Q&A Topics: How to Choose A Pain Physician

with Dr. Selina Y. Xing, MD, ABPM, ABPMR, of AdvanceXing Pain & Rehab Clinic

Q: How do I know if I need a pain physician?A: Acute pain serves as a warning that the body has been injured. When the injury heals, the pain goes away. The exception to this rule is shingles. If you suffer from shingles, your primary care physician can treat the condition with anti-viral medication. However, you should promptly obtain a referral to see a pain specialist, who will augment the anti-viral therapy with nerve blocks to minimize the chance of any permanent nerve damage. If not properly treated by a qualified pain physician, shingles can lead to Post-Herpetic Neuralgia (PHN), an extremely painful chronic disorder that is very difficult to treat.

Chronic pain is pain that continues to plague the patient even after the injury heals. While acute pain is an uncomfortable side effect of an injury, chronic pain is a disease unto itself. Alternatively, chronic pain can be caused by an injury that the body is unable to recover from without treatment. Chronic pain does not serve any useful function and can be very debilitating.
Q: How do I select a practitioner that will best help me with my pain?A: In order to have the best outcome, find a practitioner who is familiar with all of the various pain conditions and will be able to quickly and properly diagnose the root cause of your pain. In addition, the practitioner should be intimately familiar with all potential treatments and have detailed knowledge regarding the benefits and risks associated with each treatment, as well as who is a good candidate for each treatment. You will generally only be able to obtain this expertise at a multidimensional pain clinic run by one or more physicians certified by the American Board of Pain Medicine (ABPM). A multidimensional pain clinic provides services to pain patients that span a wide variety of disciplines. At a minimum, a good multidimensional pain clinic can provide the following services either directly or by referral:

• Physical therapy
• Prescription medication management, including anti-inflammatory medication, neurogenic medication, muscle relaxors, and a wide variety of medication to treat any co-morbidities, in addition to narcotics
• Acupuncture
• Regenerative therapy
• Spine and joint injections
• Muscular skeletal manipulation and therapeutic massage
• Advanced diagnostics, such as EMG and discography
• Spinal cord stimulator implantation
• Spine surgery
• Mental health services that provide support for chronic pain-related depression

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If you instead initially choose a practitioner that specializes in just one or a handful of therapies, then they will apply the treatments that they know, which may or may not be the optimum therapy for your specific condition.
Q: From a treatment perspective, is all pain the same?A: Treatments that work very well with one type of pain may be relatively ineffective when applied to a different type of pain.

Nociceptive pain is caused by injury to the body’s tissue and is a throbbing or aching pain. Most nociceptive pain is acute in nature, such as sprains, broken bones, and burns. However, some is chronic in nature, including arthritis and pain caused by cancers and other tumors when they grow and put pressure on neighboring body structures. Anti-inflammatory medication, narcotics, and other medications are typically effective in treating nociceptive pain, while neurostimulation typically is not very effective.

Neuropathic pain is caused by nerve damage. The nerve damage can be the result of injury, disease, or physical pressure on the nerve, e.g. a pinched nerve. Colloquially referred to as “nerve pain,” neuropathic pain is normally not as receptive to narcotics and anti-inflammatory medication as nociceptive pain, but is often treatable by neurostimulation. In the case of an entrapped, compressed, or otherwise impinged nerve, treatment with cortisteroids is often quite effective. As a last resort for entrapped nerves, surgical release may be necessary.
Q: What are the basics of workman’s compensation and auto insurance?A: These two often-overlooked forms of insurance can provide you with important coverage, but they are complex and can require care and effort to get the most out of them.

Regarding automotive insurance policies, a policy holder’s level of coverage is determined by the amount of Personal Injury Protection (PIP). Each state has its own mandatory minimum amount of PIP, but this is usually inadequate for fully covering serious injury that causes chronic pain. If you do not have good health insurance coverage to fall back on, you should seriously consider purchasing a higher level of PIP. If you haven’t already, you can take a defensive driving class to obtain a 10 percent safety discount on your insurance policy.

If you are injured, know how much PIP you have and keep track of how much is expended. Make an appointment with a multidisciplinary pain clinic that is familiar with all of the potential treatment options. A good multidisciplinary pain clinic will develop an individual treatment plan that is based on your specific injuries rather than a one-size-fits-all assembly line treatment that could be both costly and ineffective for your particular injury.

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Workman’s compensation insurance protects those who have been injured on the job. It even covers injuries due to repetitive motion, such as carpal tunnel syndrome or tendonitis. These sorts of injuries may not be immediately apparent. You might leave work feeling fine only to wake up the next morning experiencing pain and/or a limited range of motion.

Workman’s compensation insurance is extremely complex. If you are seriously injured, you should retain a lawyer. Physicians who treat workplace injuries can provide a list of attorneys that have a proven track record. Select an attorney with care, because once you are represented by an attorney in a workman’s compensation case, it is very difficult to switch to a new attorney.

The insurance company will assign you a case manager who normally has a medical background, most often a nursing degree. The case manager will help guide you through the process and also document what medical treatment your physician is recommending and why it is needed.

If your injuries are substantial, you may have to go for an Expert Medical Exam (EME), also sometimes referred to as an Independent or Defensive Medical Exam (IME or DME, respectively). EME doctors are selected by the insurance company to obtain a second expert opinion. In representing the client insurance company’s viewpoint, the EME physician will typically advocate for more economically conservative therapy. Of course, the Delaware Industrial Accident Board is well aware of this, and in my experience takes this bias into account when evaluating the merits of your case, so don’t get too discouraged if the EME doctor disagrees with the necessity of your treatment. More often than not, if you have a competent, ethical attorney, you will prevail in your worker’s compensation hearing with the Delaware Industrial Accident Board.
Q: How do spine and joint injections relieve pain?A: Injection therapies involve injecting medication directly into the injured location that is a significant source of pain. One exception is dry needling, which is a form of trigger point injection described below.

Injecting into muscles: When muscles are in a permanent state of contraction, forming a tense knot of muscle, this can cause local pain or referred pain in the attached tendon. The areas where muscle knotting can occur are called trigger points. Trigger point injections in the muscle can help the muscle relax and heal. When a needle is inserted into the muscle without injecting medication, it is called dry needling, and it is best performed by someone who is licensed to perform acupuncture. In fact, in some jurisdictions, it is illegal for someone who is not a licensed acupuncturist to perform dry needling. Alternatively, a local anesthetic can be injected into the trigger point. Trigger point injections can provide immediate relief to pain caused by a knotted muscle. If this relief is temporary, then it may be appropriate to conduct a follow-up injection of Botox in the muscle. Steroids should never be injected into a muscle because this can cause significant muscle atrophy. Trigger point injections do not require any x-ray or ultrasound guidance.

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Peripheral Joint Injections: In this context, peripheral refers to any location in the body except the spine. Peripheral joint injections typically involve injections of cortisone directly into the joint. For knee joint injections, sometimes a lubricant such as Hyaluronan is used instead of cortisone. These injections can be performed with x-ray or ultrasound guidance, but this is not a strict requirement.

Peripheral Nerve Blocks: An interventional pain physician will inject anesthetic along the outside of the nerve. This injection is a diagnostic injection. If the pain is effectively suppressed by the anesthetic, then the physician has confirmed that the nerve in question is the source of the pain. For more lasting relief, cortisone is injected along the outside of the nerve. The cortisone injection reduces inflammation and aids in healing.

Spinal Injections: Typically, spinal injections involve injecting medication at the site of the injury. All spinal injections must be x-ray or ultrasound guided.

An epidural injection is an injection of cortisone into the cavity in the spine, called the epidural space, that surrounds the spinal cord. If the spinal cord becomes inflamed or the epidural space narrows, a condition called spinal stenosis, the spinal cord can become compressed and cause serious back and/or leg pain. Epidural injections also can be used to treat herniated disks that also can cause significant back and/or leg pain.

Facet joint injections usually are a combination of injections of cortisone and/or local anesthetic into the facet joints in the spine at one or more levels. Alternatively, these medications can be injected along the medial branch nerves, which provide sensation to the facet joint, called a medial branch block (MBB). Once again, local anesthetic is used for diagnostic purposes while cortisone is used to reduce inflammation and facilitate healing. If a cortisone injection in a facet joint or medial branch block gives significant but short-term pain relief, a radiofrequency nerve ablation can be performed to achieve more long-term pain relief.

The sacroiliac joint is located where the tailbone meets the pelvis. Sacroiliac joint injections involve injecting local anesthetic and/or cortisone directly into the sacroiliac joint. As with other such injections, local anesthetic is used for diagnostic purposes while cortisone is used to reduce inflammation and facilitate healing.
Dr. Selina Xing attended Medical School at China Medical University, P.R.China, and completed her residency in the department of Physical Medicine and Rehabilitation at Temple University Hospital in Philadelphia, Pa. She completed a pain fellowship in the department of Anesthesia at Mayo Clinic in Rochester, Minn. She also has an extensive research background in the field of gene therapy and attended graduate school in the department of Biochemistry at the Medical College of Ohio in Toledo, Ohio. She currently works with the Delaware Orthopedic surgical group, First state surgical group, and Delaware neurosurgical group, and is a recognized expert in the field of pain management. She is affiliated with St. Francis Hospital and Christiana Hospital.

Dr. Xing is Board certified by the American Board of Physical Medicine and Rehabilitation and American Board of Anesthesia Pain Medicine. She is also certified in Medical Acupuncture. Dr. Xing is an active member of the American Society of Interventional Pain Physicians (ASIPP). She serves as secretary for the local Delaware chapter of ASIPP (DESIPP). She also engages in instruction for the Arcadia University Physician Assistant Program through its clinical rotations. She is an educational advocate for the Delaware American Chinese Association. Dr. Xing is the medical director of the AdvanceXing Pain and Rehabilitation Clinic, which is a multidimensional pain clinic. While it is not the only multidisciplinary pain clinic in Delaware, it is one of the best.
AdvanceXing Pain and Rehabilitation Clinic
620 Stanton-Christiana Road, Suite 202
Newark, DE 19713

Selina Y. Xing, MD, ABPM, ABPMR

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