients who had pain for maybe a year and they’re like, ” I’m done, I can’t live like this and let’s do this, let’s do something.” They’re more proactive and wanting to actually do something. Then there are patients that it takes some time to process.

A lot of people think, “I can just take this pill” or “We can do a few procedures,” but when that stops working and the pain starts getting worse and they see their life slipping through their hands because they can’t engage in the things that they used to. When you tell them you there is this option and it’s minimally invasive. Then I’ll say, “If you had to have a pacemaker to improve your overall quality of life or to keep you alive would you do it?” “Absolutely.” Well, this is the same thing. The generators placed just above the cushy part of your buttock or hip. You shouldn’t feel it. You always have somebody there that can help program, tweak it to make it fit and work for you.

Interviewer: That’s pretty sciency.

Michelle: It is.

Interviewer: It’s cool.

Michelle: The technology today is amazing. Between that, the interventional injections, there is- and that kind of technology with the spinal cord stimulators. There’s so much that we can offer patients. To me it’s just educating that there’s more out there than just medications and we want you to live more of a full life than just looking every four to six hours to have to take a pill.

Interviewer: Sure. What about a peripheral neurostimulator implantation for occipital headaches?

Michelle: It’s basically on the same wavelength as the spinal cord stimulator, except it works for the headaches. Basically, the same thing.

Interviewer: What about Kyphoplasty for vertebral body osteoporotic fractures? Break that down for me a little bit.

Michelle: What happens is, you’ll have a patient come in and they’re having more than just the normal, and hate to say that because it sounds awful, but they’re having intense pain that really nothing they do, they can’t get comfortable. Sometimes they know they have a fracture in their back and that’s why they’re coming to see us. Sometimes they just said, “Oh my Gosh, I’ve had this pain in my back and won’t go away.” They haven’t even done x-ray or MRI to see why, so the first thing is you would do an MRI or x-ray. On most of our back patients we have to have current, because you want to know exactly what you’re looking at, and you find out they have usually a compression fracture of one of the vertebral bodies, which is the bony part of the spine. You’re like, “You have a fracture in your back.” They are like, “Oh my gosh, that probably happen when I fell or when I twisted.” They don’t even realize that they can do that sometimes.

What a kyphoplasty does and it’s the simplest– and I will say to patients who- cancer patients are really high risk for these type of fractures. I’ve seen this when I practice oncology and now with Tulsa Pain Management and Oakland Pain & Wellness. What it is they do an injection into the area where there is that fracture and it’s kind of like filling the fragments or filling the broken area and piecing it together, if you would, like a base or if you broke something you’re gluing it. It’s cement that sures it all up, lifts it up, gets it solid and usually patients have immediate pain relief.

All of the sudden all that fracture and pressure and everything that was pushing against other things is back together and it’s solid. They’re like, “I can breathe again, I don’t hurt.” So it’s really kind of a really unique and awesome thing to see. Because it’s like a patient comes in they’re hurting, they go have this procedure done, then they come back to see me a week later and they’re like, “This is great I’m healed, it’s all better.” That’s what’s fun and rewarding.

Interviewer: What about versa injections?

Michelle: Those are fairly common. Those are for patients who have a lot of, osteoarthritis of the shoulders or knees from repetitive sports injuries or just wear and tear over time. You can do injections right into the bursa of a shoulder or knee joint and have pretty much immediate relief. It’s basically a lot of inflammation sometimes they have fluid in that bursa that might need to be drained off but, the injections help reduce the inflammation. I myself have had– one of our own doctors have had such shoulder pain. I went in for an injection and I was like right away, “Oh my gosh that feels so much better.” It took a lot for me to go and [laughs] do it, because I didn’t want to have an injection.

Interviewer: Sure. The bursa is typically at the joints?

Michelle: Absolutely. Yes. It helps decrease their pain, helps improve the range of motion, their inactivity and a lot of times there will be patients who doctors are like, “Oh let’s just hold off on that knee replacement.” The patient may be in his forties, sometimes even in the thirties. Let’s just do injections into that knee joint for as long as we can to buy us some time until we actually have to do any replacement.

Interviewer: Next question for you is, what about super hypo gastric block for chronic pelvic pain? Tell me about that.

Michelle: It’s the same type of- along the same lines of any type of nerve blocks for the area. A patient that has chronic pelvic pain could be from maybe a low back or a pelvic fracture or they could have had an injury even from having a delivery or even bladder issues. There’s a lot of different reasons why you might have that chronic pelvic pain. The hip is another area. It’s just a way that they can go in ans do a block on the nerves that innervate that area that’s causing the pain. We have what we call fluoroscopy, it’s a type of imaging machine that we have. We can go in and look exactly where that area is and target those nerves so that way we can provide, hopefully, that relief that will last for the patient.

Interviewer: Now, here in the notes, we want to talk about trigger point injections. What is that?

Michelle: Trigger points. That’s like my little specialty that I have seemed to have acquired over at our practice. Trigger points are more myofascial in the physiologic way of expressing it. A lot of patients will have like a really stiff neck or their back on one area, it’s like, “Oh my Gosh, this is just killing me.” It’s more superficial in nature. You can actually feel the area there’s usually maybe a knot or you can just touch it and a patient will jump off the chair or the table. You know exactly where– it’s like a muscle spasm or just that if they call it a tender point that you can actually touch with your finger.

All that is, it’s on the same premise. I use a long-acting numbing medication and then what I do is I put a low-dose steroid, so that we can actually do it more frequently if we need to. They usually have- a lot of times they’ll have a headache or neck ache, shoulder spasm, where it’s just so tight. You go along either the upper trapezius, the muscles that go along the neck the paracervicals, spinals, paraspinal cervical muscles, and you just inject right there kind of following the track. Usually, you can see where this spasm is and within five minutes the patients are like, “Oh, I can move my neck. I don’t have pain.” And they’re very happy.

I’ve had patients with mid back pain, low back pain. It can even– I’ve had a patient, which i think he’s really unique. He had a huge scar from crushing his upper- his humerus. Every once in a while he has scar tissue pain along that area, where it just tightens up and he can’t- it decreases his range of motion and causes him discomfort. He’ll have me just go along there and do trigger points and that will provide him with sustained relief up to six months

to a year sometimes. But it’s just another way of providing patients with reducing their pain, helping them feel better so that they can function, work, and enjoy their life.

Interviewer: That’s your specialty, are those trigger point injections.

Michelle: Yes. I seem to have the most patience with them

[laughter]

Michelle: The patients seem to think I do a good job, so I try my best to keep them happy.

Interviewer: Now, the last procedure I wanted to talk about is this intrathecal drug delivery pump implantation. Any time I see implantation, I’m just very curious, so you got to walk me through this.

Michelle: Intrathecal- what are you curious about again?

Interviewer: I’m curious what we’re implanting, and where we’re implanting it.

Michelle: It’s actually a pump that they implant. Sometimes it’s in the abdominal cavity area, that’s where I think most of it goes. I think for patients who require more of a consistent dispersing of their medications. These patients require more maybe higher doses over a 24 hour time, but it’s this delivery method of a pump delivers the pain medication more on an even keel, so to speak, not every six hours, but may release a little little bit every three to five minutes.

Sometimes if they have exacerbated pain, they can even hit the pump and give themselves a little bit of a extra dose. But there’s actually a limit to how much they get. It’s very monitored and we have to refill those every once in a while. I’m not sure, it depends on how much it lasts, but they refill them in order to give them the coverage that they need. It’s for the patient that– and this is another area, if a patient doesn’t feel like they have the self-control either to take medication the way they should, this is more of a delivery method, that’s a set method that you can’t really mess with.

Interviewer: This covers a whole plethora of different procedures and you are a rock star for getting through all of them.

Michelle: Yes.

Interviewer: I want to get into another part of tulsa pain management and what Oklahoma Pain and Wellness can do, is medication management. How important is medication management for your patients?

Michelle: I think that’s probably the, I would say the base of our practice to be honest. Medication management is extremely important. Number one, medication is– even though the patients are getting injections, they’re getting injections of medications. So medication is just an avenue that enables us to use– how do I say this? There’s different types of medications that help different types of pain, let’s just say that.

For patients that can get interventional procedures along with medication, that’s just a way of working together to bring these things to provide them with the best pain relief. Medication management is saying, “Okay, they have to–” because of the opioid crisis in our country today, we’re more closely monitored by the DEA, by the CDC, by the Oklahoma Healthcare authority to safely disperse mostly opioids to our patients to provide them with the best pain relief we can while keeping them safe. In other words, we don’t want them to over-sedate, we don’t want them to accidentally overdose.

Managing their medication along with managing their pain symptoms is crucial. So by blending that, we hope to find the most effective way to manage their pain. And I think a lot of times people come in with the mindset of, “This pill will fix it.” Well, pills will fix it for a short time, and is not the only answer. You have to be able to say, “Okay, I have chronic pain, it’s not going to probably go away because it’s probably as a result of something that’s happened that’s always going to be with me.” I think patients have to understand, they almost have to switch the way they think. They’re going to have to incorporate different things in order to manage it. It’s just not going to be pain medication, it’s going to be procedures, it’s going to be cognitive behavioral therapy, which that helps them retrain their brain into adjusting to what this pain really feels like.

They might have to do different types of therapy, like aquatic therapy, physical therapy, to learn how to better use and choose body mechanics so that they don’t aggravate their pain. A chiropractor is also an excellent source. There are different avenues, I think we need to wrap our heads around that. Cronic pain is not just treated with a pill, it’s like we have to come together, it’s going to be more of a consorted effort by different health professionals.

Interviewer: You recommend a combination?

Michelle: Yes.

Interviewer: There’s procedures and medication management, and the combination is really the best way to do it.

Michelle: Yes. That’s my personal opinion. That’s where a lot of the research has pointed to, that you have to have more of a combination approach in order to really effectively manage chronic pain. I think patients who come in and say, “The only thing that works for me is my medication,” and there are patients that are like that because, number one, they may have had three or four failed back surgeries. They have done all the interventional procedures, they’ve tried cognitive behavioral therapy, they’ve tried physical therapy, aquatic therapy. Mean, some people have been dealing with their chronic pain for 20, 30, 40, 50 years, so they feel like they’ve tried every avenue.

This where you do your best to help them to maintain their function, to help them keep them active with their daily living activities, and manage that pain. Sometimes it can be very difficult because you feel like you have all these things to offer, and things have changed quite a bit over time, even in the last 10 years, the amount of technology and the type of medications, and interventional procedures that we just talked about, they’re different than they were even five, ten years ago. So it’s hard sometimes to convince a patient, “Let’s just try this one more time. Let’s try and see if you get some relief with this.” And then even those patients, I think spinal chord simulator therapy is a great option if you can convince them to try that one more thing. Because sometimes they’re exhausted because they’ve tried so many different things, and they’re just done, and they just want to be left alone, but if you can try to say, “This might help take away the majority of your pain.”

That’s the other thing we didn’t mention with the spinal chord stimulators, before you can even have one, they will do a trial, it’s a three to five day trial, and that’s mandatory. So if your pain isn’t even reduced by 50%, you can’t have it. That’s the beauty of it, you go in, you have a trial, you actually get to try it out, you get to test drive it, and if it’s working for you, then you’re like, “Oh, my Gosh, this will work.” Then you’re more excited about getting it. I think that’s an important part to say, and that’s what I try to emphasize with my patients when we come to the end of the rope, “Let’s just try it, you have a three day trial. If that works, what do you have to loose?”

Interviewer: You talked about the opioid crisis, a little bit before, the opioid crisis across America. How does that relate to addiction? Because we talk a lot about medication management, so as it relates to addiction, and addiction treatment, and what can be done for addiction, walk me through that and what Oklahoma Pain and Wellness has done for Tulsa pain management.

Michelle: Okay. First, addiction is a disease. You and me could be in a room, and there could be cocaine here, I could try it, you could try it, you might be addicted, I might not be addicted. It’s not to say some– and that’s what they say, “Some people will immediately get addicted, and some people won’t.” So not everybody is addicted, but there are people who have more addicted personalities or addictive genetics. That being said, that doesn’t diminish the fact that that person may have had a traumatic experience or had injury that’s caused chronic pain. Does that mean we don’t treat them because they have an addiction or they are addicted? Absolutely not.

What I look at is, overtime, every patient physiologically, if they’re on chronic pain medications or opioids, they will develop a dependence on that. Is that addiction? No, it’s a dependence. Addiction becomes to where you will do anything aberrant to get that medication. You will lie about how you take your medications. You will be thinking about the medication all the time trying to figure out how you can get more of it. You might want to go to different doctors. There’s a lot of different things that come into that, so it’s more with aberrant behaviour. Now, as far as there are patients too who know that they’re dependent or even be addicted to a medication, and they’ve had to, over time, escalate their dose in order to get the same type of pain control. I had this one lady come to me, she goes, “I’m just tired of being on this medication. I’m tired of living my life depending on it, what can I do? I don’t even remember how bad is my pain. I feel like, is my pain medication ruling my pain?” And that’s something that’s– you have these mu receptors that when you first start taking opioids, they’re very tight, and so they hold on to that opioids, so that opioids does what it wants. The longer you are on these opioids, the mu receptors relax, so then it requires more to fill that area because it’s stretched out so to speak. Over time, you can never satisfy it, and you’re always going to be in pain. It’s a hyperalgesia effect that can happen.

What we recommend then is maybe changing medications, doing a medication rotation, medication holiday, or even considering what we are looking at now is addiction medicines. I had a lady who– that lady I was just talking about, she wanted to come off, so I referred her to our addiction therapy, they can wean you off a certain medication and replace it with one that fills those opioids, or those- I’m sorry, those mu receptors, in a way that you don’t have the craving for that old medication, but yet it still can help take care of pain.

It’s exciting to see patients like that, that know they’re addicted, or are really dependent, and they want to get off and take their life back so that their focus isn’t only on or solely on that medication that– I’ve seen patients now, they’re going back to work, they’re more engaged in their family. They’re more engaged in social and recreational activities. The medication that they use is suboxone or subutex, it’s this special medication that replaces what they were on, covers those receptors, and has less side effects in a significantly very low, low, low. I don’t really know anybody who’s overdosed on it. So it really does change their overall quality of life.

Interviewer: And is the suboxone- suboxone?

Michelle: Yes.

Interviewer: Is taking that medication everything? Or what role does counseling play in addiction therapy?

Michelle: I think it plays a huge role, even with chronic pain. Counseling will help a patient work through maybe– give them the tools that they need to be able to say, “Okay, what happens if for whatever reason I lost my medication, and one day I couldn’t get it?” We don’t want them to revert back to anything that would be distructive. So the counseling can help give them the tools to be able to cope or to manage the mindset. It helps them to maybe change their mindset, and equip them with tools to overcome the desire for that drug or change it some.

Interviewer: Sure. Now, we have covered just about everything for Tulsa pain management, but I want to finish on such a high note. Can you think of maybe a patient that you have helped or worked with that is really the best success story or the best example of what medication can do for pain management or some type of procedure that was done that was just game changing and just really, really improved the quality of life for a patient?

Michelle: I have quite a few of those stories, so it’s hard to come up with one because I will say, I’ve noticed since I’ve been in pain management, the patients that I work with seem very grateful for any success that they may have in their chronic pain. I’ve had numerous cards and letters from patients thanking me, and sometimes they thank me just for taking the time to listen, because I think sometimes people with chronic pain get overlooked because they think, “Oh you just want your drug, so let’s move on your way.”

A lot of times I spend my time helping just talking and counseling these patients and encouraging them to just do one thing that can take your life back, even if it’s just walking to the mailbox and back, or sitting and playing with your grandchild or cooking a meal. Just do one thing for yourself, it it’s starting to knit, read, do something that you enjoy, and then slowly you incorporate things to help take their life back.

I did have, well, this one gentleman who came in who had really really severe back injury and pain. He was even having difficulty time working. He had been on pretty high dose of medications, and he didn’t want to do that because he didn’t want the side effects because it would affect his work. We looked through a lot of different symptoms, and it’s funny because one of the medications, I’m like, “Well, have you ever tried a neuropathic agent heating on the nerve pain?” He’s like what do you mean?” “Like a gabapentin lyrica neurontin?” He goes, “No, I’ve never heard of that.” And I’m thinking, “He’s been to neurosurgeons, neurologists, a different pain group, and he’s come to us,” and I’m like, “So you mean you’ve never tried this?” and he’s like, “No. I don’t know what that is.”

We slowly tried that, and it has made a huge difference in his life. He’s like, “I can sleep, I can work, this works for my pain,” and it was his nerve pain. So it was not even a hard thing, it was just like, I’m thinking he’s already tried it because that’s probably one of the first go tos, he’s like, “No, I’ve never even heard of it,” and I’m like, here I am a nurse practitioner thinking, “Okay, surely he’s had this.” This has really been a game changer for his life, he’s working, he’s not calling in as much.

He still has pain from his injuries, but is significantly improves since starting the neuropathic agent. So that’s a fun thing for me to see is such a simple thing can make such a big difference. And that’s the other thing, I think sometimes we think the only type of pain medications are opioids, where you have medications that deal specifically with musculoskeletal pain and they’re not opioids, or nerve pain. Even topical things, I’ve come up with my own little concoction that I use like a nonsteroidal anti-inflammatory gel, and I mix it with an over the counter pain reliever. Together, those provide significant improvement of their pain, plus reduce inflammation.

They come to me and they’re like, “Oh my gosh, this is a game changer for me.” It’s just working. It’s like I said, finding a recipe that works for somebody. In the beginning we talked about, no two individuals are alike, so you have to approach their pain as what they say it is, so what is going to work best for their life?

Interviewer: So when you’re dealing with patient’s pain, especially if it’s chronic pain, working with yourself and the rest of the staff at Oklahoma Pain and Wellness, it can produce some very very life changing results. It can improve the quality of life, take away pain, reduce pain so that you can actually heal.

Michelle: Correct.

Interviewer: So I can imagine that that is just a very rewarding experience, and what Oklahoma Pain and Wellness is doing for Tulsa pain management is just been incredible, but Michelle, I really really appreciate you coming on here. Ladies and gentlemen Michelle Loeber, nurse practitioner extraordinaire with Oklahoma Pain and Wellness. Michelle thank you so much for being on the show today.

Michelle: Thank you for having me.