PMR Board Review instructor, David Rosenblum, MD brings his unique insight into this podcast where he discusses issues relevant to physiatrists and pain physicians.
Dr. Rosenblum is the author of PMRExam.com
For more information go to PMRExam.com for board review and CME credits
Site
RSS
Apple
Données mises à jour le 04/07/2026
Classements récents
Dernières positions dans les classements Apple Podcasts et Spotify.
Liens partagés entre épisodes et podcasts
Liens présents dans les descriptions d'épisodes et autres podcasts les utilisant également.
Does Kratom Relieve Pain? Risks, Benefits and more!
jeudi 11 décembre 2025 • Durée 11:14
🎙️ PainExam Podcast Show NotesKratom (Mitragyna speciosa): What Pain Physicians Must Know for the Boards
In this episode, Dr. David Rosenblum reviews the current science, pharmacology, risks, and clinical relevance of Kratom — an herbal substance widely discussed by pain patients and increasingly appearing on pain-medicine board exams. The discussion focuses on evidence-based mechanisms, safety considerations, and counseling points essential for ABA/ABPM/ABIPP/FIPP board preparation.
Kratom's primary alkaloids are mitragynine and 7-hydroxymitragynine.
They act as partial mu-opioid receptor agonists and demonstrate G-protein biased signaling, which may reduce β-arrestin–mediated respiratory depression seen with full opioids.
No FDA-approved medical use; pharmacokinetics and dose-response remain inconsistent.
2. Reported Effects
Potential Benefits (mostly anecdotal or preclinical):
Analgesia for chronic pain
Mood elevation and increased energy
Reduction of opioid withdrawal symptoms
Major Limitations:
No high-quality randomized controlled trials
Not a recommended analgesic for evidence-based pain practice
3. Adverse Effects & Safety Concerns
Commonly reported:
Nausea, vomiting, constipation
Tachycardia, palpitations
Hepatotoxicity in some users
Dependence and withdrawal syndrome similar to mild-moderate opioid withdrawal
Serious risks:
Product variability and contamination
Potential interactions with CNS depressants
Unpredictable potency of alkaloids
4. Regulatory Status
Kratom is unregulated, with significant variability in purity and composition.
FDA and multiple public-health agencies caution against its use due to safety concerns.
Not recommended as a first-line or adjunct pain therapy.
5. What Boards Like to Test
Expect questions on:
Mechanism: partial MOR agonist, G-protein bias
Differences from classical opioids
Adverse effects and withdrawal
Toxicology and contamination risks
Counseling patients who self-medicate
Lack of clinical trial data and regulatory approval
🎓 Board Prep Resources
Prepare for the ABA, ABPM, ABIPP, FIPP, and AOBPM exams with the PainExam Board Review and full curriculum at the NRAP Academy: 👉 https://www.NRAPpain.org
🫁 Hands-On Ultrasound Training for Pain Physicians
AABP Integrative Pain Care (Brooklyn & Great Neck, NY) To schedule a consultation or referral: 🌐 https://AABPpain.com 📞 Brooklyn: 718-436-7246
About the Host – David Rosenblum, MD
Dr. Rosenblum serves as Director of Pain Management at Maimonides Medical Center and Managing Partner at AABP Integrative Pain Care in Brooklyn, NY. He is recognized as an early adopter and leading educator in ultrasound-guided pain procedures, neuromodulation, and regenerative medicine.
He has:
Developed regional anesthesia training programs
Published widely in pain medicine literature
Lectured nationally and internationally through ASIPP, ASPN, NANS, IASP, and more
Helped over 3000 physicians pass pain board exams
Hosted the PainExam, AnesthesiaExam, and PMRExam podcasts
Contact available via email Info@NRAPpain.org for interested physicians
PRP Caudal Epidural Research Review
Study Overview: Randomized double-blind controlled pilot study comparing leukocyte-rich PRP versus corticosteroids in caudal epidural space
50 patients randomly assigned to two groups
Treatment options: triamcinolone 60mg or leukocyte-rich PRP from 60ml autologous blood
Follow-up assessments at 1, 3, and 6 months using VAS and SF-36 surveys
Key Findings:
Both treatments showed significant pain reduction compared to baseline
Steroid group had lower VAS scores at one month
PRP group demonstrated superior results at 3 and 6 months
Reference
Supplements for Pain, the Evidence!
mercredi 19 novembre 2025 • Durée 19:29
Episode Overview
In this episode, Dr. David Rosenblum discusses the role of supplements and complementary strategies in the management of chronic pain. Drawing from clinical practice at AABP Integrative Pain Care, as well as his teaching and training programs, Dr. Rosenblum reviews how nutraceuticals, regenerative therapies, ultrasound-guided procedures, and neuromodulation can work together to improve patient outcomes and reduce opioid reliance.
This episode also highlights educational opportunities and exam-prep resources for pain fellows, residents, anesthesiologists, physiatrists, and APPs looking to expand their interventional pain, ultrasound, and regenerative medicine skill sets.
Key Topics Discussed
Evidence and clinical rationale for select supplements in chronic pain management
The role of ultrasound guidance in improving accuracy and safety in interventional pain procedures
How regenerative medicine techniques such as PRP and BMAC are shaping personalized pain care
Practical considerations when combining supplements with neuromodulation, RFA, or injections
Patient case applications and real-world treatment planning
ABA ABPM ABIPP FIPP Pain Management Board prep, Question Banks, and Virtual Pain Fellowship
Educational Offerings and Events
Training and Courses:
Research Review: ACL Treatment Study
Study Focus: Non-surgical treatment of ACL tears using bone marrow concentrate (BMAC) and platelet products versus exercise therapy
Clinical Practice Implications
TENS: Mechanism of Action and Evidence
mercredi 1 octobre 2025 • Durée 11:11
Project Sync / Status Update SummaryPodcast Episode Overview
The host discussed Transcutaneous Electrical Nerve Stimulation (TENS) as a recurring pain board topic and reviewed mechanisms, efficacy, and clinical considerations.
Emphasis that TENS appears on pain boards annually and is a foundational topic from early podcast episodes.
ABA ABPM ABIPP FIPP Pain Management Board prep, Question Banks, and Virtual Pain Fellowship
Educational Offerings and Events
Training and Courses:
Monthly ultrasound courses in New York and upcoming courses in Detroit covering ultrasound-guided regional anesthesia and chronic pain.
Ultrasound Guided Acute and Chronic Pain course in November near Hollywood/Fort Lauderdale with venue pending confirmation.
Multiple instructors to offer diverse perspectives; registration via the CME calendar at nrappain.org.
Conferences and Teaching:
New York–New Jersey Pain Conference in November (hosted by Soudir Duwan).
ISPN conference in London next week, with ultrasound teaching participation by the host.
Community and Coaching:
Private coaching and shadowing opportunities available; contact via newsletter replies.
Access to the NRAP community forum upon signup at nrappain.org for discussions on neuromodulation, regional anesthesia, and pain.
Review TENS mechanisms with emphasis on A-beta fiber activation for board prep. Verify and publish final venue details for the November Florida ultrasound course. Share registration links and schedules for Detroit and New York ultrasound and chronic pain courses via CME calendar. Prepare teaching materials for ISPN London ultrasound sessions next week. Update board prep resources on painexam.com and nrappain.org with current TENS evidence and dosing guidance. Promote NRAP community forum access and private coaching/shadowing opportunities through the newsletter.
ADSC (Adipose Stem Cells) vs BMAC for Knee OA
vendredi 19 septembre 2025 • Durée 07:22
Exploring the Efficacy of BMAC and ADSC Injections in Knee Osteoarthritis
Hosts: David Rosenblum,MD
Overview: In this episode, we delve into a recent study published in the Indian Journal of Orthopaedics that compares the therapeutic efficacy of Bone Marrow Aspirate Concentrate (BMAC) and Adipose-Derived Stem Cells (ADSCs) for treating knee osteoarthritis (OA). The study aims to provide insights into the effectiveness of these regenerative treatments and their correlation with mesenchymal stem cell (MSC) cellularity.
Key Points Discussed:
Background on Osteoarthritis:
Definition and impact of OA, particularly in older populations.
Overview of traditional treatments and the shift towards regenerative medicine.
Study Objectives:
To compare the efficacy of BMAC and ADSC injections in symptomatic knee OA patients.
To analyze MSC quantity and quality in harvested tissues from both sources.
Methodology:
Description of the study design involving 60 patients with knee OA.
Details on patient demographics, injection protocols, and follow-up assessments (VAS, WOMAC, ROM).
Results:
Significant improvements in clinical scores for both BMAC and ADSC groups at 6 months.
Discussion on the lack of significant correlation between MSC quantity and treatment efficacy.
Insights into the success rates of MSC cultures from both bone marrow and adipose tissue.
Conclusions:
Both treatments demonstrated clinical improvements, with no substantial differences between them.
Steroid vs Ketorolac for Intra-Articular Injections: Journal Club
mercredi 6 août 2025 • Durée 14:52
Podcast Summary
This episode of the Pain Exam Podcast, hosted by Dr. David Rosenblum, discusses an interesting article about Ketorolac injections for musculoskeletal conditions. The podcast covers:
Ketorolac is an NSAID that provides analgesic and anti-inflammatory effects through inhibition of prostaglandin synthesis
Multiple studies comparing Ketorolac injections to corticosteroids and hyaluronic acid for various conditions
Research shows Ketorolac injections are equally effective as corticosteroids for subacromial conditions, adhesive capsulitis, carpal-metacarpal joint issues, and hip/knee osteoarthritis
Ketorolac may be a safer alternative to steroids for certain patients, though it has its own contraindications for those with renal, gastrointestinal, or cardiovascular disease
Dr. Rosenblum considers the potential of using Ketorolac injections directly at pain sites rather than intramuscularly
Upcoming Courses and Conferences
Ultrasound courses in New York and Costa Rica (check unwrappedpain.org)
Private ultrasound sessions available
Dr. Rosenblum will be speaking at Pain Week about ultrasound in pain practice and PRP
Presenting at a primary care conference in London
Teaching ultrasound at ISPN
LAPSES conference in Chile (Dr. Rosenblum won't attend this year)
Ketorolac Injections: An Effective Alternative for Musculoskeletal Pain Management
Musculoskeletal conditions such as bursitis, adhesive capsulitis, and osteoarthritis affect millions and often require injectable therapies to reduce pain and inflammation. Traditionally, corticosteroid injections have been the mainstay treatment. However, concerns over side effects like tendon rupture, cartilage damage, and systemic hyperglycemia have prompted exploration of alternatives. A recent narrative review by Kiel et al. (2024) highlights ketorolac—a parenteral nonsteroidal anti-inflammatory drug (NSAID)—as a promising substitute for corticosteroids in musculoskeletal injections.
Subacromial Ketorolac Injections for Shoulder Pain Intra-articular Ketorolac Injections for Adhesive Capsulitis and Osteoarthritis Safety and Pharmacologic Considerations Conclusion 1. What is ketorolac and how does it work? 2. How effective is ketorolac for musculoskeletal conditions? 3. What evidence supports subacromial ketorolac injections? 4. How does intra-articular ketorolac compare to corticosteroids for adhesive capsulitis? 5. What about ketorolac for osteoarthritis? 6. Are ketorolac injections safe? 7. What are the limitations of ketorolac use? 8. How does ketorolac's pharmacokinetics affect its use? 9. Why consider ketorolac over corticosteroids? 10. What further research is needed?
Post Herpetic Neuralgia- An Update
mardi 24 juin 2025 • Durée 27:40
Summary
In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures.
ChaptersIntroduction to the Pain Exam Podcast and Topic Overview
Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease.
Upcoming Conferences and Educational Opportunities
Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities.
The Neurolytic Celiac Plexus Block
mercredi 11 juin 2025 • Durée 14:34
Summary
In this Pain Exam Podcast episode, Dr. David Rosenblum discusses a journal club article on low volume neurolytic retrocrural celiac plexus blocks for visceral cancer pain. The study reviewed 507 patients with severe malignancy-related abdominal pain, with data retained for 455 patients at the 5-month mark. Dr. Rosenblum explains that the procedure involves injecting 3-5ml of 6% aqueous phenol at the T12-L1 level under fluoroscopic guidance, with an average procedure time of 16.3 minutes. The study found significant pain relief lasting up to six months, reduced opioid consumption, and improved quality of life for patients with primary abdominal cancer or metastatic disease. Dr. Rosenblum shares his personal experience with celiac plexus blocks, including the trans-aortic approach he trained on, and mentions his interest in ultrasound-guided approaches. He also announces upcoming teaching engagements at ASPN, Pain Week, and other conferences, as well as CME ultrasound courses available through nrappain.org. Additionally, he mentions a new community page on the website where users can share board preparation information, though he emphasizes that remembered board questions should not be posted as he is a board question writer himself.
Create an Account and get Free Access to the PainExam- NRAP Academy Community
HighlightsIntroduction and Upcoming Events
Dr. David Rosenblum introduces the Pain Exam Podcast and shares information about upcoming events. He mentions teaching ultrasound at ASPN in July, attending Pain Week in September, and participating in the Latin American Pain Society conference. Dr. Rosenblum also promotes his CME ultrasound courses available at nrappain.org and mentions he's considering organizing another regenerative medicine course in fall or winter. He offers private training for those wanting more intensive ultrasound instruction.
PRP Epidural Injections for Radicular Pain
mercredi 28 mai 2025 • Durée 15:31
PRP in the Epidural Space for Radiculopathy
Brooklyn Based Pain Physician, David Rosenblum, MD known for his work publishing and teaching Regenerative Pain Medicine and Ultrasound Guided Pain Procedures hosts this podcast covering the latest and most advanced concepts in Pain Medicine.
Summary
Dr. David Rosenblum delivered a comprehensive lecture covering several key topics in pain management. He discussed his upcoming speaking engagements at PainWeek, ASPN and great upcoming meetings like the Latin American Pain Society, and other conferences. Dr. Rosenblum shared his extensive experience with PRP (Platelet-Rich Plasma) epidural injections, reviewing multiple research studies that support their efficacy. He highlighted three significant studies: a randomized control trial comparing PRP epidural injections to traditional treatments, a CT-guided epidural PRP study, and a 2025 meta-analysis comparing PRP to steroids. Dr. Rosenblum emphasized that PRP treatments are showing comparable or better results than traditional steroid injections, with potentially fewer required treatments and longer-lasting relief. He noted that while PRP is currently not covered by insurance, it represents a growing trend in 'natural' treatment approaches that patients increasingly prefer.
ChaptersIntroduction and Upcoming Events
Dr. Rosenblum announced his upcoming lectures at Pain Week focusing on ultrasound and regenerative medicine, followed by presentations at the Latin American Pain Society in Chile and the New York, New Jersey Pain Conference. He mentioned the SoMeDocs online pain conference accessible through nrappain.org, and upcoming ultrasound training sessions in New York City.
PRP Epidural Research Review
Dr. Rosenblum discussed a randomized control trial involving 30 patients receiving transforaminal epidural injections. The study showed that PRP patients demonstrated significant improvements in leg pain scores at 6, 12, and 24 weeks. He noted that while the study didn't use contrast, he personally prefers using contrast diluted with saline for better visualization.
CT-Guided Epidural Study Analysis
Dr. Rosenblum reviewed a study comparing CT-guided epidural PRP versus steroid injections, questioning the necessity of CT guidance. The study included 60 patients and showed similar results between PRP and steroid groups at six weeks, though he criticized the short follow-up period, noting that PRP typically takes months to show full effects.
Podcasts Similaires Basées sur le Contenu
Découvrez des podcasts liées à The PMRExam Podcast. Explorez des podcasts avec des thèmes, sujets, et formats similaires. Ces similarités sont calculées grâce à des données tangibles, pas d'extrapolations !
PRP group showed significant improvement across all SF-36 domains at 6 months
No complications or adverse effects in either group during 6-month follow-up
Personal Treatment Experience
Dr. Rosenblum received transforaminal PRP injection 9-10 weeks ago
Gradual improvement noted from weeks 4-8, with more noticeable benefits from weeks 8-10
Current status: minimal pain (0.5/10) only during weather changes
Clinical Practice Philosophy
Treatment Approach: Minimalist philosophy focusing on turmeric, PRP, and Pilates
Medication Strategy: Low-dose naltrexone as go-to medication, avoiding long-term drugs with side effects
Surgical Avoidance: Prioritizing conservative treatments over unnecessary surgical interventions
Emergency Department PRP Implementation
Case Study Results: Ultrasound-guided caudal epidural steroid injection in ER setting
100% pain resolution achieved
Patient discharged directly from ER
Cost savings: reduced from $33,000 to $4,800 (approximately $28,000 savings)
Training Opportunities: Private training sessions available for ER physicians interested in ultrasound-guided procedures
Patient Testimonial Highlights
Case Background: Nurse with herniated disc from March, previously considering $30,000 surgery
Treatment Outcome: PRP injection completed two months ago with nearly complete pain relief
Reduced from multiple pain medications to one Advil daily
Eliminated antalgic posture and muscle spasms
Returned to full 12-hour hospital shifts without difficulty
Overall quality of life restored to normal levels
David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.
Awards
New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025
Schneps Media: 2015, 2016, 2017, 2019, 2020
Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025
Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023
Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!
Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.
Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators.
He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call
Brooklyn 718 436 7246
Irvan J. Bubic, Jessica Oswald, Ultrasound-Guided Caudal Epidural Steroid Injection for Back Pain: A Case Report of Successful Emergency Department Management of Radicular Low Back Pain Symptoms, The Journal of Emergency Medicine,Volume 61, Issue 3,2021,Pages 293-297,ISSN 0736-4679
Ruiz‐Lopez, Ricardo, and Yu‐Chuan Tsai. "A randomized double‐blind controlled pilot study comparing leucocyte‐rich platelet‐rich plasma and corticosteroid in caudal epidural injection for complex chronic degenerative spinal pain." Pain Practice 20.6 (2020): 639-646.
AABP Integrative Pain Care (Brooklyn & Great Neck, NY) To schedule a consultation or referral: 🌐 https://AABPpain.com 📞 Brooklyn: 718-436-7246
About the Host – David Rosenblum, MD
Dr. Rosenblum serves as Director of Pain Management at Maimonides Medical Center and Managing Partner at AABP Integrative Pain Care in Brooklyn, NY. He is recognized as an early adopter and leading educator in ultrasound-guided pain procedures, neuromodulation, and regenerative medicine.
He has:
Developed regional anesthesia training programs
Published widely in pain medicine literature
Lectured nationally and internationally through ASIPP, ASPN, NANS, IASP, and more
Helped over 3000 physicians pass pain board exams
Hosted the PainExam, AnesthesiaExam, and PMRExam podcasts
Evidence strength varies widely; preclinical support is more robust than human RCT data for most supplements.
Potentially reasonable adjuncts in select contexts
Vitamin D: plausible benefit in deficiency states, including diabetic neuropathy and chronic pain-related quality-of-life factors; confirm deficiency and monitor.
Magnesium: consider IV regimens for refractory neuropathic components (e.g., cancer pain, PHN); oral efficacy uncertain.
Curcumin: consider as adjunct, especially formulated phytosome combinations; monitor for additive effects and tolerability.
B vitamins: consider B12 in deficiency or neuropathy with suspected demyelination; overall human evidence limited.
Zinc: mechanistic rationale with preclinical support; limited human data—consider deficiency correction rather than supraphysiologic dosing.
Cautions and contraindications
St. John's wort: significant drug–drug interaction potential via CYP/P-gp induction.
Alpha lipoic acid: may cause hypoglycemia; monitor glucose, especially in diabetes.
Heterogeneity in study designs, small samples, lack of controls, and multi-ingredient formulations limit causal inference.
Need for large, well-designed RCTs stratified by neuropathic pain etiology (e.g., CIPN vs. DPN vs. PHN) with standardized outcomes.
Translational gap between animal models and human clinical efficacy remains significant.
References
Frediani, Jennifer K., et al. "The role of diet and non‐pharmacologic supplements in the treatment of chronic neuropathic pain: A systematic review." Pain Practice 24.1 (2024): 186-210.
Huang, Wei MD, PhD*,†; Shah, Shivani DO†; Long, Qi PhD‡; Crankshaw, Alicia K. MD†; Tangpricha, Vin MD, PhD§,∥. Improvement of Pain, Sleep, and Quality of Life in Chronic Pain Patients With Vitamin D Supplementation. The Clinical Journal of Pain 29(4):p 341-347, April 2013. | DOI: 10.1097/AJP.0b013e318255655d
Haddad, H.W., Mallepalli, N.R., Scheinuk, J.E. et al. The Role of Nutrient Supplementation in the Management of Chronic Pain in Fibromyalgia: A Narrative Review. Pain Ther10, 827–848 (2021). https://doi.org/10.1007/s40122-021-00266-9
Abdelrahman, K.M.; Hackshaw, K.V. Nutritional Supplements for the Treatment of Neuropathic Pain. Biomedicines2021, 9, 674. https://doi.org/10.3390/biomedicines9060674
Key Findings:
BMAC group showed significantly greater improvement in Lower Extremity Function Scale (LEFS) and Single Assessment Numeric Evaluation (SANE) scores at three months
Sustained improvement in function and decreased pain maintained through two-year follow-up
Patients reported median subjective improvement of 90% at final follow-up
No significant improvements observed in exercise-only group during initial three months
Treatment Protocol:
Bone marrow harvest from posterior superior iliac crest (60-90ml from 6-8 sites)
PRP preparation from 60ml whole blood
Fluoroscopy-guided injection directly into ACL ligament
Comprehensive 52-week rehabilitation protocol with activity restrictions
Current ACL Treatment Landscape: Over 400,000 ACL reconstruction surgeries performed annually in the US
Surgical Limitations: Risk of graft failure, persistent instability, cartilage injury, and increased arthritis risk
Return to Sport Statistics: Post-surgical rates vary significantly (33-92% return to sport, 65% return to pre-injury level)
Practice Integration Considerations: Potential incorporation of BMAC/PRP protocols for ACL tears, though insurance coverage remains limited
David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.
Awards
New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025
Schneps Media: 2015, 2016, 2017, 2019, 2020
Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025
Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023
Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!
Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.
Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators.
He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call
TENS delivers adjustable pulse frequency and intensity; configurations include low (<10 Hz), high (>50–100+ Hz), and mixed frequencies.
Mechanisms of Analgesia:
Activation of large-diameter, non-noxious A-beta afferent fibers in the periphery, driving descending inhibitory pathways and reducing hyperalgesia.
Board-relevant point: selective activation of A-beta fibers is frequently tested.
Central effects:
Reduces central excitability and nociceptive dorsal horn neuron activity in uninjured and injured models.
Frequency-dependent opioid receptor mediation:
High-frequency analgesia blocked by delta receptor antagonists.
Low-frequency analgesia blocked by mu receptor antagonists (spinal cord and rostral ventral medulla).
Additional receptor involvement: muscarinic M1/M3, GABA-A, and cannabinoid (CB1) receptors; blockade reduces or prevents TENS analgesia depending on frequency.
Peripheral effects:
High-frequency TENS reduces injury-related increases in substance P in DRG neurons.
Blockade of peripheral opioid and CB1 receptors can prevent analgesia from both low- and high-frequency TENS.
Clinical dosing considerations:
Adequate dosing (timing, frequency of use, intensity achieving strong but non-painful paresthesia) influences efficacy.
Analgesia has rapid onset/offset and may require repeated administration throughout the day for sustained relief.
Evidence and Efficacy Summary
Practical Interpretation:
TENS is inexpensive, low-risk, self-administered, and titratable; commonly used by patients and physical therapists.
Clinical experience suggests potential adjunctive benefit for acute pain, but systematic reviews are conflicting; more rigorous studies are needed.
For board preparation, the critical takeaway is A-beta fiber activation.
Key Takeaways for Board Prep
TENS targets large-diameter non-noxious A-beta afferents to reduce nociceptive signaling.
High-frequency TENS: analgesia mediated via delta opioid receptors; blocked by delta antagonists.
Low-frequency TENS: analgesia mediated via mu opioid receptors; blocked by mu antagonists in spinal cord and RVM.
Additional receptor systems influencing TENS efficacy include muscarinic (M1/M3), GABA-A, and CB1.
Action Items
David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.
New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025
Schneps Media: 2015, 2016, 2017, 2019, 2020
Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025
Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023
References
Johnson M. Transcutaneous Electrical Nerve Stimulation: Mechanisms, Clinical Application and Evidence. Rev Pain. 2007 Aug;1(1):7-11. doi: 10.1177/204946370700100103. PMID: 26526976; PMCID: PMC4589923.
Vance, C.G.T.; Dailey, D.L.; Chimenti, R.L.; Van Gorp, B.J.; Crofford, L.J.; Sluka, K.A. Using TENS for Pain Control: Update on the State of the Evidence. Medicina2022, 58, 1332. https://doi.org/10.3390/medicina58101332
BMAC showed higher MSC counts and faster recovery rates, but further research is needed to understand the underlying factors affecting efficacy.
Implications for Clinical Practice:
Considerations for clinicians when choosing between BMAC and ADSC treatments.
Future directions for research in regenerative therapies for knee OA.
References:
Vitali, M., Ometti, M., Montalbano, F., et al. (2025). Bone Marrow Aspirate Concentrate (BMAC) Versus Adipose-Derived Stem Cells (ADSCs) Intra-articular Injection Therapeutic Efficacy in Knee OA Correlated to Their Mesenchymal Stem Cell (MSC) Cellularity: An Exploratory Comparative Pilot Study. Indian Journal of Orthopaedics. https://doi.org/10.1007/s43465-025-01525-z
Listener Engagement:
Join the conversation! Share your thoughts on BMAC and ADSC treatments for knee OA on social media using #JournalClubPodcast.
Don't forget to subscribe for more discussions on the latest research in orthopaedics and regenerative medicine.
Warning: OFF Label use of Ketorolac discussed. Please consult your physician.
Subacromial bursitis and impingement syndrome are common causes of shoulder pain and disability. Several randomized controlled trials have shown that subacromial ketorolac injections provide pain relief and functional improvement comparable to corticosteroids:
Goyal et al. demonstrated significant reductions in pain scores after subacromial injection of 60 mg ketorolac versus 40 mg methylprednisolone, with no difference in outcomes between groups.
Taheri et al. found similar short-term pain relief at 1 and 3 months with either ketorolac or corticosteroid subacromial injections.
Kim et al. reported equivalent clinical improvement in rotator cuff syndrome patients receiving ketorolac or triamcinolone injections.
Min et al. noted ketorolac led to better forward flexion and patient satisfaction at 4 weeks compared to corticosteroids.
These studies support ketorolac as an effective agent for subacromial injection, offering an alternative for patients where corticosteroid use is limited.
Adhesive capsulitis (frozen shoulder) and osteoarthritis of the hip, knee, and carpometacarpal joint are often treated with intra-articular corticosteroids. Ketorolac injections have shown comparable efficacy in these conditions:
Akhtar et al. found intra-articular ketorolac significantly reduced shoulder pain at 4 weeks in adhesive capsulitis compared to hyaluronic acid.
Ahn et al. reported similar pain relief between intra-articular ketorolac and corticosteroid injections in adhesive capsulitis, with ketorolac providing superior shoulder mobility at 3 and 6 months.
Koh et al. showed that adding ketorolac to hyaluronic acid injections in carpometacarpal osteoarthritis resulted in faster onset of pain relief compared to hyaluronic acid alone.
Park et al. observed equivalent functional improvements with intra-articular ketorolac or corticosteroids in hip osteoarthritis.
Jurgensmeier et al. demonstrated similar symptom improvement at 1 and 3 months post-injection for ketorolac and triamcinolone in hip and knee osteoarthritis.
Xu et al. and Bellamy et al. confirmed ketorolac's comparable pain relief and functional benefits to corticosteroids for knee osteoarthritis, with ketorolac being more cost-effective.
Lee et al. noted quicker pain reduction with intra-articular ketorolac combined with hyaluronic acid versus hyaluronic acid alone in knee osteoarthritis.
Ketorolac's anti-inflammatory action stems from cyclooxygenase inhibition, reducing prostaglandin synthesis. Its half-life is approximately 5.2–5.6 hours, and it is metabolized in the liver. Unlike corticosteroids, ketorolac avoids systemic hyperglycemia and cartilage damage risks. Animal and in vitro studies suggest ketorolac may protect cartilage by inhibiting inflammatory cytokines.
While gastrointestinal, renal, and cardiovascular risks associated with NSAIDs remain considerations, localized intra-articular and subacromial ketorolac injections may limit systemic exposure and adverse effects. Mild, transient post-injection pain has been reported but resolves without intervention.
Ketorolac injections, administered intra-articularly or subacromially, are a safe, effective, and economical alternative to corticosteroids for managing common musculoskeletal conditions. Their comparable efficacy in reducing pain and improving function, combined with a more favorable side effect profile, makes ketorolac an appealing option for clinicians and patients alike. Further research is warranted to fully elucidate long-term safety and optimal dosing strategies.
FAQS
Ketorolac Injections for Musculoskeletal Conditions: Frequently Asked Questions
Musculoskeletal pain from conditions like bursitis, adhesive capsulitis, and osteoarthritis often requires injectable treatments. Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is emerging as a promising alternative to corticosteroids. Below are common questions and answers based on a recent narrative review by Kiel et al. (2024).
Ketorolac is a parenteral NSAID that reduces pain and inflammation by inhibiting cyclooxygenase enzymes, which decreases prostaglandin synthesis. It can be administered orally, intramuscularly, intravenously, or by injection directly into joints or around bursae.
Studies show ketorolac injections provide significant pain relief and functional improvement comparable to corticosteroids in conditions like:
Subacromial bursitis and shoulder impingement (subacromial injections)
Osteoarthritis of the hip, knee, and thumb carpometacarpal joint (intra-articular injections)
Randomized controlled trials found:
Goyal et al. and Taheri et al. reported similar pain reduction and functional outcomes between ketorolac and corticosteroids for subacromial injections.
Kim et al. and Min et al. observed comparable or better patient satisfaction and shoulder mobility with ketorolac versus corticosteroids.
Akhtar et al. showed ketorolac reduced shoulder pain more than hyaluronic acid.
Ahn et al. found ketorolac and corticosteroids equally effective for pain relief, with ketorolac providing better shoulder mobility at 3 and 6 months.
Ketorolac combined with hyaluronic acid provided faster pain relief than hyaluronic acid alone in thumb carpometacarpal joint osteoarthritis (Koh et al.).
Intra-articular ketorolac had similar efficacy to corticosteroids in hip (Park et al., Jurgensmeier et al.) and knee osteoarthritis (Bellamy et al., Xu et al.).
Ketorolac injections were more cost-effective compared to corticosteroids (Bellamy et al.).
Ketorolac's side effects are similar to other NSAIDs, mainly involving gastrointestinal, renal, and cardiovascular risks. However, localized intra-articular and subacromial injections may reduce systemic exposure. Animal studies suggest ketorolac does not harm cartilage and may protect against inflammatory damage. Mild, transient local pain post-injection is possible but usually resolves without treatment.
Ketorolac is not suitable for patients with:
Renal impairment
Gastrointestinal ulcers or bleeding risk
Cardiovascular disease or hypertension
NSAID hypersensitivity, especially in asthma or chronic urticaria patients
Clinicians should assess individual risks before choosing ketorolac injections.
Ketorolac has a plasma half-life of about 5.2 to 5.6 hours and is metabolized in the liver. Pharmacokinetics for subcutaneous or intra-articular administration are less defined but systemic absorption occurs. Its relatively short half-life supports repeated dosing if needed.
Ketorolac avoids corticosteroid-associated risks such as tendon rupture, cartilage damage, and steroid-induced hyperglycemia. It is also more cost-effective, making it a favorable option for patients and healthcare systems.
More large-scale, long-term studies are needed to fully understand ketorolac's intra-articular effects, optimal dosing, and safety profile compared to corticosteroids and other treatments.
Summary: Ketorolac injections, whether intra-articular or subacromial, offer a safe, effective, and economical alternative to corticosteroids for managing various musculoskeletal conditions. This makes ketorolac an important option in pain management and inflammation control.
Reference:
Kiel J, Applewhite AI, Bertasi TGO, Bertasi RAO, Seemann LL, Costa LMC, Helmi H, Pujalte GGA. Ketorolac Injections for Musculoskeletal Conditions: A Narrative Review. Clinical Medicine & Research. 2024;22(1):19-27. DOI: https://doi.org/10.3121/cmr.2024.1847
Disclaimer: This Podcast, website and any content from NRAP Academy (PMRexam.com) otherwise known as Qbazaar.com, LLC is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user's own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.
Overview of Postherpetic Neuralgia
Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life.
Treatment Options Overview
Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics.
Phases of Herpes Zoster and Definitions
Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash.
Incidence and Risk Factors
Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia.
Impact on Quality of Life
Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia.
Literature Review and Pathophysiology
Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia.
Central Sensitization and Nerve Damage
Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome.
Different Phenotypes and Classification
Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration.
Deafferentation Phenotype
Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial.
Diagnosis and Physical Examination
Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients.
Sensory Testing and Assessment
Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons.
Prevention Through Vaccination
Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions.
Treatment Objectives
Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation.
Antiviral Medications
Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised.
Benefits of Antiviral Therapy
Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible.
Corticosteroids and Opioids
Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction.
Methadone and Antidepressants
Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction.
Antiepileptics and Pharmacological Treatment Summary
Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011.
Topical Agents
Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group.
Intracutaneous Injections
Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study.
Summary of Local Anesthetics
Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy.
Interventional Treatments: Epidural and Paravertebral Injections
Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster.
Comparative Studies on Injection Approaches
Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster.
Timing of Interventions and Continuous Epidural Blockade
Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality.
Interventions for Postherpetic Neuralgia
Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence.
Summary of Epidural and Paravertebral Injections
Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy.
Pulsed Radiofrequency (PRF) Evidence
Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy.
PRF Studies for Acute Herpes Zoster
Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group.
PRF for Trigeminal Neuralgia
Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group.
PRF Compared to Other Interventions
Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate.
Summary of PRF and Final Recommendations
Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature.
Sympathetic Blocks and Conclusion
Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia.
Personal Clinical Approach and Closing
Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast.
Create an Account and get Free Access to the PainExam- NRAP Academy Community
Highlights
David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.
Awards
New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025
Schneps Media: 2015, 2016, 2017, 2019, 2020
Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025
Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023
Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!
Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.
Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators.
He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call
Dr. Rosenblum announces a new community page on the nrappain.org website for board preparation. He explains that registered users can access free information and keywords relevant to board exams. He emphasizes that users should not post remembered questions as this would be inappropriate, noting that he himself is a board question writer for various pain boards. Dr. Rosenblum mentions that a post about phenol in this community inspired today's podcast topic.
Journal Article Overview on Celiac Plexus Block
Dr. Rosenblum introduces a journal article on low volume neurolytic retrocrural celiac plexus block for visceral cancer pain, a retrospective review of 507 patients with severe malignancy-related abdominal pain. He explains that the study assessed pain relief provided by this procedure, its duration, reduction in daily opioid consumption, and quality of life improvements. The patients received neurolytic blocks without previous diagnostic blocks due to multiple comorbidities, which Dr. Rosenblum acknowledges is sometimes necessary with very sick patients despite the typical preference for diagnostic blocks before neurolysis.
Dr. Rosenblum's Personal Experience with Celiac Plexus Blocks
Dr. Rosenblum shares his personal training experience with trans-aortic celiac plexus blocks, where a needle is inserted through the aorta after confirming no plaques or aneurysms are present. He describes it as a safe and effective procedure despite sounding intimidating. He mentions he's only performed a handful of these procedures and doesn't do many now as an outpatient pain doctor.
Study Methods and Results
Dr. Rosenblum details the study methods, noting that of 507 patients studied, data for 455 was retained at the end of the review. Patients were evaluated before and after the neurolytic retrocrural celiac plexus block under fluoroscopic guidance. Assessment included procedure duration, pain scores (0-10 scale), daily opioid consumption, and quality of life improvement. Follow-up was completed six months after the procedure, showing improved pain scores, reduced opioid consumption, and better quality of life throughout the study period. Some pain returned during months 4-6 due to disease progression and the anticipated duration of the neurolytic agent. The study noted a 6.7% initial vascular contrast uptake during the procedure while using digital subtraction angiography with fluoroscopy.
Study Limitations and Conclusions
Dr. Rosenblum discusses the study's limitations, including the need for a larger sample size and a prospective trial with a control group, though he acknowledges this is unrealistic given the patient population. He mentions that a proven quality of life questionnaire would be beneficial, and that comparing alcohol, phenol, and RF thermocoagulation would be interesting to evaluate duration effects and side effects. The study concluded that low volume neurolytic retrocrural celiac plexus block with phenol is safe, providing up to six months of pain relief for abdominal pain due to primary malignancy or metastatic spread.
Detailed Procedure Technique
Dr. Rosenblum explains the detailed procedure technique used in the study. The retrocrural celiac plexus was targeted at L1 level with aim towards T12. Anterior and posterior radiographic imaging aligning the spinous process of T12-L1 junction was used with 15-20 degree oblique rotation. Local anesthetic (1% lidocaine with sodium bicarbonate) was infiltrated along the injection path. A 22 or 25 gauge 3.5-7 inch curved spinal needle was used depending on patient body habitus. Dr. Rosenblum notes he typically uses a 6-inch Chiba needle or 25 gauge spinal needle for such procedures.
Procedure Execution and Monitoring
Dr. Rosenblum continues describing the procedure, noting that the needle was advanced to the anterior border of T12-L1 under multiple imaging views. Contrast dye studies verified spread and location, with digital subtraction angiography used to check for intravascular uptake. A test dose of 1ml of 0.5% bupivacaine with epinephrine per site was administered, which Dr. Rosenblum finds interesting as he typically doesn't mix bupivacaine with epinephrine. After confirming no vascular uptake, 3-5ml of 6% aqueous phenol was injected in 1ml aliquots while communicating with the patient. The average procedure time was 16.3 minutes with minimal or no sedation. Patients remained prone for 30 minutes afterward to avoid neuroforaminal spread, as phenol is heavier and more viscous than alcohol.
Post-Procedure Care and Study Evaluation
Dr. Rosenblum explains that patients were monitored in recovery for one hour for adverse events and their ability to eat and void easily. They were discharged once hospital post-anesthetic criteria were met and received a follow-up call 24 hours later. Dr. Rosenblum praises the study and notes that the procedure looks similar to a lumbar sympathetic plexus block, which is also a sympathetic block.
Ultrasound Considerations and Alternative Approaches
Dr. Rosenblum shares his interest in ultrasound-guided celiac plexus blocks but acknowledges concerns about bowel perforation. He mentions a conversation with an interventional radiology colleague who suggested a transhepatic approach. Dr. Rosenblum recalls scanning a very thin patient where the aorta was easily visible and close to the anterior abdominal wall, making the celiac plexus potentially accessible if bowel perforation, liver bleeding, or gallbladder perforation could be avoided. He shares an experience with a patient suffering from severe pancreatitis pain who received temporary relief from a paravertebral thoracic nerve block at T8-T10, noting that paravertebral blocks provide some sympathetic spread.
Conclusion and Community Resource Reminder
Dr. Rosenblum concludes by recommending the article, noting its well-written analysis and graphs showing morphine consumption dropping over months following the procedure. He suggests neurolytic procedures are underutilized because they sound intimidating. He again encourages listeners to check out the community he created with separate chat rooms for regenerative medicine, regional anesthesia, and pain boards, where users can share keywords but not specific board questions. Dr. Rosenblum reminds listeners about upcoming courses and his website resources, mentions an upcoming PRP lecture, and asks for five-star reviews if listeners enjoy the podcast. The episode ends with a standard medical disclaimer.
Dr. Rosenblum presented a 2025 meta-analysis comparing PRP to steroids in epidural injections. The analysis included 310 patients across five RCTs, demonstrating comparable efficacy between PRP and steroid injections without increased adverse events. He emphasized that his clinical experience shows patients typically require fewer PRP injections compared to steroid treatments.
Wongjarupong, Asarn, et al. ""Platelet-Rich Plasma" epidural injection an emerging strategy in lumbar disc herniation: a Randomized Controlled Trial." BMC Musculoskeletal Disorders 24.1 (2023): 335.
Bise, Sylvain, et al. "Comparison of interlaminar CT-guided epidural platelet-rich plasma versus steroid injection in patients with lumbar radicular pain." European radiology 30 (2020): 3152-3160.
Muthu S, Viswanathan VK, Gangadaran P. Is platelet-rich plasma better than steroids as epidural drug of choice in lumbar disc disease with radiculopathy? Meta-analysis of randomized controlled trials. Exp Biol Med (Maywood). 2025 Feb 4;250:10390. doi: 10.3389/ebm.2025.10390. PMID: 39968415; PMCID: PMC11832311.
