Workers Comp Matters

Using Neuroplasticity to Manage Chronic Pain

Currently, there are very few non-pharmaceutical pain management options for workers suffering from neuropathic injuries. What advancements have been made in treatment techniques for patients who are looking to move away from opioid-based treatment?

In this episode of Workers Comp Matters, host Alan Pierce talks with Dr. Roberto Feliz about pain management and Scrambler Therapy. Roberto opens the interview by defining chronic pain and shares that the body maintaining localized inflammation within the tissue is how acute pain transforms into chronic pain. He states that the continued bombardment of pain signals to your spinal cord and central nervous system forces the neurons in your brain to change and form new neural connections. Roberto explains that Scrambler Therapy, a pain management technique that blocks pain signal transmission and provides non-pain information to the affected nerve fibers, aims to deceive the brain into reading the pain signals in a different way. He analyzes what types of pain respond well to this therapy style and what pain types, like degenerative arthritis, do not. Roberto closes the interview with a comparison of how accepting private insurance and workers’ comp services are of this new therapy and discusses the cost and frequency of treatment.

Roberto Feliz, M.D. is a board certified pain management physician and anesthesiologist. Dr. Feliz is widely recognized for his clinical interests in Complex Regional Pain Syndrome, neuropathic pain, Rhizotomy, epidurals and nerve blocks, opioid tapering and sports injuries.

Dr. Feliz earned his medical degree from Dartmouth Medical School. He completed his residency at Harvard Medical School at Beth Israel Hospital. He has a fellowship in pain management from Beth Israel Deaconess Hospital completed in 1993 and Massachusetts General Hospital in 1994. He currently serves as an impartial physician for the Massachusetts Workers’ Compensation Judges.

Special thanks to our sponsors, Casepacer and PInow.

View transcript

Workers Comp Matters

Using Neuroplasticity to Manage Chronic Pain

07/15/2016

Intro: This is Workers’ Comp Matters hosted by attorney Alan S. Pierce; the only Legal Talk Network program that focuses entirely on the people and the law in workers’ compensation cases. A nationally recognized trial attorney, expert and author, Alan S. Pierce, is a leader committed to making a difference with workers’ comp matters.

Alan S. Pierce: Welcome to another edition of Workers’ Comp Matters here on the Legal Talk Network. I am your host, Alan Pierce. I am an attorney with the firm of Pierce, Pierce & Napolitano in Salem, Massachusetts.

In today’s edition of Workers’ Comp Matters, we are pleased to introduce Dr. Roberto Feliz. Dr. Feliz is an anesthesiologist and pain management specialist. He is affiliated with Hyde Park Pain Management in Hyde Park, Massachusetts.

So before we get to Dr. Feliz, we would like to thank our sponsors, Case Pacer, Practice Management Software dedicated to the busy trial attorney. To learn more, go to  HYPERLINK “http://www.casepacer.com” casepacer.com and also PInow, find a local qualified private investigator anywhere in the United States, visit  HYPERLINK “http://www.pinow.com” pinow.com to learn more.

Well Dr. Feliz, welcome to Workers’ Comp Matters.

Dr. Roberto Feliz: Thank you very much. Thank you for having me here.

Alan S. Pierce: Doctor, the thing that interested me and the reason I wanted to have you in particular as a guest on our show is that I become acquainted with a relatively new type of therapy for dealing with chronic pain.

It’s a therapy known as scrambler therapy and those of us in the workers’ comp field, whether we are lawyers, whether we are doctors, whether we are insurance companies, one of the things that causes us the most difficulty is dealing with claimants or patients that are suffering from chronic pain that results in extensive medical care, results in extensive absence from work, results in disruption of activities of daily living and a happy and normal life and is very costly.

Dr. Roberto Feliz: Correct.

Alan S. Pierce: And I know there are various modalities of dealing with chronic pain. So I do want to address scrambler therapy because I know this is something that you’ve been working with so —

Dr. Roberto Feliz: Correct.

Alan S. Pierce: — perhaps you can begin by defining what is chronic pain and then we can get into the various ways of dealing with it?

Dr. Roberto Feliz: Well, chronic pain, by definition, is anyone who has ongoing pain and this is where they line some time across. Some physicians believe that chronic pain begins after three months of ongoing pain and there are other physicians that say, no, a chronic pain develops after six months.

What chronic pain is, in addition to the definition of the abnormal sensation and that it hurts kind of incident that most individuals always talk, if you have acute pain, let’s say that you have an injury in your back or you have sprained an ankle or a knee, you develop an acute inflammation.

The body, let’s say that the injury occurred, you herniated a disc in your back or you sprained an ankle, the body normally when that occurs sends to the area of the injury what we call, physicians call the mediators of inflammation, and those are all the substances that your body needs to inflame, to call attention to decide that there is an injury and some of those processes are called prostaglandins, histamine, kinins,

in most of that are there substances for which we take medications like an ibuprofen or anti-inflammatory to decrease it.

Most people that have an injury to the back or the ankle usually within four or six weeks they heal and that’s because the body begins to remove from the area of the injury, the area of inflammation, all of the mediators of inflammation back to the circulation, back away and with time individuals get back better.

What occurs is that in certain individuals with the back or as sprained ankle the body maintains in the region of the injury all of those mediators and now you hear a lot of us who are specialized in chronic pain, the body maintains an ultra-localized inflammation within the tissues.

When that occurs, and this is how you go from acute pain to chronic pain, when the body maintains that there, there is a whole bunch of reaction that occurs and ultimately the continued bombardment, this continued sending of messages to your spinal cord and to your central nervous system, your brain or the neurons in your brain, forces the neurons to change. This we will call our confirmation or change or wind up.

(00:04:53)

When that occurs and if you ask me the second one that occurred time-wise we really don’t know. We know that it occurs between three to six months, if you don’t stop the acute pain and the acute inflammation and you are continuously sending the body, to the spinal chord these messages using substances called substance B and glutamine in particular, then you convert from acute to chronic pain and what occurs is that the brain begins to memorize the pain, the brain begins to change.

So you hear the terms nowadays on TV something called neuroplasticity, the brain basically becomes neuroplastic. It changes, it kind of memorizes. Well guess what, that is chronic pain. So suddenly you went from having an acute injury to a chronic injury and that’s how we now understand the conversion from one to the other and what chronic pain is.

Alan S. Pierce: Doctor, my clients who complain of chronic pain, traditionally have been given pain medication, it could be opioid or it could be something without narcotics in it and the results have not been great and we know that there has been a great deal of activity both in the industrial accident board and generally in society we are trying to curb the use of opiates.

Scrambler therapy as I understand it and I want you to speak to me as a layman, is this a way of helping the brain or deceive the brain into reading the pain signals in a different way?

Dr. Roberto Feliz: Correct. What we are trying to do is exactly what it means. We’re trying to scramble the brain to forget the chronic pain that’s coming in and I’ll try to simplify it as best as possible.

As you know the options to treat patient with chronic pain, in 2016, believe it or not, are very few. I could probably name in my hand how many options we have, that actually have been shown to be effective and that’s the issue.

We have thousands of thousands of individuals with chronic pain yet usually when I talk to patients I only have seven good options to tell them about and if they fail those, guess what, there is nothing else.

So as clinicians we have always been looking for ways to try to change pain at the neuron or at the brain level, whereas most of the stuff that we have either have tremendous side effects like opioid that you mentioned, in old days it was narcotics, but it really is not changing anything.

If anything sometimes patient with chronic opioid get worse because of issues of hypersensitivity they develop and tolerance and all of that, so all along we have been trying to find or researchers have been trying to find other means of managing pain and in particular trying to finally change where the problem is perceived at the neurons, and that’s where scrambler therapy comes.

Scrambler therapy, let’s say I am going to try to simplify it, you have an injury in a leg or in an arm, the pain message from your injured foot or your injured back or arm travels to your brain through two types of nerve fibers.

They are usually five nerve fibers inside each nerve, but two fibers in particular, one called the C fiber and the Delta fiber, and those two fibers are the one almost like the railroad tracks that bring the pain from the periphery, from the joint or from the lower back or wherever the injury is are along the nerve up to the spinal chord, the back of the spinal cord and up to your thalamus and up to your brain to be integrated.

So what a scrambler therapy does, it’s very simple. It takes EKG leads, like normal EKG leads that are placed for you at the hospital in an emergency room if you have one on EKG or heart attack or something like that, and we place it in certain areas exactly where the injuries are.

What we are trying to do is send nice — I am going to simplify it, nice message through the same train track, through the same nerve routes, and what we are trying to do is stimulate these small C fibers. Those fibers are the ones that we believe that maintain most of your chronic pain.

So that every day when you have chronic pain in your back and in an ankle or a leg or an arm, the C fibers are the ones that are continuously bringing this very angry message to your spinal cord and to the brain.

So what we now try to do is connect this stimulation through the C fibers, through the skin, and it doesn’t hurt that much, and then just send messages, different types of formulations, different types of messages through the C fibers that are coming up to your spinal cord but they are non-painful, they don’t hurt.

(00:09:52)

And when you continuously send those messages through those fibers, the brain, at the neuron level, begins to forget the pain. So suddenly the neuron in your brain that is used to accepting very painful inputs through that same nerve or you can call it a railroad track, continuously painful inputs are coming in, suddenly we are beginning to send very nice soft, massage, music type of messages to the brain.

And what the neurons do is they begin to forget the painful message. They begin to accept the nice messages, and for a while if you do that between 10 to 12 times repeatedly over one to two weeks, the brain seems to forget the pain for a while.

In most patients, at least when we do it in our clinic we try do this here, they usually get two to three months of significant relief. It’s not a cure. It is a way to provide relief without the need to be on high dose of narcotic or the need to be on high dose medication such as Gabapentin or Lyrica, usually you can get the patient off those when the scrambler therapy works.

It can be repeated. Most doctors that use scrambler therapy within three to six months, they tend to do a booster therapy again to maintain the relief. Some patients, they last longer, they can get months and months of relief; other patients they get lesser amount of relief.

I see it and I use it as another weapon in my armamentarium of options to treat patient in pain especially now that I’m trying to get most of my patients down or off those high does opioid that we all talk about in a literature and obviously in the news now to keep this patient as comfortable as possible.

Alan S. Pierce: All right, at this point we’re going to take a short break and when we come back, we’re going to continue our discussion with Dr. Roberto Feliz on scrambler therapy and pain control.

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Alan S. Pierce: Okay, welcome back to Workers’ Comp Matters. This is Alan Pierce. We are talking about scrambler therapy, a relatively new and a somewhat unique device or mechanism of controlling chronic pain with Dr. Roberto Feliz, and Dr. Feliz has just given us a description of the ways that these neurons are tricked by these electrodes that are placed on the skin.

Doctor, I’ve been familiar with TENS Unit. These are, I guess TENS or TNS — Transcutaneous Nerve Stimulators where these are devices that patients or clients of mine have worn where they place something on their body that somehow disrupts the pain impulse. Is this another type of TENS —

Dr. Roberto Feliz: No, no, no. The TENS Unit first of all works locally, the TENS Unit is a deep stimulation through the tissues into the muscles and it tends to break the cycle of spasm, it tends to increase blood flow locally. So if you apply a TENS Unit for example in your back, you are trying to provide relief in that area.

Now the scrambler therapy was actually invented by an individual in Italy. Since it’s deigned to send message to the brain itself where the problem is, one of the issues that we have always had with chronic pain patients is that we had a lot of pills but we really never had anything that can actually work at the brain level.

Even if you mention other treatments such as spinal cord stimulator, it will work at the back of spinal chord but it’s really not working at the neurons where the pain is finally received and interpreted. So no, a TENS Unit works very differently from a scrambler.

(00:14:55)

Scrambler is designed to as best as possible alter how the brain, the neurons themselves perceive the message.

Alan S. Pierce: I got you.

Dr. Roberto Feliz: Yeah. I usually think of scrambler as a way for the final train station to be changed, and that’s the only real way that physicians now have to try to begin to change how the neurons in your brain perceive the pain, so that although we are full in it, but at least we are trying it to get back to some kind of normalcy whereas at TENS Unit, it does not do that, no.

Alan S. Pierce: Okay, I want to ask you about the types of pain that respond well to scrambler therapy and the types of pain that do not respond. For example, you mentioned herniated disc, you mentioned a broken leg or an ankle in your description of chronic pain, how about something like complex regional pain syndrome or reflex sympathetic dystrophy, the scrambler therapy, is that an effective tool for those types of pain?

Dr. Roberto Feliz: Correct, actually that’s exactly where at least in my office we begin to think of scrambler. It tends to work well for nerve injury type of pain, for neuropathic type of pain, and as you know, CRPS or RSD, depending on how people mention it, is a nerve injury type of pain or a neuropathic type of pain. So scrambler therapy tends to work best for neuropathic type of pain or for nerve injury type of pain. As you know, a physician like myself will try it for everything because we just need hope, we are just looking for hope.

Alan S. Pierce: What about phantom limb pains, amputees who experience phantom pain?

Dr. Roberto Feliz: Correct, it would help that because as you know a phantom limb pain all it is, is the neuron in your brain have not realized that your leg or toe or foot is no longer there, so anything that we can put that will force the neuron to begin to realize something different is coming up, it tends to help that.

The pain that — actually it’s not very helpful for arthritic type of pain, for the generative arthritis type of pain, that’s actually more of a localized process, more of a localized information, but any type of pain that comes from the periphery through the nervous system, as an injury, scrambler therapy tends to respond. Again, those now work for everyone. I am not here to try to say that scrambler therapy is a cure all for everything. The reason that we as pain management physicians are beginning to get more excited about it, it’s because of that fact that this is the first time I’ve been doing pain management for a long time now that I feel that I have something that gets to where the problem is at the neuron and your brain whereas — although all I have before was pills to give you, to try to cause an effect.

Now this is something that I gradually send a message to the neurons and the brain themselves, and what we hope is that we more research, eventually we will be able to shut the message itself, shut the neuron itself and there is a lot of research being done with that, eventually this will be possible. So there is a lot of hope for patients with neuropathic nerve injury type of pain, and I gave kudos to those individuals who continue to do this type of research.

Alan S. Pierce: And do you find that insurance is covering scrambler therapy, let’s talk first about workers’ compensation insurance.

Dr. Roberto Feliz: Yeah. I am going to give an anecdote here. This is the only treatment modality that I actually have had two workmen companies calling me to see if we were offering it, and not only that, that’s one of the reasons that I actually said. I really began to look into this option. Obviously that private insurance do not pay for it, they do not accept it, but in general, the workmen comp insurances are beginning, most of them you can negotiate, you can explain it. As you know, part of any modality like this, is for the insurance adjusters, for their supervisor to understand what this issue is all about, but in general, because of the issue with opioid that they are all trying to get patient of opioid, when you present this modality to a workmen comp insurance, at least in my practice they have a very open, very willing to consider this as an option in a lot of treatment modality, which is very different from the private insurance individuals, it’s very difficult to get this approved.

Alan S. Pierce: Yeah, it’s funny you mentioned that because in my experience usually workers’ comp is the last system of insurance that will adopt something new, and in that vein I have one client that has, at the request of the insurance company, undergone scrambler therapy treatment. This is a client who has been diagnosed with Complex Regional Pain Syndrome, she was a very difficult client to manage, as a client and as a patient. She was taking opioids, she was on fentanyl patches. Her life was miserable and she reported after five days of sessions, not in your facility, but — and the only other one in New England that I am aware of, she received incredible relief and she is now back down there again for, I guess she’d called the booster.

(00:20:02)

Dr. Roberto Feliz: Boosters, yeah.

Alan S. Pierce: And there is now some optimism in her life.

Dr. Roberto Feliz: Yeah. When you see a patient who is planning for scrambler they do respond very nicely. Sometimes, especially as you know, we treat a lot of patients with CRPS here, and some of their presentation is there are swollen, blue type of legs. When they respond to scrambler, even the swelling goes down, the circulation goes down, it’s so much that if we are able to tell the brain with these EKG messages to the brain that for a while the leg is okay, and therefore the brain just kind of forgets the body and things go back to normal.

The issue now is, can we sustain that treatment, can we prolong the effect? That’s what the research is being done right now, but if a modality that I incorporate into this office because I see that, just like anyone else, I don’t have any trouble with the opioid, I want patient down from an opioid and just trying to find other types of treatment modalities that can help patients.

Alan S. Pierce: Well, I remain hopeful from at least my one client experience, I am looking forward to the next client that an insurance company is willing to prescribe or pay for scrambler therapy. I know it’s not inexpensive, but it’s not very expensive, generally speaking what is the cost?

Dr. Roberto Feliz: Correct. Generally speaking in our office it’s around $500 a section. So if it’s there, then you want to do between 10 to 12 sections. In some patients you only have to do five, like this individual that you mentioned, in some patients you do 10, it really depends, and I also must admit, I must admit, there are some patients that you try it and it just doesn’t work. So patient selection is also very important, but in general, it’s another modality that works. The price ranges between, like I said, in our office it’s around $500 a section, which is 45 minutes. The other centers that I have seen around a country that they can go a little higher, it’s just really between $500 to $600.

So far most workmen comp insurance that I have dealt with especially when we send them a letter and we are explaining to them exactly what it is, they have been very open to try it especially you mentioned that you want to get the patient down from opioid and you’re trying to find other ways to manage the pain. So from that end I have been very, very impressed with the support that I have gotten from the workmen comp. The private sector is a whole different story.

Alan S. Pierce: Right. Well, doctor, thank you very much for your description of the scrambler therapy and the work that you’re doing, we’re going to be watching this develop, we’re hoping research will lead to longer relief, and I want to thank you for sharing your expertise with us on this edition of Workers Com Matters.

So this is Alan Pierce, wishing you all a good day and tune in for future shows on Legal Talk Network and Workers Comp Matters. Go out and make the day that matters.

Outro: Thanks for listening to Workers Comp Matters today on the Legal Talk Network, hosted by attorney Alan Pierce. Will we try to make a difference in workers’ comp legal cases for people injured at work? Be sure to listen to other Workers Comp Matters shows on the Legal Talk Network; your only choice for legal talk.