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Welcome to the next installment of Live Well

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with UCI Health.

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My name is Ryan Manno with KOST 103.5

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and iHeartRadio.

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Thrilled to be sitting with Doctor

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Navid Alem today, a board-certified...

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I want to get this right...

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UCI Health anesthesiologist

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who has advanced

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training in pain management

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and anesthesia.

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That's correct.

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I appreciate the opportunity

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and hopefully we could talk about

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pain management options

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for folks with knee pain.

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That's what we're going to do.

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So first things first, I see, you know

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obviously in your, in your title

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we see the word anesthesiologist.

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I think most people

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myself included,

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think of an anesthesiologist

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only in surgery.

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Talk about what

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what it is that you do

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outside of the OR.

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That's a great question.

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You know,

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anesthesiologists basically

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are there at the time of surgery

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and they help patients, right,

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When you're under an anesthetic

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all the way to recovery.

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They really care

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for the acute phase, right?

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But a pain

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specialist is a distinct part

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of it, right?

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It's a completely different area.

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You've done extra fellowship training,

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and you're more in an outpatient

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setting where you're dealing with folks

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and forming a partnership longitudinally.

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Okay.

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So these are folks that might have back pain.

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They might have knee pain, shoulder pain.

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And you basically

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are seeing them in a clinic sense.

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Not really in the acute

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inpatient hospital setting.

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So then what is it

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that when you say you're

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seeing them in the, like,

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what is it that you're,

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you're primarily working with them on?

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Whatever they come in with, right?

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So patients come in

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and they say my back hurts,

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I have sciatica,

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my knee hurts, my shoulder hurts.

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And you basically then talk to them

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and figure out how you can get them back

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to a better quality

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of life, functionality,

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doing the things that they want to do

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with their loved ones.

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And everybody's different.

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Sometimes it's an acute thing,

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sometimes it's more

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of a chronic condition. Then,

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then again,

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where does that the anesthesia

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part of that come in to play?

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It's not necessarily

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an anesthesia background.

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You can get the pain medicine

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through a physiatry background.

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You can get to it

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through a neurology background.

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But the anesthesia backbone

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really gives you a good understanding

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of interventional techniques,

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operating room techniques, procedural... I see.

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And so it's one of the different routes

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you could take.

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But that's a foundation

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that you built upon.

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And then you did

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a dedicated year of fellowship

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training specifically

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in the niche of pain management.

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I understand this now.

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So it's more or less like a pillar.

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It's a tool in your tool bag.

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It's part of the pathway to get to it.

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It's your arsenal. I love it.

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But the clutch here is that pain fellowship here.

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Yeah, of course.

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So you mentioned knee pain.

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Knee pain.

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I feel like we don't

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talk enough about knee pain,

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but I feel like there's a lot of knee

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pain that no one talks about.

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Even the phrases like pain in the butt,

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pain in my neck.

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You know?

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No one ever says a pain in my knee,

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you're a pain in my knee.

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Well, it's prevalent, I'll tell you.

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One in four adults

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over the age of 50 has knee arthritis.

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Yeah.

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That doesn't mean everybody symptomatic.

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It doesn't mean everybody needs surgery.

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But there's a lot of folks out there

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with knee pain.

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I'll tell you, I had any pain.

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I tore my ACL, I tore my meniscus.

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At the end of the day,

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those were repaired.

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And that's not the same

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as somebody that has knee

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pain later on in life,

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maybe from osteoarthritis.

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But you got to understand

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that the cartilage in our knees

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is susceptible to wear and tear.

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Do you wear an Apple Watch? I do.

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How many steps a day do you usually take?

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I'm usually clocking

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because I have a dog

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and I usually do about five miles,

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which is about 11,000,

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12,000 steps a day.

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Okay, well,

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if you did 7,000 steps a day,

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because that's what I did the math on...

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Okay.

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Then you lived 80 years,

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you would put 200 million

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steps on your knees. Yeah, that's a lot.

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So think of that. That's a lot.

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And the cartilage in your knee

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is essentially like a brake pad, right?

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Yep. It's got a half life.

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Eventually those brake pads

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are going to wear down.

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So you got to figure out

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how do I make

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these brake pads last longer?

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And if they wear down

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what do I got to do to make it

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so I don't care about it

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or I stay active?

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Otherwise you're going to become more

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and more sedentary.

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Because you don't want

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to be walking around

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with hurt, achy knees.

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And you don't want to be sedentary.

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It's a vicious cycle.

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You can't sleep,

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you can't get anxiety,

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all this other stuff, it's

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a whole intertwined thing. Yeah.

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And would you say that

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the breakdown of that cartilage is

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traditionally the most common

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cause of knee pain?

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It depends on the demographic,

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the age group, right?

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If you're talking about what I see

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in clinic, yeah.

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More commonly it's someone of the elderly

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then it's been wear and tear over time.

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You know,

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the enzymes have broken down a cartilage.

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So cartilage is like ice.

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And it's very,

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you know, frictionless

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if you rub ice,

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but it's even less frictionless.

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It's like five times

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less frictionless than ice.

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But once the cartilage

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starts to break down

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now you start to feel,

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you know,

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clicking and locking

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and that kind of stuff.

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But in somebody younger, like,

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you know,

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when I hurt myself,

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I heard a pop in my ACL

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and that had nothing to do

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with cartilage breakdown, right?

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That wasn't osteoarthritis.

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That can be ligaments.

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It could be tendons.

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It could be bursa.

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The knee's a very complex joint.

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So you really, like, tailor

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what's going on for that patient

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to figure out

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what the treatment options are.

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Just curious,

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what were you doing

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when you heard that pop?

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What were you, how did you do it?

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It depends. There's a lot of them.

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So the first injury

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I was actually

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playing basketball. I was 27, 28,

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and I heard a big pop,

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and that was one thing.

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I'm kind of embarrassed to tell you

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how I tore my meniscus, but I'll tell you anyway.

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Let me hear it, I asked. Let's go.

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So initially it was a basketball injury

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and I heard a little bit of a, like, pop,

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but it was a minor

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and it was not that big of a deal.

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And then I waited two or three months,

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and then I went to a Christmas party

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and they had a Grinch there,

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a real Grinch.

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It was 200 pounds.

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And I picked the Grinch up...

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Oh no. And buckled my knee.

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And that was what's called the bucket

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handle tear. Okay.

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And that ended up needing

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emergent surgery to repair.

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How the Grinch stole your knee, you know?

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Unbelievable. It's actually a true story.

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I know, it's what a story.

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I'm glad you shared it.

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Yeah,

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but anyways, the treatment options

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for that were I needed surgery.

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Okay, hold the first story.

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Then when you come to me

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as a pain specialist and say,

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what are my options? Yes.

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So do

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most people assume

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that if they do have knee pain,

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they start to feel this stuff...

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Like, I think most people would assume,

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oh God, I need surgery.

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That's a good point you make,

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but that's not necessarily true at all.

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It really depends on the cause

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and high velocity

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injury in an elite athlete,

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yeah, you're probably thinking

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somebody younger

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you're going to need surgery.

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But most folks – as I said, one in, what,

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four people develop osteoarthritis.

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But the number of patients

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in each surgery is about 5% of that.

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Right?

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So the lifestyle changes,

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the physical therapy,

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the medication options,

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all the steps that come before surgery

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help the vast majority of patients.

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So they never end up under the scalpel.

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That's great.

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How do you make that distinction

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between, like,

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let's just say someone's, like,

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my knee hurts,

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like acute pain and chronic pain? Yeah.

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What's, how do you handle that?

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Well,

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first of all, acute pain and chronic

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pain are two different beasts.

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Yes. Right?

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So acute pain

284
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is your body working

285
00:06:17,733 --> 00:06:19,233
normally, it's a smoke alarm

286
00:06:19,233 --> 00:06:19,966
going off to tell you

287
00:06:19,966 --> 00:06:21,700
I got to get out of the house, right?

288
00:06:21,700 --> 00:06:21,966
Yeah.

289
00:06:21,966 --> 00:06:22,833
If you imagine

290
00:06:22,833 --> 00:06:23,766
there's some folks out there

291
00:06:23,766 --> 00:06:24,300
that actually have

292
00:06:24,300 --> 00:06:25,500
genetic predispositions

293
00:06:25,500 --> 00:06:28,200
and they can't feel pain.

294
00:06:28,200 --> 00:06:29,633
That's not good, right?

295
00:06:29,633 --> 00:06:30,933
Because if I touch a hot stove,

296
00:06:30,933 --> 00:06:32,700
I've got to be able to pull my hand away.

297
00:06:32,700 --> 00:06:33,433
Yes. Right?

298
00:06:33,433 --> 00:06:35,166
So acute pain is typically like

299
00:06:35,166 --> 00:06:36,166
less than three months.

300
00:06:36,166 --> 00:06:38,166
And that's the body working normally.

301
00:06:38,166 --> 00:06:38,800
And the treatment

302
00:06:38,800 --> 00:06:39,766
for that is different

303
00:06:39,766 --> 00:06:40,966
than somebody who's now

304
00:06:40,966 --> 00:06:42,933
in pain now for three to six months. Okay.

305
00:06:42,933 --> 00:06:44,233
This is past the amount of time

306
00:06:44,233 --> 00:06:45,400
the body should have healed.

307
00:06:45,400 --> 00:06:47,100
This is a smoke alarm going off,

308
00:06:47,100 --> 00:06:48,833
pissing off the whole neighborhood.

309
00:06:48,833 --> 00:06:51,366
And there's no reason for it to go off.

310
00:06:51,366 --> 00:06:52,533
And it's the rewiring

311
00:06:52,533 --> 00:06:53,566
that needs to get done now

312
00:06:53,566 --> 00:06:55,300
because we're past the acute phase.

313
00:06:55,300 --> 00:06:57,333
This is the body not reacting normally.

314
00:06:57,333 --> 00:06:59,000
That's a really great analogy.

315
00:06:59,000 --> 00:06:59,633
I appreciate that.

316
00:06:59,633 --> 00:07:00,833
So okay, so someone let's say

317
00:07:00,833 --> 00:07:02,733
someone has this, this chronic pain.

318
00:07:02,733 --> 00:07:04,366
They've they've crossed that path, like

319
00:07:04,366 --> 00:07:05,833
you said of when it should be normal.

320
00:07:05,833 --> 00:07:06,333
Right.

321
00:07:06,333 --> 00:07:07,166
How do you then

322
00:07:07,166 --> 00:07:08,966
determine the underlying cause

323
00:07:08,966 --> 00:07:11,033
and what are we going to do about it?

324
00:07:11,033 --> 00:07:11,500
Yeah.

325
00:07:11,500 --> 00:07:12,133
I mean,

326
00:07:12,133 --> 00:07:13,200
first thing you got to do

327
00:07:13,200 --> 00:07:14,933
is see the patient,

328
00:07:14,933 --> 00:07:16,500
you got to have a conversation.

329
00:07:16,500 --> 00:07:17,233
You got to figure out

330
00:07:17,233 --> 00:07:18,333
what their goals are,

331
00:07:18,333 --> 00:07:19,966
what they've already tried,

332
00:07:19,966 --> 00:07:22,166
what the impact on life is.

333
00:07:22,166 --> 00:07:22,733
You know,

334
00:07:22,733 --> 00:07:24,000
is this something minor

335
00:07:24,000 --> 00:07:25,433
you just wanted to kind of prevent

336
00:07:25,433 --> 00:07:26,033
it stuff?

337
00:07:26,033 --> 00:07:26,733
Or is this something

338
00:07:26,733 --> 00:07:27,533
you've already dealt with?

339
00:07:27,533 --> 00:07:29,433
You've seen a thousand doctors already.

340
00:07:29,433 --> 00:07:30,900
Have you already had knee replacement?

341
00:07:30,900 --> 00:07:32,600
And this is a whole different patient

342
00:07:32,600 --> 00:07:34,133
than somebody that's more naive

343
00:07:34,133 --> 00:07:35,600
in terms of the things they've tried

344
00:07:35,600 --> 00:07:37,233
and other sorts of stuff, right?

345
00:07:37,233 --> 00:07:39,833
So what I really do is I see the patient,

346
00:07:39,833 --> 00:07:41,233
I have a conversation,

347
00:07:41,233 --> 00:07:42,333
and then we do an exam.

348
00:07:42,333 --> 00:07:44,200
Exam, very clutch.

349
00:07:44,200 --> 00:07:45,633
It tells you a lot of stuff, right?

350
00:07:45,633 --> 00:07:45,800
Yeah.

351
00:07:45,800 --> 00:07:46,233
It tells you

352
00:07:46,233 --> 00:07:48,300
if the patients are hypersensitive,

353
00:07:48,300 --> 00:07:49,900
if they have any laxity,

354
00:07:49,900 --> 00:07:51,800
if it's just arthritis,

355
00:07:51,800 --> 00:07:52,733
what are we dealing with?

356
00:07:52,733 --> 00:07:54,033
Sometimes you'll find specific

357
00:07:54,033 --> 00:07:56,133
tender spots suggesting bursitis.

358
00:07:56,133 --> 00:07:56,833
Sometimes you'll see

359
00:07:56,833 --> 00:07:58,433
other sorts of stuff.

360
00:07:58,433 --> 00:08:00,533
Then you take imaging into play.

361
00:08:00,533 --> 00:08:01,733
You can get X-rays, you can get

362
00:08:01,733 --> 00:08:03,300
MRIs, really figure out

363
00:08:03,300 --> 00:08:04,933
what's going on with the anatomy.

364
00:08:04,933 --> 00:08:06,033
And then you

365
00:08:06,033 --> 00:08:07,500
come up with a development plan

366
00:08:07,500 --> 00:08:10,166
in shared decision with the patients

367
00:08:10,166 --> 00:08:11,500
and saying what they want to do

368
00:08:11,500 --> 00:08:12,100
with their goals.

369
00:08:12,100 --> 00:08:13,833
Do you ever find that

370
00:08:13,833 --> 00:08:15,200
maybe some people just don't

371
00:08:15,200 --> 00:08:16,166
handle pain as well,

372
00:08:16,166 --> 00:08:17,533
and you're like,

373
00:08:17,533 --> 00:08:19,233
I don't know if it's that bad?

374
00:08:19,233 --> 00:08:20,966
Well, pain is completely subjective.

375
00:08:20,966 --> 00:08:21,933
Of course, that's what I mean.

376
00:08:21,933 --> 00:08:23,533
So it's like they sit and talk with you

377
00:08:23,533 --> 00:08:26,100
and what they may describe as like...

378
00:08:26,100 --> 00:08:27,100
This is the biggest thing

379
00:08:27,100 --> 00:08:28,033
we always see, right?

380
00:08:28,033 --> 00:08:29,433
You're rounding on the patient.

381
00:08:29,433 --> 00:08:30,533
Somebody says, I'm in a ten

382
00:08:30,533 --> 00:08:31,366
out of ten pain.

383
00:08:31,366 --> 00:08:32,733
What's your ten is different than my...

384
00:08:32,733 --> 00:08:33,833
They're on the cell phone.

385
00:08:33,833 --> 00:08:35,200
They're flipping through the channels

386
00:08:35,200 --> 00:08:35,633
and you're like,

387
00:08:35,633 --> 00:08:37,400
this just can't be a ten out of ten pain.

388
00:08:37,400 --> 00:08:38,400
And then you go to next door

389
00:08:38,400 --> 00:08:40,233
and someone's in two out of ten pain,

390
00:08:40,233 --> 00:08:41,900
but they can't do physical therapy.

391
00:08:41,900 --> 00:08:43,066
They can't get off the commode.

392
00:08:43,066 --> 00:08:44,433
It's a whole different story, right?

393
00:08:44,433 --> 00:08:45,366
So really what I care about

394
00:08:45,366 --> 00:08:46,200
is functionality.

395
00:08:46,200 --> 00:08:47,133
What I really care about

396
00:08:47,133 --> 00:08:48,133
is your quality of life.

397
00:08:48,133 --> 00:08:49,000
What I really care about

398
00:08:49,000 --> 00:08:50,600
is how much opioid you're on

399
00:08:50,600 --> 00:08:51,633
or are you on opioid?

400
00:08:51,633 --> 00:08:52,400
What is going on here

401
00:08:52,400 --> 00:08:54,700
that I can tangibly improve for you? So,

402
00:08:55,933 --> 00:08:57,300
you know, okay, so we've gotten,

403
00:08:57,300 --> 00:08:58,333
we've gotten it through that

404
00:08:58,333 --> 00:08:59,833
you understand their level of pain,

405
00:08:59,833 --> 00:09:01,033
be it a two or a ten or whatever

406
00:09:01,033 --> 00:09:01,800
that is for them.

407
00:09:01,800 --> 00:09:03,366
Then what do you start looking at?

408
00:09:03,366 --> 00:09:05,433
Do you start looking at like,

409
00:09:05,433 --> 00:09:06,200
physical therapy

410
00:09:06,200 --> 00:09:07,733
first? Do you start looking at medication

411
00:09:07,733 --> 00:09:09,533
or is it just different for that person?

412
00:09:09,533 --> 00:09:11,066
Look, my approach is

413
00:09:11,066 --> 00:09:12,500
you got to partner with the patient.

414
00:09:12,500 --> 00:09:13,633
You got to do shared decision

415
00:09:13,633 --> 00:09:14,566
like I said.

416
00:09:14,566 --> 00:09:14,766
You know,

417
00:09:14,766 --> 00:09:17,166
you got to figure out what they've tried

418
00:09:17,166 --> 00:09:18,833
and tailor it to that patient. Right.

419
00:09:18,833 --> 00:09:21,200
But physical therapy is absolutely clutch

420
00:09:21,200 --> 00:09:21,566
right?

421
00:09:21,566 --> 00:09:22,733
You know the,

422
00:09:22,733 --> 00:09:24,200
we talked about my own knee injury.

423
00:09:24,200 --> 00:09:25,400
The only reason I ever got back

424
00:09:25,400 --> 00:09:25,833
to sports

425
00:09:25,833 --> 00:09:27,100
was because of physical therapy.

426
00:09:27,100 --> 00:09:28,933
You got to make your hamstrings back.

427
00:09:28,933 --> 00:09:30,900
You got to get your thigh muscles,

428
00:09:30,900 --> 00:09:32,600
the actual quad, all that back,

429
00:09:32,600 --> 00:09:34,433
your hip muscles, your core.

430
00:09:34,433 --> 00:09:36,033
That's absolutely integral

431
00:09:36,033 --> 00:09:37,633
to be able to have alignment

432
00:09:37,633 --> 00:09:39,333
and functionality the way that you want,

433
00:09:39,333 --> 00:09:39,733
right?

434
00:09:39,733 --> 00:09:40,166
At what point,

435
00:09:40,166 --> 00:09:41,000
though, do you listen to

436
00:09:41,000 --> 00:09:41,966
somebody of like,

437
00:09:41,966 --> 00:09:43,833
because my dad had a hip replacement,

438
00:09:43,833 --> 00:09:44,900
he has had a couple. And

439
00:09:45,833 --> 00:09:48,033
he later found out that something wasn't

440
00:09:48,033 --> 00:09:49,133
right with the replacement.

441
00:09:49,133 --> 00:09:50,366
So he would be going to PT

442
00:09:50,366 --> 00:09:51,433
and being like almost leaving there

443
00:09:51,433 --> 00:09:53,000
with tears in his eyes.

444
00:09:53,000 --> 00:09:54,733
But that's because there was a problem.

445
00:09:54,733 --> 00:09:56,300
So at what point do you go, oh,

446
00:09:56,300 --> 00:09:57,000
maybe this

447
00:09:57,000 --> 00:09:58,033
maybe this physical therapy

448
00:09:58,033 --> 00:10:00,733
isn't going to help them. Absolutely.

449
00:10:00,733 --> 00:10:02,700
I mean, the cases

450
00:10:02,700 --> 00:10:03,600
that are typical

451
00:10:03,600 --> 00:10:04,633
that are working properly

452
00:10:04,633 --> 00:10:05,633
after hip replacement

453
00:10:05,633 --> 00:10:06,633
or a knee replacement

454
00:10:06,633 --> 00:10:08,800
have incremental gains, right? Yes.

455
00:10:08,800 --> 00:10:10,333
And you set realistic goals

456
00:10:10,333 --> 00:10:12,033
and you have a little bit of pain

457
00:10:12,033 --> 00:10:13,033
when you're doing therapy.

458
00:10:13,033 --> 00:10:14,800
But if you are having that acute

459
00:10:14,800 --> 00:10:16,833
fire alarm go off like we talked about,

460
00:10:16,833 --> 00:10:18,100
then you got to reassess.

461
00:10:18,100 --> 00:10:19,433
Is there something going on here?

462
00:10:19,433 --> 00:10:20,633
And that's where you want to partner back

463
00:10:20,633 --> 00:10:21,433
with your surgeon

464
00:10:21,433 --> 00:10:23,166
and or your pain specialist and say, hey,

465
00:10:23,166 --> 00:10:24,433
can we do some updated imaging?

466
00:10:24,433 --> 00:10:25,233
Can we take a look

467
00:10:25,233 --> 00:10:26,500
if there's something going on?

468
00:10:26,500 --> 00:10:28,800
Yeah. Because that's the rare case,

469
00:10:28,800 --> 00:10:29,833
but it's the real case,

470
00:10:29,833 --> 00:10:31,333
and you don't want to necessarily power

471
00:10:31,333 --> 00:10:31,766
through something

472
00:10:31,766 --> 00:10:32,966
that was organically telling you

473
00:10:32,966 --> 00:10:34,633
something is going on. That's right.

474
00:10:34,633 --> 00:10:35,533
In terms of medication...

475
00:10:35,533 --> 00:10:36,100
So you mentioned

476
00:10:36,100 --> 00:10:37,533
like if they're on opioids or whatever

477
00:10:37,533 --> 00:10:38,500
like what's your

478
00:10:38,500 --> 00:10:40,100
where are you at on, on, on,

479
00:10:40,100 --> 00:10:42,200
what kind of medications you like to, to,

480
00:10:42,200 --> 00:10:43,733
you know, help people with?

481
00:10:43,733 --> 00:10:45,766
So it's obviously contingent

482
00:10:45,766 --> 00:10:46,766
on your medical history

483
00:10:46,766 --> 00:10:48,533
and what other comorbidities you have.

484
00:10:48,533 --> 00:10:49,400
But you usually try

485
00:10:49,400 --> 00:10:50,833
to start with the creams,

486
00:10:50,833 --> 00:10:52,366
the really safe stuff.

487
00:10:52,366 --> 00:10:54,966
So, you know, like Voltaren gel,

488
00:10:54,966 --> 00:10:55,900
lidocaine gels,

489
00:10:55,900 --> 00:10:57,766
actually sometimes CBD creams.

490
00:10:57,766 --> 00:10:58,766
There are actual creams

491
00:10:58,766 --> 00:10:59,800
that we can compound.

492
00:10:59,800 --> 00:11:01,833
We can put in, like, nerve agents in there.

493
00:11:01,833 --> 00:11:03,333
We could put in,

494
00:11:03,333 --> 00:11:04,000
you know,

495
00:11:04,000 --> 00:11:05,333
anti-inflammatory

496
00:11:05,333 --> 00:11:06,600
in higher concentration.

497
00:11:06,600 --> 00:11:07,800
Then you put in the Tylenols.

498
00:11:07,800 --> 00:11:08,933
Tylenol 1000

499
00:11:08,933 --> 00:11:10,133
every eight hours is clutch

500
00:11:10,133 --> 00:11:11,433
for anyone that is,

501
00:11:11,433 --> 00:11:13,933
you know, having osteoarthritic pain.

502
00:11:13,933 --> 00:11:15,033
And then you want

503
00:11:15,033 --> 00:11:16,166
to use anti-inflammatories

504
00:11:16,166 --> 00:11:17,133
but judiciously,

505
00:11:17,133 --> 00:11:18,100
especially if you have any

506
00:11:18,100 --> 00:11:20,566
like gastric issues or renal issues

507
00:11:20,566 --> 00:11:22,233
or cardiovascular issues.

508
00:11:22,233 --> 00:11:23,766
But, you know, the NSAIDs,

509
00:11:23,766 --> 00:11:24,566
as we call them.

510
00:11:24,566 --> 00:11:25,900
So the Aleve,ibuprofen,

511
00:11:25,900 --> 00:11:27,400
the prescription meloxicams,

512
00:11:27,400 --> 00:11:28,700
those can be very helpful.

513
00:11:28,700 --> 00:11:30,200
And then if you have the faulty wiring,

514
00:11:30,200 --> 00:11:31,366
then you want to use the faulty

515
00:11:31,366 --> 00:11:32,900
wiring medications, right?

516
00:11:32,900 --> 00:11:34,433
So you have the,

517
00:11:34,433 --> 00:11:36,000
you know, antidepressants

518
00:11:36,000 --> 00:11:38,233
and the neuropathic medicines.

519
00:11:38,233 --> 00:11:39,100
And then

520
00:11:39,100 --> 00:11:41,933
you obviously have your role for opioids

521
00:11:41,933 --> 00:11:43,533
depending on the acuity of the situation

522
00:11:43,533 --> 00:11:44,733
or what's already been done

523
00:11:44,733 --> 00:11:45,566
or hasn't been done,

524
00:11:45,566 --> 00:11:47,500
but you try to typically avoid opioids

525
00:11:47,500 --> 00:11:47,966
in the vast

526
00:11:47,966 --> 00:11:48,766
majority of patients.

527
00:11:48,766 --> 00:11:50,800
But there's a special subset of patients

528
00:11:50,800 --> 00:11:52,433
that would benefit from it. Right.

529
00:11:52,433 --> 00:11:54,433
And then you got your newer agents

530
00:11:54,433 --> 00:11:56,733
like this new drug, suzetrigine, that came out.

531
00:11:56,733 --> 00:11:57,833
That's really for acute pain.

532
00:11:57,833 --> 00:11:58,733
It's a two-week course

533
00:11:58,733 --> 00:12:00,333
you take for acute pain.

534
00:12:00,333 --> 00:12:00,966
So really

535
00:12:00,966 --> 00:12:03,233
you got to tailor to the patient history

536
00:12:03,233 --> 00:12:04,533
and what they need

537
00:12:04,533 --> 00:12:05,366
and what they don't need,

538
00:12:05,366 --> 00:12:06,700
and that's what we do.

539
00:12:06,700 --> 00:12:08,133
You mentioned something in there.

540
00:12:08,133 --> 00:12:10,500
You said, did you say anxiety.

541
00:12:10,500 --> 00:12:10,833
Like there's anti-anxiety

542
00:12:11,833 --> 00:12:12,400
something like that?

543
00:12:12,400 --> 00:12:12,700
I think

544
00:12:12,700 --> 00:12:14,000
that a lot of us think of pain

545
00:12:14,000 --> 00:12:16,133
as just a physical thing.

546
00:12:16,133 --> 00:12:18,000
But it, it, it hits a point, right,

547
00:12:18,000 --> 00:12:18,400
where then

548
00:12:18,400 --> 00:12:20,000
it becomes stress and anxiety

549
00:12:20,000 --> 00:12:22,200
and oh yeah, even leading to depression

550
00:12:22,200 --> 00:12:23,900
or these other things. So do you,

551
00:12:23,900 --> 00:12:26,533
how do you deal with with that sort of,

552
00:12:26,533 --> 00:12:27,700
you know, undercurrent?

553
00:12:27,700 --> 00:12:28,200
Yeah.

554
00:12:28,200 --> 00:12:29,800
So acute pain, like we said,

555
00:12:29,800 --> 00:12:31,000
is your body working normally.

556
00:12:31,000 --> 00:12:32,133
But when you start to transition

557
00:12:32,133 --> 00:12:33,133
to chronic pain... Yes.

558
00:12:33,133 --> 00:12:34,400
A lot of thoughts and emotions

559
00:12:34,400 --> 00:12:36,166
are starting to play a bigger role.

560
00:12:36,166 --> 00:12:36,733
You know, in fact,

561
00:12:36,733 --> 00:12:37,800
when you have poor sleep

562
00:12:37,800 --> 00:12:39,633
or if you have anxiety and depression

563
00:12:39,633 --> 00:12:41,566
and pain, we call that the triad, right?

564
00:12:41,566 --> 00:12:43,000
They all interplay with each other.

565
00:12:43,000 --> 00:12:44,433
And if you actually do studies,

566
00:12:44,433 --> 00:12:46,233
you see that your prefrontal cortex

567
00:12:46,233 --> 00:12:47,433
starts to have atrophy

568
00:12:47,433 --> 00:12:49,100
with chronic pain conditions,

569
00:12:49,100 --> 00:12:50,333
and you just have a lower

570
00:12:50,333 --> 00:12:51,600
threshold to manage pain.

571
00:12:51,600 --> 00:12:54,300
Your ability to handle

572
00:12:54,300 --> 00:12:56,766
pain is not as resilient

573
00:12:56,766 --> 00:12:57,833
as someone else.

574
00:12:57,833 --> 00:12:59,533
So we form partnerships.

575
00:12:59,533 --> 00:13:00,533
We got to have,

576
00:13:00,533 --> 00:13:00,800
you know,

577
00:13:00,800 --> 00:13:02,233
fighting pain as a team sport

578
00:13:02,233 --> 00:13:03,333
with the psychologist,

579
00:13:03,333 --> 00:13:04,566
with the physical therapist,

580
00:13:04,566 --> 00:13:05,566
with the surgeon,

581
00:13:05,566 --> 00:13:06,800
who work at it together.

582
00:13:06,800 --> 00:13:08,100
Vecause if you improve your sleep,

583
00:13:08,100 --> 00:13:09,033
you improve your diet,

584
00:13:09,033 --> 00:13:09,966
you have weight loss,

585
00:13:09,966 --> 00:13:11,633
all those things come together.

586
00:13:11,633 --> 00:13:13,533
And that's how you have improved

587
00:13:13,533 --> 00:13:16,166
sleep, improved depression, improved pain.

588
00:13:16,166 --> 00:13:16,533
Right?

589
00:13:16,533 --> 00:13:19,300
Every one pound of weight loss

590
00:13:19,300 --> 00:13:21,733
is four pounds of pressure on the knee.

591
00:13:21,733 --> 00:13:22,700
So... Say that again.

592
00:13:22,700 --> 00:13:24,333
Every one pound of weight loss

593
00:13:24,333 --> 00:13:24,900
is taking off

594
00:13:24,900 --> 00:13:26,033
four pounds of pressure on the knee?

595
00:13:26,033 --> 00:13:27,633
Exactly. Holy moly.

596
00:13:27,633 --> 00:13:28,533
So you'll have patients

597
00:13:28,533 --> 00:13:30,366
that do years of physical therapy.

598
00:13:30,366 --> 00:13:31,400
They'll try

599
00:13:31,400 --> 00:13:32,633
all these different interventions

600
00:13:32,633 --> 00:13:33,100
and they'll say,

601
00:13:33,100 --> 00:13:34,233
I can't get back to the sport.

602
00:13:34,233 --> 00:13:35,200
I can't get back to golfing,

603
00:13:35,200 --> 00:13:35,800
I can't do this,

604
00:13:35,800 --> 00:13:36,766
I can't do that.

605
00:13:36,766 --> 00:13:37,366
And you'll tell them,

606
00:13:37,366 --> 00:13:38,533
have you ever thought about losing

607
00:13:38,533 --> 00:13:38,966
10 pounds?

608
00:13:38,966 --> 00:13:40,300
You'll say it in a more nice way.

609
00:13:40,300 --> 00:13:41,333
But... Yeah. Don't

610
00:13:41,333 --> 00:13:41,900
come at me with

611
00:13:41,900 --> 00:13:42,900
that, doc.

612
00:13:42,900 --> 00:13:44,333
And then all of a sudden they come back

613
00:13:44,333 --> 00:13:45,000
and they say,

614
00:13:45,000 --> 00:13:46,133
that's all I needed,

615
00:13:46,133 --> 00:13:48,200
because that 10 pounds is 40

616
00:13:48,200 --> 00:13:49,333
pounds of pressure on the knee,

617
00:13:49,333 --> 00:13:50,200
which, believe it or not,

618
00:13:50,200 --> 00:13:50,833
is really

619
00:13:50,833 --> 00:13:51,300
the difference

620
00:13:51,300 --> 00:13:52,500
between doing the activities you love

621
00:13:52,500 --> 00:13:53,933
and not doing the activities you love.

622
00:13:53,933 --> 00:13:54,833
And then that circles

623
00:13:54,833 --> 00:13:55,500
back to the other thing

624
00:13:55,500 --> 00:13:56,500
you were saying about the importance

625
00:13:56,500 --> 00:13:57,966
of restrengthening your core.

626
00:13:57,966 --> 00:14:00,966
And because I assume that a

627
00:14:01,200 --> 00:14:01,966
stronger core,

628
00:14:01,966 --> 00:14:02,333
less weight,

629
00:14:02,333 --> 00:14:04,166
I mean, all of that works in unison to

630
00:14:04,166 --> 00:14:05,966
to treat and target

631
00:14:05,966 --> 00:14:08,033
what it is that you're there to help.

632
00:14:08,033 --> 00:14:10,833
I mean, it's, it's really all intertwined,

633
00:14:10,833 --> 00:14:11,433
right? Yes.

634
00:14:11,433 --> 00:14:11,700
I mean,

635
00:14:11,700 --> 00:14:12,300
I can only tell it

636
00:14:12,300 --> 00:14:13,366
from my own circle-back.

637
00:14:13,366 --> 00:14:14,633
And when I tore my ACL,

638
00:14:14,633 --> 00:14:15,233
I mean, it's different

639
00:14:15,233 --> 00:14:16,366
than a knee replacement,

640
00:14:16,366 --> 00:14:17,300
but I was trying to get back

641
00:14:17,300 --> 00:14:18,566
to competitive sports,

642
00:14:18,566 --> 00:14:19,500
and you couldn't do it

643
00:14:19,500 --> 00:14:20,833
until you realize it's

644
00:14:20,833 --> 00:14:22,566
not about just getting on a bicycle.

645
00:14:22,566 --> 00:14:24,200
It's not just about,

646
00:14:24,200 --> 00:14:24,733
you know,

647
00:14:24,733 --> 00:14:25,233
trying to do

648
00:14:25,233 --> 00:14:26,633
low-impact exercises all day.

649
00:14:26,633 --> 00:14:29,100
It's really about everything else:

650
00:14:29,100 --> 00:14:30,100
the weight loss,

651
00:14:30,100 --> 00:14:30,733
the core,

652
00:14:30,733 --> 00:14:32,200
the strength, the

653
00:14:32,200 --> 00:14:34,300
the whole thing came together.

654
00:14:34,300 --> 00:14:36,000
And that's what made it

655
00:14:36,000 --> 00:14:37,766
so that I could get back.

656
00:14:37,766 --> 00:14:38,133
All right.

657
00:14:38,133 --> 00:14:40,200
So what is your advice

658
00:14:40,200 --> 00:14:41,500
to somebody who's been living

659
00:14:41,500 --> 00:14:42,766
with this chronic pain for years,

660
00:14:42,766 --> 00:14:44,200
and they feel in their mind

661
00:14:44,200 --> 00:14:45,966
they've seen doctors and specialists

662
00:14:45,966 --> 00:14:48,133
and they come to you and they go, doc,

663
00:14:48,133 --> 00:14:50,033
I feel like I've tried everything

664
00:14:51,133 --> 00:14:51,633
and they look

665
00:14:51,633 --> 00:14:52,966
at you for help with their hands out.

666
00:14:52,966 --> 00:14:53,566
What do you say?

667
00:14:53,566 --> 00:14:55,133
Well, first of all, I say I believe you.

668
00:14:55,133 --> 00:14:55,800
I understand,

669
00:14:55,800 --> 00:14:57,366
I mean, I'm not disregarding

670
00:14:57,366 --> 00:14:58,200
anything you say.

671
00:14:58,200 --> 00:14:59,366
And oftentimes

672
00:14:59,366 --> 00:15:01,000
it turns out that while you've tried

673
00:15:01,000 --> 00:15:02,533
everything that you've tried,

674
00:15:02,533 --> 00:15:04,633
it's nice to have a fresh set of eyes

675
00:15:04,633 --> 00:15:05,900
and you'll see that

676
00:15:05,900 --> 00:15:07,733
there are incremental gains

677
00:15:07,733 --> 00:15:09,333
that can be made, things that haven't

678
00:15:09,333 --> 00:15:11,033
necessarily been tried yet.

679
00:15:11,033 --> 00:15:12,833
And technology is pretty cutting-edge.

680
00:15:12,833 --> 00:15:13,700
It's always changing.

681
00:15:13,700 --> 00:15:13,933
I mean,

682
00:15:13,933 --> 00:15:15,433
the things I learned in fellowship 12,

683
00:15:15,433 --> 00:15:16,133
13 years ago

684
00:15:16,133 --> 00:15:16,766
are not the things

685
00:15:16,766 --> 00:15:18,300
I'm doing today, right?

686
00:15:18,300 --> 00:15:21,300
And so what I would say is

687
00:15:21,433 --> 00:15:22,566
it's not a bad idea

688
00:15:22,566 --> 00:15:23,766
to get a fresh set of eyes,

689
00:15:23,766 --> 00:15:24,800
get some new imaging,

690
00:15:24,800 --> 00:15:27,033
get a new physical exam going.

691
00:15:27,033 --> 00:15:29,533
Even myself, I might do an injection

692
00:15:29,533 --> 00:15:31,233
and have a different result

693
00:15:31,233 --> 00:15:32,566
if I do the injection again

694
00:15:32,566 --> 00:15:33,333
six months later.

695
00:15:33,333 --> 00:15:35,033
Because medicine is an imperfect science,

696
00:15:35,033 --> 00:15:35,333
right?

697
00:15:35,333 --> 00:15:36,966
If I throw a water balloon at a car, it's

698
00:15:36,966 --> 00:15:37,966
going to splash differently

699
00:15:37,966 --> 00:15:39,233
every time, right?

700
00:15:39,233 --> 00:15:42,833
And so sometimes, depending on the risk

701
00:15:42,833 --> 00:15:44,000
associated with something,

702
00:15:44,000 --> 00:15:44,900
it might make sense

703
00:15:44,900 --> 00:15:46,566
to have someone else do the same thing.

704
00:15:46,566 --> 00:15:47,633
It's like an electrician

705
00:15:47,633 --> 00:15:48,966
that came and rewired your house

706
00:15:48,966 --> 00:15:50,500
and it's still making the noise.

707
00:15:50,500 --> 00:15:51,366
Maybe you need to call

708
00:15:51,366 --> 00:15:52,600
a different electrician,

709
00:15:52,600 --> 00:15:54,566
and that might not be the worst idea

710
00:15:54,566 --> 00:15:55,366
as well too.

711
00:15:55,366 --> 00:15:56,366
But really,

712
00:15:56,366 --> 00:15:57,766
you want to form a partnership.

713
00:15:57,766 --> 00:15:59,000
And if somebody comes to me

714
00:15:59,000 --> 00:16:00,333
and says, I've tried everything

715
00:16:00,333 --> 00:16:01,933
and there's nothing else I could try,

716
00:16:01,933 --> 00:16:03,333
and I let them walk out of the office

717
00:16:03,333 --> 00:16:04,000
without some hope

718
00:16:04,000 --> 00:16:05,533
or optimism, then I failed my job.

719
00:16:05,533 --> 00:16:06,433
You can usually find

720
00:16:06,433 --> 00:16:08,333
something that they can try

721
00:16:08,333 --> 00:16:10,233
and then tailor it and go

722
00:16:10,233 --> 00:16:11,800
with what ends up working for them.

723
00:16:11,800 --> 00:16:12,566
And as you're talking,

724
00:16:12,566 --> 00:16:14,100
as you're saying that, I, you know,

725
00:16:14,100 --> 00:16:15,633
sometimes I do feel like maybe

726
00:16:15,633 --> 00:16:17,433
when someone says, I've tried everything,

727
00:16:17,433 --> 00:16:18,133
what they really mean is

728
00:16:18,133 --> 00:16:19,966
I've tried everything I know of.

729
00:16:19,966 --> 00:16:21,933
So what, what is it that I don't know yet?

730
00:16:21,933 --> 00:16:22,433
Right? Yeah.

731
00:16:22,433 --> 00:16:22,600
Yeah.

732
00:16:22,600 --> 00:16:23,400
And honestly,

733
00:16:23,400 --> 00:16:24,633
you could go to two pain doctors

734
00:16:24,633 --> 00:16:25,433
and they'll have two different

735
00:16:25,433 --> 00:16:26,233
opinions, right?

736
00:16:26,233 --> 00:16:27,200
Especially if they have different

737
00:16:27,200 --> 00:16:28,733
training backgrounds, different kind

738
00:16:28,733 --> 00:16:29,833
of, you know,

739
00:16:29,833 --> 00:16:31,700
biases towards what they think works

740
00:16:31,700 --> 00:16:32,600
better or not.

741
00:16:32,600 --> 00:16:34,166
So, you know, you might go to

742
00:16:34,166 --> 00:16:35,533
I mean, I work at a tertiary center

743
00:16:35,533 --> 00:16:36,400
at UC Irvine, right?

744
00:16:36,400 --> 00:16:36,900
So patients

745
00:16:36,900 --> 00:16:37,300
come to me

746
00:16:37,300 --> 00:16:37,933
that have gone to

747
00:16:37,933 --> 00:16:39,333
every doctor in the community,

748
00:16:39,333 --> 00:16:39,900
and then they're like,

749
00:16:39,900 --> 00:16:40,933
did you try this basic thing?

750
00:16:40,933 --> 00:16:41,400
And they're like, no,

751
00:16:41,400 --> 00:16:42,200
no one offered me that.

752
00:16:42,200 --> 00:16:43,000
And you're like, how could they

753
00:16:43,000 --> 00:16:43,966
not offer you that? Yes.

754
00:16:43,966 --> 00:16:44,700
And so

755
00:16:44,700 --> 00:16:46,633
I really want to hear what everything is

756
00:16:46,633 --> 00:16:48,000
when you come to me, right? Right.

757
00:16:48,000 --> 00:16:49,733
And then sometimes it ends up

758
00:16:49,733 --> 00:16:50,300
being that

759
00:16:50,300 --> 00:16:51,533
you got to repeat something that was done

760
00:16:51,533 --> 00:16:52,333
because it wasn't even done

761
00:16:52,333 --> 00:16:53,633
right in the first place.

762
00:16:53,633 --> 00:16:55,033
Wow, I love this.

763
00:16:55,033 --> 00:16:57,133
If I had knee pain, you'd be my guy.

764
00:16:57,133 --> 00:16:58,300
Like, just don't carry the Grinch,

765
00:16:58,300 --> 00:16:58,566
that's all I got to tell you. 

766
00:16:58,566 --> 00:16:59,766
I won't pick him up, I promise.

767
00:16:59,766 --> 00:17:00,633
Yeah, I swear.

768
00:17:00,633 --> 00:17:00,900
All right.

769
00:17:00,900 --> 00:17:01,800
Last thing before we cut

770
00:17:01,800 --> 00:17:03,433
you loose, doctor. Let's...

771
00:17:03,433 --> 00:17:04,666
Because I always like to, to,

772
00:17:04,666 --> 00:17:05,400
to hear

773
00:17:05,400 --> 00:17:07,033
where you feel as a,

774
00:17:07,033 --> 00:17:07,833
as an expert in this

775
00:17:07,833 --> 00:17:09,033
and as a specialist,

776
00:17:09,033 --> 00:17:11,300
where do you feel like the future of knee

777
00:17:11,300 --> 00:17:12,600
pain management is going?

778
00:17:12,600 --> 00:17:12,966
Where...

779
00:17:12,966 --> 00:17:14,133
Look, five years out,

780
00:17:14,133 --> 00:17:14,566
two years out,

781
00:17:14,566 --> 00:17:16,733
I don't know, 10 years, whatever.

782
00:17:16,733 --> 00:17:17,866
Well, where we've been

783
00:17:17,866 --> 00:17:20,300
is this concept of like multimodal,

784
00:17:20,300 --> 00:17:21,100
like baking a cookie.

785
00:17:21,100 --> 00:17:22,700
We got to put different ingredients

786
00:17:22,700 --> 00:17:23,233
in, right?

787
00:17:23,233 --> 00:17:24,600
Don't just do physical therapy.

788
00:17:24,600 --> 00:17:25,766
Don't just do medications,

789
00:17:25,766 --> 00:17:26,766
don't just do injections.

790
00:17:26,766 --> 00:17:27,633
And we didn't really talk about

791
00:17:27,633 --> 00:17:28,400
some of the injection

792
00:17:28,400 --> 00:17:29,400
therapies that are out there.

793
00:17:29,400 --> 00:17:30,433
Oh well, let's talk. About it.

794
00:17:30,433 --> 00:17:31,400
You want to talk about it?

795
00:17:31,400 --> 00:17:33,033
Yeah yeah I do. Let's do it.

796
00:17:33,033 --> 00:17:35,500
Okay. So first thing I look at is,

797
00:17:36,633 --> 00:17:37,200
is it

798
00:17:37,200 --> 00:17:38,400
inside the knee or outside

799
00:17:38,400 --> 00:17:39,700
the knee that I want to target, right?

800
00:17:39,700 --> 00:17:40,733
And a lot of that has to do

801
00:17:40,733 --> 00:17:42,133
with how bad your arthritis is

802
00:17:42,133 --> 00:17:43,566
and what you've already tried, right?

803
00:17:43,566 --> 00:17:45,533
So inside of the knee,

804
00:17:45,533 --> 00:17:46,833
we have a few different things

805
00:17:46,833 --> 00:17:47,800
we could put in there, right?

806
00:17:47,800 --> 00:17:49,733
So we could put steroid in there,

807
00:17:49,733 --> 00:17:51,733
which is an anti-inflammatory.

808
00:17:51,733 --> 00:17:53,766
We could put gel in there,

809
00:17:53,766 --> 00:17:54,700
which is basically

810
00:17:54,700 --> 00:17:55,733
like a viscous solution

811
00:17:55,733 --> 00:17:56,833
that you put in there.

812
00:17:56,833 --> 00:17:58,566
Because remember, our collagen,

813
00:17:58,566 --> 00:18:00,833
which we talked about earlier, is...

814
00:18:00,833 --> 00:18:02,133
it has no blood supply.

815
00:18:02,133 --> 00:18:03,433
So once you tear it,

816
00:18:03,433 --> 00:18:05,233
it doesn't heal on its own, right?

817
00:18:05,233 --> 00:18:07,200
So putting in some gel in there

818
00:18:07,200 --> 00:18:08,866
can provide a barrier.

819
00:18:08,866 --> 00:18:09,300
I like that.

820
00:18:09,300 --> 00:18:10,966
And sometimes we do what's called PRP,

821
00:18:10,966 --> 00:18:12,733
which is platelet rich plasma

822
00:18:12,733 --> 00:18:15,600
because the, the platelets in our own autologous,

823
00:18:15,600 --> 00:18:16,533
our own blood,

824
00:18:16,533 --> 00:18:17,933
have a lot of growth factors.

825
00:18:17,933 --> 00:18:19,600
It can help repair.

826
00:18:19,600 --> 00:18:20,000
Oh wow.

827
00:18:20,000 --> 00:18:21,300
So those are the shots that we do

828
00:18:21,300 --> 00:18:22,000
in the knee.

829
00:18:22,000 --> 00:18:23,166
But a lot of the things we do

830
00:18:23,166 --> 00:18:25,033
go outside the knee. And outside=the-knee.

831
00:18:25,033 --> 00:18:26,033
procedures are typically

832
00:18:26,033 --> 00:18:28,100
when folks have end-stage arthritis

833
00:18:28,100 --> 00:18:30,033
and/or they've already had a replacement.

834
00:18:30,033 --> 00:18:30,533
Okay.

835
00:18:30,533 --> 00:18:31,366
And one of the things

836
00:18:31,366 --> 00:18:32,166
we do is something called a

837
00:18:33,533 --> 00:18:34,633
genicular nerve ablation.

838
00:18:34,633 --> 00:18:36,933
So there's three tiny nerves outside the,

839
00:18:36,933 --> 00:18:38,566
the knee that we could target.

840
00:18:38,566 --> 00:18:39,766
And we put a little numbing.

841
00:18:39,766 --> 00:18:42,033
And then we heat those nerves up.

842
00:18:42,033 --> 00:18:43,900
And folks care less about pain.

843
00:18:43,900 --> 00:18:44,833
It's just basically, I don't,

844
00:18:44,833 --> 00:18:45,300
I don't care

845
00:18:45,300 --> 00:18:46,533
if you have an alien in your knee.

846
00:18:46,533 --> 00:18:47,033
At the end of the day,

847
00:18:47,033 --> 00:18:47,700
if I take the nerve

848
00:18:47,700 --> 00:18:49,366
that goes to your knee and I zap it,

849
00:18:49,366 --> 00:18:51,366
you don't care about it anymore.

850
00:18:51,366 --> 00:18:52,200
Another option is

851
00:18:52,200 --> 00:18:53,566
there's a big nerve in our thigh called

852
00:18:53,566 --> 00:18:54,833
the saphenous nerve. Okay.

853
00:18:54,833 --> 00:18:56,100
And I could put a little wire

854
00:18:56,100 --> 00:18:57,300
there and stimulate it

855
00:18:57,300 --> 00:18:57,766
with what's called

856
00:18:57,766 --> 00:18:59,433
a peripheral nerve stimulator. Okay.

857
00:18:59,433 --> 00:19:00,833
And then you wear a device

858
00:19:00,833 --> 00:19:02,900
for two months on your thigh,

859
00:19:02,900 --> 00:19:05,200
and it sends pleasant signals to the knee

860
00:19:05,200 --> 00:19:07,400
to completely distract you from the pain.

861
00:19:07,400 --> 00:19:07,766
Right?

862
00:19:07,766 --> 00:19:08,200
So I don't know

863
00:19:08,200 --> 00:19:09,400
if you've ever had a vaccine.

864
00:19:09,400 --> 00:19:11,500
You get the poke. It hurts, right?

865
00:19:11,500 --> 00:19:12,733
What if I rub your arm

866
00:19:12,733 --> 00:19:13,900
gently with a pleasant signal?

867
00:19:13,900 --> 00:19:15,400
You care less about the poke.

868
00:19:15,400 --> 00:19:16,400
It's the same concept.

869
00:19:16,400 --> 00:19:18,333
Our brain, our spinal cord, is primitive.

870
00:19:18,333 --> 00:19:19,900
It only has certain bandwidth.

871
00:19:19,900 --> 00:19:21,366
So if I overwhelm it

872
00:19:21,366 --> 00:19:22,433
with a pleasant signal,

873
00:19:22,433 --> 00:19:24,100
you care less about the painful signal.

874
00:19:24,100 --> 00:19:24,366
Yeah.

875
00:19:24,366 --> 00:19:25,233
So this is where I go to

876
00:19:25,233 --> 00:19:26,600
when you say I've tried everything.

877
00:19:26,600 --> 00:19:27,566
I want to know what you've tried.

878
00:19:27,566 --> 00:19:28,966
I want to know what nerve they targeted.

879
00:19:28,966 --> 00:19:29,833
What do they do?

880
00:19:29,833 --> 00:19:30,666
Did they try this?

881
00:19:30,666 --> 00:19:32,166
And who did it. Right? Yeah.

882
00:19:33,166 --> 00:19:35,233
So that's kind of current state, right?

883
00:19:35,233 --> 00:19:36,600
We said you got to bake a cookie.

884
00:19:36,600 --> 00:19:37,533
You got to put the different

885
00:19:37,533 --> 00:19:38,600
ingredients in.

886
00:19:38,600 --> 00:19:40,366
You know, I'm not much of a baker.

887
00:19:40,366 --> 00:19:41,833
Or do you bake much? I do not.

888
00:19:41,833 --> 00:19:43,566
Okay. But my understanding is...

889
00:19:43,566 --> 00:19:44,100
I like eating baking, but I'm not going...

890
00:19:44,100 --> 00:19:44,766
My understanding is

891
00:19:44,766 --> 00:19:45,766
you don't just put, like,

892
00:19:45,766 --> 00:19:46,733
you know, chocolate chips in there.

893
00:19:46,733 --> 00:19:48,033
You put flour in there. You

894
00:19:48,033 --> 00:19:48,700
put... Some salt.

895
00:19:48,700 --> 00:19:51,033
Yeah. Maybe, I don't know... Butter? Yeah.

896
00:19:51,033 --> 00:19:52,033
All the things that go together

897
00:19:52,033 --> 00:19:53,366
and then it tastes good, right?

898
00:19:53,366 --> 00:19:54,700
So the current mode of thought

899
00:19:54,700 --> 00:19:56,033
has also been for pain management

900
00:19:56,033 --> 00:19:57,200
to do a lot of this,

901
00:19:57,200 --> 00:19:58,900
various things tailored to the patient

902
00:19:58,900 --> 00:19:59,400
that kind of

903
00:19:59,400 --> 00:20:01,100
make a better product altogether.

904
00:20:01,100 --> 00:20:02,966
But for future state, as you mentioned,

905
00:20:02,966 --> 00:20:04,100
there's a lot of stuff going on.

906
00:20:04,100 --> 00:20:05,166
One of the things that's going on

907
00:20:05,166 --> 00:20:06,500
is actually how to regenerate

908
00:20:06,500 --> 00:20:07,700
cartilage, right?

909
00:20:07,700 --> 00:20:08,733
Remember, I told you, it's like brakes

910
00:20:08,733 --> 00:20:10,533
you wear and tear over,

911
00:20:10,533 --> 00:20:12,000
you know, 80 to 100 years.

912
00:20:12,000 --> 00:20:13,966
You get you're going to walk

913
00:20:13,966 --> 00:20:15,966
200 million steps, right?

914
00:20:15,966 --> 00:20:16,800
What if I could actually

915
00:20:16,800 --> 00:20:18,366
regenerate cartilage? Oh, my.

916
00:20:18,366 --> 00:20:19,033
And that's something

917
00:20:19,033 --> 00:20:19,933
that's going to be out there

918
00:20:19,933 --> 00:20:21,733
maybe in the not-too-distant future.

919
00:20:21,733 --> 00:20:22,233
And that might

920
00:20:22,233 --> 00:20:23,966
actually change the game altogether.

921
00:20:23,966 --> 00:20:24,300
Right? Of course.

922
00:20:24,300 --> 00:20:25,000
So okay, let's say

923
00:20:25,000 --> 00:20:26,166
you, let's say we get there.

924
00:20:26,166 --> 00:20:27,933
Then how do we get the new cartilage.

925
00:20:27,933 --> 00:20:29,366
I mean, you don't ask me those details.

926
00:20:30,400 --> 00:20:31,166
We're not there yet.

927
00:20:31,166 --> 00:20:31,900
We're not there yet.

928
00:20:31,900 --> 00:20:33,933
If we were there yet, we'd be there.

929
00:20:33,933 --> 00:20:34,233
Yeah.

930
00:20:34,233 --> 00:20:36,233
But, you know, it's really cool stuff,

931
00:20:36,233 --> 00:20:37,500
because if you think about it,

932
00:20:37,500 --> 00:20:38,366
you know, the knee

933
00:20:38,366 --> 00:20:39,733
replacement option, which

934
00:20:39,733 --> 00:20:41,600
our orthopedics colleagues do, is phenomenal.

935
00:20:41,600 --> 00:20:42,600
It's currently right now

936
00:20:42,600 --> 00:20:44,100
the only curative thing we have.

937
00:20:44,100 --> 00:20:44,433
Right, right.

938
00:20:44,433 --> 00:20:46,600
But not everyone is a candidate for it,

939
00:20:46,600 --> 00:20:46,933
right?

940
00:20:46,933 --> 00:20:48,033
You might have,

941
00:20:48,033 --> 00:20:48,366
you know,

942
00:20:48,366 --> 00:20:50,333
not the ability to have some downtime.

943
00:20:50,333 --> 00:20:50,700
You know,

944
00:20:50,700 --> 00:20:52,966
you also might not have the

945
00:20:52,966 --> 00:20:54,333
ability to go under

946
00:20:54,333 --> 00:20:56,000
either a spinal or a general anesthetic.

947
00:20:56,000 --> 00:20:58,133
You are too sick.

948
00:20:58,133 --> 00:20:59,700
And a lot of folks

949
00:20:59,700 --> 00:21:00,833
just don't want to have surgery

950
00:21:00,833 --> 00:21:02,933
and the risk associated with that, right?

951
00:21:02,933 --> 00:21:05,600
But if you can find out another way

952
00:21:05,600 --> 00:21:07,500
to get that native cartilage

953
00:21:07,500 --> 00:21:10,500
back to where it was, it's oftentimes

954
00:21:10,566 --> 00:21:11,533
a lot more effective

955
00:21:11,533 --> 00:21:12,733
because when you do a new replacement,

956
00:21:12,733 --> 00:21:13,700
sometimes you're,

957
00:21:13,700 --> 00:21:13,933
you know,

958
00:21:13,933 --> 00:21:15,100
you're removing your anterior

959
00:21:15,100 --> 00:21:15,900
cruciate ligament.

960
00:21:15,900 --> 00:21:18,433
You're, you know, removing the menisci.

961
00:21:18,433 --> 00:21:19,433
Depending on the technique

962
00:21:19,433 --> 00:21:19,766
they do,

963
00:21:19,766 --> 00:21:20,766
sometimes some of the other

964
00:21:20,766 --> 00:21:23,033
native structures also get impacted.

965
00:21:23,033 --> 00:21:25,833
And so it's not necessarily,

966
00:21:25,833 --> 00:21:26,700
you know, a bad option.

967
00:21:26,700 --> 00:21:27,733
It's a phenomenal option

968
00:21:27,733 --> 00:21:28,900
for a lot of patients.

969
00:21:28,900 --> 00:21:30,333
But if you could figure out an option

970
00:21:30,333 --> 00:21:31,300
that doesn't involve

971
00:21:31,300 --> 00:21:33,800
such a makeover per se... Yep.

972
00:21:33,800 --> 00:21:35,233
And much more mentally invasive,

973
00:21:35,233 --> 00:21:36,500
that's an emerging technology

974
00:21:36,500 --> 00:21:37,533
that's pretty promising.

975
00:21:37,533 --> 00:21:38,366
I love this. Right?

976
00:21:38,366 --> 00:21:40,800
And we've also got biologics like PRP,

977
00:21:40,800 --> 00:21:41,966
as we talked about. Yep.

978
00:21:41,966 --> 00:21:43,600
A lot of interventional radiologists

979
00:21:43,600 --> 00:21:44,800
are doing something called genicular

980
00:21:44,800 --> 00:21:46,033
artery embolization.

981
00:21:46,033 --> 00:21:47,100
I talked about the nerves

982
00:21:47,100 --> 00:21:49,100
where we could zap them. With the artery,

983
00:21:49,100 --> 00:21:49,900
they kind of affect

984
00:21:49,900 --> 00:21:51,200
blood flow to the knee,

985
00:21:51,200 --> 00:21:53,366
and that really changes

986
00:21:53,366 --> 00:21:55,133
the inflammation pathways.

987
00:21:55,133 --> 00:21:56,433
And so there's a lot of promise

988
00:21:56,433 --> 00:21:57,366
there as well.

989
00:21:57,366 --> 00:21:58,733
And so again,

990
00:21:58,733 --> 00:21:59,800
there's a lot of options

991
00:21:59,800 --> 00:22:00,766
that are emerging.

992
00:22:00,766 --> 00:22:02,100
And what I did

993
00:22:02,100 --> 00:22:03,100
five years ago,

994
00:22:03,100 --> 00:22:04,500
let alone 10 years ago

995
00:22:04,500 --> 00:22:05,500
is not what I'm going to do

996
00:22:05,500 --> 00:22:06,966
in five years from now, right?

997
00:22:06,966 --> 00:22:08,733
And you got to be dynamic in this field.

998
00:22:08,733 --> 00:22:09,333
It's kind of annoying.

999
00:22:09,333 --> 00:22:10,300
I kind of want to stop reading,

1000
00:22:10,300 --> 00:22:10,733
but you can't...

1001
00:22:10,733 --> 00:22:12,500
Yeah. Because it's changing all the time.

1002
00:22:12,500 --> 00:22:12,633
Yeah.

1003
00:22:12,633 --> 00:22:13,533
You want to wake up and go, like,

1004
00:22:13,533 --> 00:22:14,433
I know what I know, okay?

1005
00:22:14,433 --> 00:22:15,733
But then no, you don't get to.

1006
00:22:15,733 --> 00:22:16,733
You don't get to coast like that.

1007
00:22:16,733 --> 00:22:18,100
Exactly, exactly.

1008
00:22:18,100 --> 00:22:19,100
Because people need

1009
00:22:19,100 --> 00:22:20,733
the thing that that will help them.

1010
00:22:20,733 --> 00:22:23,200
And you can't become stagnant. No. Yeah.

1011
00:22:23,200 --> 00:22:23,800
One thing

1012
00:22:23,800 --> 00:22:25,833
that I have been so impressed by,

1013
00:22:25,833 --> 00:22:26,100
you know,

1014
00:22:26,100 --> 00:22:26,733
during this series

1015
00:22:26,733 --> 00:22:27,633
and meeting different doctors

1016
00:22:27,633 --> 00:22:29,200
from different specialties,

1017
00:22:29,200 --> 00:22:30,400
is that team approach

1018
00:22:30,400 --> 00:22:31,766
that you talked about, right?

1019
00:22:31,766 --> 00:22:33,166
It's not just the one doctor

1020
00:22:34,433 --> 00:22:35,333
with their opinion and

1021
00:22:35,333 --> 00:22:37,200
then just leaving it out between that.

1022
00:22:37,200 --> 00:22:38,600
Like it's the whole group

1023
00:22:38,600 --> 00:22:40,166
that I'm so impressed by –

1024
00:22:40,166 --> 00:22:41,433
you guys the way you do things

1025
00:22:41,433 --> 00:22:42,400
at UCI Health.

1026
00:22:42,400 --> 00:22:43,733
I mean, listen,

1027
00:22:43,733 --> 00:22:45,133
the captain of the team

1028
00:22:45,133 --> 00:22:46,300
is the patient, right? Yeah.

1029
00:22:46,300 --> 00:22:48,900
And it's a collaborative partnership.

1030
00:22:48,900 --> 00:22:51,400
And I honestly would be lost

1031
00:22:51,400 --> 00:22:52,533
without the physical therapist,

1032
00:22:52,533 --> 00:22:53,500
without the surgeons,

1033
00:22:53,500 --> 00:22:54,933
without the sports medicine folks,

1034
00:22:54,933 --> 00:22:55,966
without our nutritionists,

1035
00:22:55,966 --> 00:22:58,966
without our psychologists and

1036
00:22:59,200 --> 00:23:00,800
fighting pain, getting you back to

1037
00:23:00,800 --> 00:23:01,333
doing the things

1038
00:23:01,333 --> 00:23:03,166
you want is a team sport.

1039
00:23:03,166 --> 00:23:04,633
There's no I in team.

1040
00:23:04,633 --> 00:23:07,633
It's really I have what I can offer

1041
00:23:07,733 --> 00:23:08,900
and I'll do what I can

1042
00:23:08,900 --> 00:23:10,600
to support the patient wishes,

1043
00:23:10,600 --> 00:23:12,133
whether they've already had surgery

1044
00:23:12,133 --> 00:23:13,800
or they haven't had surgery.

1045
00:23:13,800 --> 00:23:17,533
And I oftentimes will message my surgeons

1046
00:23:17,533 --> 00:23:19,166
directly and say,

1047
00:23:19,166 --> 00:23:21,033
what's the game plan here? Yep.

1048
00:23:21,033 --> 00:23:23,033
Because at the end of the day,

1049
00:23:23,033 --> 00:23:25,366
the only way that we can really make

1050
00:23:25,366 --> 00:23:26,166
the patient

1051
00:23:26,166 --> 00:23:27,533
live the life they want

1052
00:23:27,533 --> 00:23:29,633
is if we're all on one page.

1053
00:23:29,633 --> 00:23:31,900
It's completely a collaborative model.

1054
00:23:31,900 --> 00:23:34,566
But as I said, the patient is the star.

1055
00:23:34,566 --> 00:23:36,033
Yeah, I love that.

1056
00:23:36,033 --> 00:23:36,800
And that's what I think

1057
00:23:36,800 --> 00:23:37,500
anyone would want.

1058
00:23:37,500 --> 00:23:38,333
Ten times out of ten.

1059
00:23:38,333 --> 00:23:39,900
Sign me up for a team like that

1060
00:23:39,900 --> 00:23:41,233
rather than one guy being like,

1061
00:23:41,233 --> 00:23:42,733
all right, I have the answer.

1062
00:23:42,733 --> 00:23:44,500
Absolutely. That's it. Awesome.

1063
00:23:44,500 --> 00:23:45,800
Thank you, doctor. Anytime.

1064
00:23:45,800 --> 00:23:46,633
Really appreciate it.