All right, so we are going to start this session, so I wanted to thank everyone for coming. We're going to be doing updates on post-mastectomy pain, where we have a presentation of three different parts. My name is Trey Barksdale. I'll be doing the assessment of post-mastectomy pain, after myself, Dr. Eric Wasatsky will be doing the management of post-mastectomy pain, and Dr. Whitney Luke will be doing advanced interventional procedures for post-mastectomy pain. So post-mastectomy pain, first the assessment of it. Well, I want to say this is one of my favorite topics to talk about, also one of my favorite patient populations to see. I say that because this is a very complex patient population, where it's never one size treats all for this. Every presentation you're going to see is going to be very unique, whether it's pain associated with lymphedema, axillary cording, shoulder dysfunction, neuropathic pain, it's going to be something very unique every time you see these patients. One of the most important thing about this patient population is actually more education and acknowledgement of what's going on. A lot of times these patients are coming to you, it's somewhat out of desperation. They've been seen by five or six different providers by the time they step into your office. A lot of times no one can figure out what exactly is going wrong with them. They need someone just to listen to them and understand what's going on, explain to them what can be done, and give them hope again that this can improve and get better. For example, I want you to imagine you have a 67-year-old woman coming into your office with shoulder pain and neuropathic pain after her breast cancer surgery. Her surgery, chemotherapy, radiation, that was a year ago. But despite that, she's still having significant pain whenever she's reaching above her head, behind her back, and she can't do things at work. So she went back to her oncologist. They did a workup. There's no recurrence of cancer, there's no infection, no one can see what's exactly wrong with her. So they send her back to the surgeon. The surgeon says, well, my job went well, the surgery went well, I only had to sacrifice one sensory nerve. I don't understand why you're having so much pain or so much dysfunction. Maybe you just need to go to physical therapy. By the time she does physical therapy, her shoulder pain has gotten a little better, but she's still having significant discomfort with doing things. She can't pick up her grandchild anymore. She's not as effective at work because she has pain doing things all the time, and her family's confused because the cancer's gone, there's no recurrence of cancer, there's no infection they can see. So they're beginning to think maybe it's just in your head, and nothing actually is wrong, but what can we do? So by the time she gets to you in her office, she's starting to lose hope, and I think we all can have a really important job here really telling her and saying, I'm here, I'm hearing what you're saying, I understand what you're going through, I can't even imagine what you're feeling right now. You've been having this pain for over a year, and yeah, there are things and reasons why you have this pain. There are things we can do about it, and there are things we can do to make you feel better, which you're going to learn about a little bit later this morning, sorry, this afternoon. So this is why this is one of my favorite topics to talk about, because you can really help these patients and make a difference in their lives if you sit down and listen to them, perform a good physical examination, and let them realize there are things we can do to help improve your quality of life and your function in your life. So we always have to have learning objectives. So my job is to teach you what post-mastectomy pain is, talk about the different subsets of post-mastectomy pain, and physical examination findings. So in order to do that, we're going to go over some epidemiology, some risk factors and prevention, which we'll go over a little more quickly just due to time. We'll talk about the different causes of post-surgical breast pain, whether it's neuropathic, musculoskeletal, or central cause, and talk about clinical assessment. So first thing on these slides, when it comes to breast cancer, I just want you to know that this is the most diagnosed cancer among women in the United States, and it's actually the most common cancer in the world. But the more important part here is I want you to see that we are getting very good at treating breast cancer. If you look at five and 10-year survival rates of breast cancer, it's 91 and 84 percent respectively. So we're getting very, very good at diagnosing this and very, very good at treating this. Now if we take a step back and just look at cancer in general, we know that cancer, the effects of cancer, and the sequela of cancer treatment all cause impairments in our patients. We know it's about a fifth of childhood and just over half of adults report some sort of impairment after the diagnosis and treatment of cancer. Now if we take a step and look at breast cancer in particular, we know that breast cancer survivors are reporting limitations in their function after diagnosis and treatment of breast cancer, and the more advanced the cancer is, the more impairments they're starting to report as well. Now the unfortunate part of this is, though patients are reporting these impairments after cancer, these impairments are not being addressed and they're not being treated. These are simple musculoskeletal complaints at times, other times a little more advanced, but the general consensus is there's a lot of room for growth because we're getting very, very good at diagnosing and treating cancer, we're still not getting very good at treating the entire person though. That's what we're forgetting when it comes to cancer care and the continuum of cancer care. Now when it comes to persistent pain following breast cancer surgery, around 80,000 people undergo breast cancer surgery in our country, and pain after the surgery is fairly common though it's not really brought up to patients a lot of the time because we're more focused on the cancer and just treating the cancer itself. The prevalence of this does vary in the literature because a lot of times it's thought to be more of a neuropathic condition, sometimes it's a musculoskeletal condition, sometimes it's combinations of the two. So it varies between 20 to 70% of people who undergo breast cancer surgery that are reporting pain. A lot of times this can convert into chronic pain which actually is post-mastectomy pain which we'll talk about. Now post-mastectomy pain has been around for a long time, since the 1970s people were describing this pain after breast cancer surgery where it's going to be in the chest, the arm, gall pain, achy pain, numbness and tingling pain, it's been present for a long time. Now it's mostly known as persistent pain following breast cancer surgery but we call post-mastectomy pain which is a very misleading term because it also includes things like lumpectomy, breast reconstruction, augmentation and reduction procedures too. Actually in my clinic I have a fair amount of patients who have never had breast cancer but they have pain after breast augmentations and breast reduction so I still see them and treat them as well for this condition too. Now it is more common if you have someone who has an upper quadrant tumor in the breast or axilla but all this is lumped under post-mastectomy pain though it does include all these other types of breast cancer surgery as well. Now thinking of the diagnosis of post-mastectomy pain, this pain has to be present for at least three months or more where other sources have been ruled out such as infection or cancer recurrence that we talked about earlier. And if you look at the card for chronic pain, this is a chronic pain syndrome. A lot of times it's classified as a chronic neuropathic pain condition but as we'll see later in this presentation, there are a lot more things besides nerve pain that can cause post-mastectomy pain. It's also referred to a lot of different things in the literature that you can see down here but just for simplification we're going to call it post-mastectomy pain for the remainder of this lecture. Now when it comes to risk factors, I don't want to go over all of these but some of the main ones you do need to be aware of because these are things we see in clinic on a much more regular basis. Underage at diagnosis, extensiveness of actually lymph node dissection, upper quadrant tumors, preoperative mood disorders such as depression, anxiety, chronic fatigue, insomnia. All these things really predispose you to getting post-mastectomy pain and these patients need to be followed a little more carefully as opposed to if they don't have these. Now there's no difference in mastectomy, lymphectomy rates and getting post-mastectomy pain so this is something you do need to be aware of as well. And surgical scenarios that perform more than 100 breast cancer surgeries a year do have a lower incidence of this but in general if you're seeing some of these risk factors this is a patient that you want to pay a little more closer attention to. Now looking at prevention, there have been a lot of studies out there looking at things we can do to help prevent this. Unfortunately, none of these things actually really work that well. There's no single modality that really works well preventing this so we're looking more of a multi-modal approach in order to help prevent this but typically speaking it's still going to occur. There have been some trials out there looking at IV lidocaine interestingly in the perioperative area of time, I'm sorry, to help prevent post-mastectomy pain that does have some good effects of this. I myself do palliative medicine, the only time I typically use intravenous lidocaine is really for refractory neuropathic pain that's been refractory to things like methadone, ketamine. Sometimes we go to IV lidocaine, I've never seen it used in a perioperative period but there is some good literature out there about that. Talking about the different causes of post-mastectomy pain, we have the neuropathic, musculoskeletal and the central. Central, we won't spend as much time on during this lecture just due to time, it'll spend most of the focus on neuropathic and musculoskeletal conditions. A lot of these things you're going to know, some of them might be a little more new though. So looking at all the different neuropathic causes, some of these are causation, some of these are more correlation with post-mastectomy pain, some of these might be a little more new but these are all things you'd know as this is a more interesting presentation because they're more associated with breast cancer itself. The first one is intercostal brachial nerve neuropathy. So this typically arises from the lateral branch of the second intercostal nerve and it's going to provide sensation to the medial part of the arm and the axilla and somewhat of the chest wall too. A lot of the times this is going to cause more numbness but you will have times where this can cause significant pain as well. This isn't probably the most popular nerve at the party when you're thinking about different dermatomes, different peripheral nerves, but when it comes to post-mastectomy pain, this pretty much is transected every time someone's doing actually lymph node dissection. So a lot of times these patients will have numbness in the area but you need to make sure it's not causing pain. There are things that can be done to help with that which you learn about a little later. Now intercostal and intercostal cutaneous branch neuromas. These are also something you need to be aware of when it comes to pain, especially in breast cancer population. A lot of the times these can be transected due to things like surgery or radiation. It can cause significant pain and radiation of pain. I practice in the great state of Minnesota and if you meet someone there who's a native, especially if it's more of the Minnesota or Wisconsin area, you do something to surprise them or alarm them, you hear them say, oofta, and it's a pretty common thing. I call this my positive oofta sign when I'm doing the tunnels in the area and you feel it there and you say, oofta, Dr. Barksdale, that hurt. That might be a neuroma around the area, especially around something like a scar line too. So make sure you're palpating around these areas to see if there's not something like a neuroma. And if so, you might want to use an ultrasound to see if you can actually see that neuroma and then go after it a little later. Phantom breast pain. Very similar to phantom limb sensation and phantom limb pain, this can also happen to breast cancer patients as well. Where actually having phantom breast sensation is fairly normal. That typically gets better with time. But just like phantom limb pain, if it's phantom breast pain, that's something you need to treat. If it's causing a lot of pain, causing a lot of impairment of function, that's something you need to go after and treat. But education about the difference between the two is important just like in our amputee population as well. Now neurogenic thoracic outlet syndrome. This is maybe more of a correlation than a causation, but this has been reported in the literature. It's not something I've seen. But theoretically, this definitely can happen when you can get compression on that some pectoral tunnel. A lot of times during breast cancer surgery, you're going to get irritation of your pectoralis muscles or during the immobility period after the surgery, you get tightening of the shortness of those muscles too which theoretically can press on those nerves and those vascular structures. This can also happen during radiation as well. It may not be a common phenomenon that does occur, but this is something you do need to look out for. This might be more of a correlation than a causation, but anatomically this can occur so it's something you do need to look out for and make sure that you're examining your patients for thoracic outlet syndrome. Same thing for cervical radiculopathy. This is more of a correlation than a causation. Cervical radix happens usually around the fourth and fifth decades of life. We're finding breast cancer a lot of times during those periods of life as well. So I have had patients come to me for post mastectomy pain. After a physical examination, I find this is more of a radiculopathy and we can treat that and it's not so much post mastectomy pain, but this is something you do need to look for as well because this needs to be on the differential diagnosis. Now the musculoskeletal causes, I think everyone here is going to be aware of the vast majority of these, but there are a couple new ones that are more special to breast cancer that you really do need to pay attention to. The first one is shoulder impingement. I think everyone here knows what shoulder impingement is. The pathophysiology of this is a little more specialized in breast cancer. Again, that's going to be caused by a shortening of the pectoralis muscles, which is going to cause protracted inferior scapula, which is going to cause rotator cuff tendinopathy and impingement. This is something that you really do need to look out for, not just the side of the surgery, but the opposite side as well will also have some scapular thoracic dyskinesia and is also prone to getting rotator cuff issues too. So don't just look on the side of the procedure, make sure you're asking about the opposite side too. They might have other issues there as well. A little less known cause of shoulder pain is scapular thoracic bursitis. Most commonly we see this with snapping scapula syndrome, but this also can happen with post mastectomy pain too. Again, this is going to be caused by the protracted and depressed scapula, which is going to make them more prone to getting scapular thoracic bursitis. Now this can be confused with chest wall pain because the radiation of this pain can go into the chest wall too and can be confused for chest wall or anterior chest pain. This can be scapular thoracic bursitis, so making sure that you're palpating around those areas, make sure you're not missing this. This is something that is commonly missed and something that can be intervened with injection management, but this is something that's fairly common in this patient population as well. Now adhesive capsulitis is an interesting one. This can occur in the immediate post-operative period if people are having more pain, holding their shoulder in a protracted position, or in the later stages during radiation if someone develops radiation fibrosis, they're also more prone to getting this. Hopefully it's more in the acute post-operative period where you can work on range of motion and it's not so much radiation fibrosis where you don't have a lot of fantastic treatments for and it's going to be more palliative rehabilitation at that standpoint. This is something else to look out for as well because a lot of patients do end up getting adhesive capsulitis. Hopefully it's not during times around radiation or months after radiation where you're thinking as if it's more due to the fibrosis. Now myofascial pain is going to be very, very prevalent in this patient population. Studies have shown that patients who undergo breast cancer surgery get more myofascial pain than those who do not. So this is something to think about, talk with your therapist about when treating post-vasectomy pain because things like manual or instrument assisted myofascial release can help prevent and actually, I'm sorry, help improve this pain too. Now something that's a little more specialized to post-vasectomy pain in breast cancer patient is axillary web syndrome axillary cording where this is thought to be due to thrombosis of axillary lymphatic vessels or the veins themselves which actually do create these strings that you can see in the patient here. A lot of the times these are going to be more so in the axillary and you can actually palpate them all the way down to the forearm as well where they do feel like thick guitar strings. A lot of the times these can restrict range of motion. These can cause significant pain and impairment in patients. Now when you're feeling these, it's not uncommon for them to pop or snap which can also be very alarming. It kind of can create your own oofta moment there and look at the patient like, oh no, what did I just do? That's something that's very, very common though. There's a couple of trains of thought with this. Some therapists like to break these apart because if they're causing a lot more pain and impairment, they're broken apart and you see improvements of range of motion and pain. The therapists don't like to break these apart because they think that it might help reduce the risk of getting lymphedema in the future so they like to keep them intact but kind of loosen them up more. Not a lot of great data out there showing which way is more correct. I've never seen any worsening of symptoms, worsening of lymphedema or pain if you do break these apart but this is something that's a little more specialized to the breast cancer patient though theoretically this could happen in other cancers as well. This is just pretty much known for breast cancer. But the good news is, typically speaking, these do get better with time. Sometimes it requires a lot more intensive therapy but you do see improvement of this. Now radiation fibrosis is another one out there that usually happens months or sometimes years later where typically a classic presentation is years later after radiation you see a patient that has progressive fibrosis in the area of the radiation. Unfortunately we don't have a lot of great cures or treatments for this. There are some studies out there looking at pentoxifilin and vitamin E. Anecdotally I've not seen the best evidence or the best treatment of that using those medications. Sometimes with wounds I've seen some good improvement but a lot of times when you're having patients come in with this sort of fibrosis after radiation this is going to be more palliative rehabilitation. We're looking at maintaining strength, maintaining range of motion and function as best we can knowing that this is a progressive disease and it can get worse. The skin can even become rock hard at times as well. So there's a lot of education that has to go along when it comes to radiation fibrosis. Incisional pain is another thing you'll see on a regular basis as well where a lot of patients report pain around the incisions especially if it's around intercostal brachial nerve area or sometimes around the ribs. We have to really make sure that you're palpating around these. Make sure it's not a hypomobile scar because these are things that can cause a lot of pain and discomfort. They're going to talk about the treatment of these a little later but a lot of times this is due to hypomobility of the scar itself. A lot of manual therapies can be beneficial but you'll learn about those a little later. Lymphedema is another one. So lymphedema in itself doesn't typically cause pain. What it does cause is a lot of heaviness in the extremity which can also pull on the shoulder, cause decreased range of motion and cause subsequent shoulder dysfunction too. So treating lymphedema is going to be key to treating some of these pains at times because if there's an arm that has a lot of lymphedema in it you need to treat the lymphedema, you need to treat the shoulder and pain typically gets better. But this is something to look out for too if you have a patient who's ever been seen by a lymphedema therapist and having shoulder issues, you need to address both at the same time if possible. Now when it comes to the clinical assessment post-mastectomy pain, a lot of these things everyone in this room already knows what to do. It requires a very intensive physical examination, intensive history gathering as well to figure out what exactly is going on with this patient. Imaging is something you don't always need to order. We have a clinical suspicion for something else like a radiculopathy or a thoracic outlet syndrome. You can order a test for that as well. The other thing I really wanted to touch upon is social history support and financial distress. Especially in the cancer patient, a lot of these patients that come see you, they've been seen by multiple specialists who can't help them and they have this concept of total pain that we talk about a lot in palliative medicine, which is you have your physical pain, you have a psychological pain, your social pain, and your spiritual pain. We are very good at addressing physical pain in a lot of different things that we do, whether it's things like physical therapy, injections, medication management, surgery, we are very good at doing this. But unfortunately, especially a lot of times in cancer patients, it's not just the physical pain you have to address. There's psychological distress. There's spiritual distress, whether the person is a religious atheist, it doesn't matter. What's giving them meaning is causing pain. There's social distress. What's going on in their life? How is it affecting them? How is it affecting their job? All these things need to be addressed. So if you're seeing one of these patients and you feel like you're maxing out on the physical symptoms, you can't do any more injections, they're maxed out on medications, you need to address these other domains of pain as well. You'll find a lot of the times, even just addressing spiritual pain, someone's pain gets better. Because you're not just treating the cancer, you're not just treating the pain, you're treating them as an entire person. So you have to really account all those different domains of pain to really effectively treat a cancer patient, because you're going through more than just the physical pain. So in summary, this is relatively common after breast cancer surgery, it can occur despite multiple skin-sparing procedures, there are multiple causes of this, whether it's going to be neuropathic, multiple skeletal, the combination of the two, and even central pain. You really have to do a thorough history of physical examination to find out what exactly is causing the pain and realize just doing the physical exam and the history is not enough. You need to think about those other domains too when it's coming to cancer patients to effectively treat their pain. So thank you. And next will be Dr. Eric Wasatsky here talking about the manager. Thank you, Andrew. All right. Hi, everyone. Great to see so many of you. And thanks, Dr. Barksdale, for inviting me to participate in this panel today. So we're going to get into the treatment here after we've had that great overview of assessing our patients. So I have no disclosures, and my goals and objectives are pretty much what it says in the title. We're going to talk about rehab, meds, very briefly, and injections. So as we kind of frame our approach to rehabilitation for these patients, as Dr. Barksdale nicely cued up for us, there's a huge focus on the shoulder in these patients. And if you get a chance to dig into some of these studies, there's some really wonderful biomechanical studies that have been done through the years, quite sophisticated, looking at shoulder mechanics in these patients, finding lots and lots and lots of abnormalities. So primary planes of range of motion in the shoulder that tend to be abnormal in our breast cancer patients include flexion, abduction, and external rotation. And sometimes we can see this in the contralateral limb as well. We talked a little bit about scapulothoracic bursitis, and that can come from abnormalities in our scapulothoracic motion, which really can be altered in every single way the scapula can move has been shown to be altered in our breast cancer patients as well. And then beyond just range of motion, thinking about weakness as well. And really, many different planes of motion have demonstrated weakness in the shoulder as well in our breast cancer patients. We want to assess these, and we're going to utilize that to help tailor our rehabilitation prescription. So, you know, as we think about rehabilitation here, along the lines of what I just discussed, you know, and Dr. Barksdale mentioned a lot about the chest wall, we often see a lot of tightening of the chest wall musculature. So certainly stretching is going to be an important component of this. Posture is huge. You know, many of our patients have this kind of forward slump, protracted posture, and we really need to work on correcting that. Certainly improving range of motion in the most affected planes, strengthening the most affected planes of motion as well, always scapular stabilization, and almost everybody has some kind of myofascial pain, so focusing on myofascial release as well. Looking at some of the more specific pain syndromes, so post-reconstruction pain, this is not necessarily a real term in the literature that I found, but this was sort of passed to me by Dr. Stubblefield, and it kind of makes sense as a subset because, you know, there just are certain pain syndromes that we really commonly see with different types of reconstruction that we may approach in a certain way. Certainly for our patients with implants, this is kind of, as you can see on the right in this picture, this is kind of the old-fashioned sub-pectoral implant that's sitting underneath the pec muscle. Thankfully, now we're seeing more of the pre-pectoral implants that are above the pec that at least some studies seem to show there's less morbidity in those patients, although we can still see some, but it's very easy to imagine that something like this sitting underneath your muscle could cause a lot of muscle-related symptoms that we want to manage, and, you know, stretching in your rehabilitation program and myofascial release are, you know, particularly important for these patients. So switching gears to cording, as we had discussed before, and I think we actually kind of went through most of this before, you know, our therapists can provide great treatments for this, soft tissue techniques, nerve glide exercises have been shown to be helpful, obviously focusing on range of motion, and we already talked earlier about the snap, which, you know, I think for many of our patients, when these cords do snap, they feel better. It's usually a good thing, but as was eloquently stated before, it can definitely be alarming for the patient. I've had patients say, like, should I go to the emergency room? So it's nice to kind of warn people that this is a possible outcome for this and that it's not necessarily bad. So just in terms of looking at the literature on rehab protocols, you know, the punchline is, you know, there's a lot more for us to know. The various studies that have been done and continue to come out on post-mastectomy rehabilitation, you know, like lots of PM&R, you know, rehab studies, there's a lot of heterogeneity in protocols and it can make it difficult to come to very firm conclusions. This study that was in the archives in 2015 was a nice systematic review of rehab protocols. They had a couple kind of final recommendations in this paper, which, you know, I think most of us and our surgeons would probably follow in the first week post-op, a low-intensity program just involving the distal part of the extremity, elbow, wrist. From there, you can gradually increase intensity, typically as long as drains have come out, including passive mobilization, manual stretching, and more active exercises. And then they really concluded, you know, they could not make strong recommendations on timing, content, and intensity. So we don't know these things. So we had a great cancer rehab talk this morning about research. There's definitely a lot of opportunity out there to, you know, think of more research protocols to help us kind of pin this down of exactly what we should be doing in terms of timing, content, and intensity with our patients. And as we talk about rehabilitation, I just wanted to give a shout-out to OT because I think we tend to be very PT-focused a lot, but, you know, certainly our patients have a lot of functional needs when dealing with their ADLs, household chores, dressing, so certainly occupational therapy should be a strong consideration for our patients as well. So just very briefly on therapy precautions with these patients, you know, I think one of the main things is just thinking, you know, sort of more in the immediate post-operative period, thinking about implanted devices in the chest wall, tissue expanders, implants, you know, there could be some potential concerns early on with maybe how much our therapist might be using their hands and mobilizing that area. I think at least where I work, a lot of times it's very, very easy to kind of communicate this with our plastic surgeons who, many of them have kind of specific protocols of kind of what they prefer, you know, depending on the type of surgery. So, you know, it's really helpful, you know, one of the great parts about cancer rehab is our interdisciplinary team, including the oncologic side, and we can often coordinate very well with them to kind of come up with the best plan for our patients. So switching gears from rehabilitation to medications, this is going to be really quick. So basically there's really not much data at all specifically looking at medications, pharmacologic therapy for post-mastectomy pain. Basically there's lots and lots of different kinds of medications all of us might use for different pain syndromes that are perfectly appropriate, whether it be neuropathic pain medications and other muscle relaxants, et cetera. In terms of what's been studied, there's a little bit of data on venlafaxine, amitriptyline, capsaicin, but there's not a lot else. I know, I guess at Mayo Clinic they had done a study on lidocaine patches, which showed no difference compared to a placebo patch. So not a lot of data here, so another potential area of study. I did want to just give kind of in terms of future directions, I wanted to mention the high-concentration capsaicin patch. So this is kind of a non-controlled, relatively small study looking at pre- and post-pain scores in post-mastectomy patients using the high-concentration patch. This is not an FDA-approved indication for this use, and there are actually ongoing controlled studies of post-surgical pain syndromes. It's a multi-site study for the high-concentration patch that is including patients with post-mastectomy pain. So I'm excited. I'm hoping something comes out in the future that may show some evidence-based benefit with this, because I do think this is intriguing, but it is not generally an FDA or insurance-approved indication for the utilization of this treatment. All right, so switching gears from medications to injections. So first of all, some really sort of basic stuff, and I know I'm looking around the room seeing the who's who of cancer rehab experts. So for many of you, this is rather basic, but I think for anyone who is new to cancer rehab or thinking about tipping your toes more on this, I sometimes do get these basic questions. Like, I've never done an injection on a cancer patient before. Is this OK? What do I have to be concerned about? So the answer is yes, for the most part, but just a few things to be thinking about, I would say. So certainly, if you're injecting into an area that was recently radiated where there may be skin concerns with sticking a needle through that area, that's something to consider, usually in the more immediate post-radiation time period, not chronically. Certainly looking at blood counts for patients under chemotherapy and how those blood counts might influence the safety of your injection. And lymphedema, as well, is something just to consider as a potential factor. Injections can be performed in a lymphedematous limb, but certainly just weighing the risks and benefits. Thank you very much. So it's just one factor to take into consideration, but not an absolute contraindication in any way. So as we talk about specific types of injections, and I should, as a preview, I'm going to be talking about more sort of office-based, I guess what I might consider simpler kinds of injections that we perform in the office. And then I'm going to pass the baton to Dr. Luke, who's going to talk about much fancier things. So I'm excited to hear what she has to say. So first of all, just in terms of more basic musculoskeletal pathology, we've already talked about rotator cuff issues, frozen shoulder as well. So of course, we can do all of those types of procedures for our patients, for the rotator cuff. You can consider your old-fashioned subacromial injection or potentially a regenerative procedure such as needle tenotomy for tendinopathy in our patients. In terms of adhesive capsulitis, of course, you can do your glenohumeral injection. So other options for post reconstruction or any sort of chest wall-related pain, botulinum toxin can be considered. Not a ton of data on this, definitely an area where we can use more studies. This was a randomized trial that's mentioned on this slide. Also in the archives published in 2018, 100 units to the chest wall musculature compared to a placebo injection. There were 25 patients in each of the groups. And it was interesting in this study showing a significant difference in pain intensity at six months in the botulinum toxin group, which is obviously a little different than we might think of the usual efficacy of botulinum toxin. And I think some of this is getting at, you know, what are we using this for? This is not an upper motor neuron syndrome per se like we might treat with a stroke patient. We're using this more for pain. So maybe that may be a factor as to why there was a longer period of efficacy than we might expect. But obviously a further study is needed. And you know, I do like to use ultrasound for these procedures. You can see under ultrasound here, this is actually the implant, breast implant. So it is helpful to kind of know where these structures are before you're injecting around the chest wall. So now we'll get into nerve blocks. And there'll be a little bit of overlap with what Dr. Luke is going to discuss here. I really, really like this rubric. So there's all kinds of different nerve blocks for the chest wall. And I've been sort of toying with these for several years. There's several different options. And sometimes I've asked myself, well, what should I be injecting here? What makes the most sense for the patient's particular symptoms? So this was kind of a nice rubric. This was published by the Pain Medicine Group at Memorial Sloan Kettering. And they kind of lined this up really nicely, kind of showing the different types of nerve blocks and kind of the distribution of pain in which it would be helpful for. And this was published in 2021. So you know, just kind of going through this, we talked a little bit about intercostobrachial neuralgia, which is going to be innervating that kind of medial upper arm. So you can do an intercostobrachial nerve block. It's usually relatively easy to find the nerve in that kind of medial upper arm right under the subcutaneous tissue there. This is kind of a very common setup we might do for the injection, except with gloves on. But this certainly is something that can be helpful. So what else for nerve blocks? So the next section I'm going to talk about are the serratus plane blocks and erector spinae block. I'll talk a little bit about erector spinae under ultrasound. And Dr. Luke will talk about it under fluoro, which I don't do. So as you can see here, deep serratus plane block and erector spinae block may be helpful for that more anterolateral chest pain. Whereas the superficial serratus plane block is going to kind of denervate further back in that axillary, mid-axillary area as well. So those are kind of times when we may think about those. So in terms of the anatomy with these injections, you can see. So for the superficial serratus plane block is where this arrow is here. So that's going to be between your more superficial latissimus muscle and deeper serratus anterior here. And of course, you can see your ribs and pleura, which are always wonderful to be able to see well. So you don't get too close to that. So the superficial is going to go in this plane between the lat and serratus. And then your deep serratus plane block will be down here, actually kind of at the rib essentially between the serratus and the intercostal muscle down here. And that certainly can be performed under ultrasound. And the erector spinae plane block, which also can help with chest wall pain, is just kind of coming back more proximally along the nerve course, if you will. And you can see under ultrasound here, this is actually deep to your erector spinae muscle at the transverse process, around the transverse process of four or five in that region. And you'll see some fluoroanatomy of this as well. What else can we do? So we have PEC-1 and or PEC-2 blocks. And this is really more for the anterior chest wall in this area, upper anterior. So the difference anatomically and actually, I'll show you the anatomy here first, I think would be easier. So basically, you're looking at your PEC-major, PEC-minor, serratus is down here. You can see your ribs here with the acoustic shadowing. So the PEC-1 is between your PEC-major and minor. So it's kind of this plane, the white arrow here. PEC-2 block is deeper between your PEC-minor and the serratus anterior here. PEC-1 block will anesthetize your medial and lateral pectoral nerves. PEC-2 block down here will anesthetize your intercostal brachial nerve, some intercostal nerve blocks, intercostal nerves, and the long thoracic nerve as well. In terms of kind of deciding, and you could kind of see on this rubric, it says PEC-1 and or PEC-2. I mean, to be honest, at least from all the literature that I review, I don't know that there's a really clear protocol in terms of when you would use one or the other, or many people will use both. For PEC-1, it's thought to be maybe more just for that upper anterior chest. PEC-2, because it's anesthetizing more nerves, it may be more helpful for a more diffuse kind of chest wall pain syndrome. So I think that's the way a lot of people may think of it. It's a little bit more of a kitchen sink approach of anesthetizing more nerves. This is kind of a little bit more uncommon one, but I wanted to mention this because this was a relatively new publication, 2022. This was an ultrasound guided nerve block of the thoracodorsal nerve, and this was specifically for persistent pain in a patient who had a latissimus dorsi flap, which is a type of breast reconstruction in which the latissimus is moved to recreate the breast, and this patient was having persistent pain in that muscle. So one way you might potentially reduce that pain is anesthetizing the nerve that goes to that muscle, your thoracodorsal nerve. So they were looking at that under ultrasound here, along the lat, in the flap, and this is kind of a long axis view of the nerve. So this is not something I've done myself. I've not necessarily had this scenario come up in my office, but I thought this was helpful just to be aware of in case I do see it or any of you see it. I thought this was a pretty interesting case report here. So neuromas, I know we prepped you on that a little bit. So what's been reported in the literature in terms of post-mastectomy neuromas is most classically they tend to be kind of lateral to the breast and inferior to the breast. So that would be 3 o'clock and 6 o'clock on the left, 9 o'clock, 6 o'clock on the right. So in terms of injecting these, that is something that you certainly can consider. These surgeons will do these kind of palpation guided. I often would prefer to do it with some kind of ultrasound guidance. This is kind of the biggest study on this, although it's a non-controlled study. 91 patients with suspected neuromas were injected, and amazingly, 91% had complete relief of their pain, which they defined as continued relief of pain at three months. And they were injecting these, what they call sort of T4 and T5 neuromas, the more superior being T4, the one inferior to the breast being T5, and they injected these with anesthetic and corticosteroid. I did want to point out, so this was a publication by breast surgeons, and I've watched some of their kind of instructional videos on how they do these. So they do call these trigger points, which I don't think the breast surgeons necessarily know what a trigger point is. But they did call it that in their studies, and that's OK. But I just wanted to point that out in case you see this. They're supposed to be injecting neuromas, but they're calling it trigger points in the study. And as you can see, again, this is not necessarily high-level evidence. There's no control group. So here's another study on a platter that could potentially be looked at. So we talked about scapulothoracic bursitis, which can be injected. Dr. Barksdale already kind of reviewed this, but this was a study looking at injecting these. 103 patients were diagnosed with this. 83.5% had complete relief of their pain. And again, as Dr. Barksdale mentioned, it's helpful to kind of think about this, because this can radiate to the anterior chest, even though this is a more posterior issue. And at 12.6%, a partial improvement of their pain. If you're going to inject this, if you have this scenario here where your bursa is kind of sticking out from under the scapula like this, you should be able to see this under ultrasound. If it's all underneath the scapula, you're not going to see it due to the acoustic shadowing of the scapula. So that's one just confounder to think about that may make it more difficult to at least visually diagnose it. You could use your clinical diagnosis. So just a few more things that are not injection on the treatment realm that I just wanted to put a plug in for. Fat grafting, I think, is a really interesting thing to be thinking about. There's a couple nice randomized studies showing significant improvement in pain in using autologous fat from the patient for incisional pain. This is really for soft tissue pain syndrome. So incisional pain, radiation fibrosis, where your tissues are hardened and uncomfortable. I have one plastic surgeon that Dr. Power and I work with who really likes to do this specifically for pain syndromes. And he's had a lot of great outcomes in his practice. So I think this is an interesting thing to be aware of and to kind of talk to your plastic surgeons about. And of course, Dr. Barksdale did a wonderful job kind of talking about spiritual pain, psychological pain. And I think we really want to be thinking about this. In this syndrome, we went over risk factors. There's so many papers on risk factors in post-mastectomy pain. And a lot of them say different stuff, like what are the risk factors. This particular paper that was in Journal of Pain in 2013, it's old now, they actually found that none of the oncologic factors contributed to pain, that it was all more of the psychological factors, especially catastrophizing, which I didn't know until I read this paper that you can measure that. That sky is falling feeling. And I think for me, I feel like I have become better at taking care of my patients overall when I make sure I'm addressing these factors kind of right away, as opposed to like, let's do some PT first and then worry about your psychological factors later. I think when we're getting up front with addressing these things from the beginning, we have better outcomes. And looking out for kinesiophobia, that fear of movement is going to be a huge risk factor for immobility, weakness, and a prolonged course of pain and disability. So looking out for that is key. And then it was mentioned before about central sensitization. Also important to think about, especially with our patients with more chronic pain that's lasting a long time. A couple of studies looking at this, patients with pain greater than a year and a half after treatment, showing reductions in pain pressure thresholds. So more hypersensitivity, significant movement associated pain as well. And then this one that was actually in PM&R Journal literally a couple of months ago. There was greater upper limb performance was associated with less central sensitization. So something going on here. So I think it's really helpful and important to be aware of this, because I think with our patients with central sensitization, we want to be thinking probably less so about kind of anatomic treatments, although you certainly can do those. And thinking about more types of treatments we would typically use for this, cognitive behavioral therapy, potentially medications, et cetera. And I think that is all I have. Please reach out any time. Happy to chat with any of you. And I will pass things on to Dr. Luke for some fancy stuff. Hello, everybody. My name is Whitney Luke, and I practice at The Ohio State University. And I specialize in interventional pain management, mainly cancer pain management. And I think I serve as an expert witness. That's the only disclosure I have. But I do think it's important just to lean a little bit in into what we were talking about today is my clinic, I have a PT and OT embedded in it. But the biggest piece that we often are missing is I actually have a pain rehab psychologist embedded within my clinic who sees all my patients with me, every new patient in tandem with me. And we often find, like has been said multiple times today, that pain is mostly existential oftentimes, and we're missing that piece. So while I think of myself as a needle jockey, I really learned just because we can do something doesn't mean we should. And often, really, injections are not what's going to help this patient. It's treating them as a whole person and identifying what's actually causing them their distress. So we talked already a little bit about here, about PEC 1 and 2 used for anterior chest wall pain. So I'm going to keep on moving along here. So speaking about thoracic paravertebral blocks, often we use these pre-operatively, but you can do it post-surgically as well. And really what we're doing is trying to prevent serious pain after procedure. It can be post-sarcoma or post-mastectomy. Looking along the spinous processes into that paravertebral space, inject a large amount of anesthetic there, and you're going to hit the intercostal nerves. There's also some sympathetic fibers that run along in there as well. And so while data has not really shown a decrease in an incidence of chronic pain after surgery, patients have reported less overall pain symptoms and higher quality of life. So kind of an interesting outcome. If the incidence of pain isn't less, but then you're actually having less symptoms and higher quality of life, what does that actually mean? Serratus block. The innervation of the serratus is via the long thoracic nerve. And then the intercostal brachial nerve perforates the muscle in the mid-axillary line. So you can also target this here with ultrasound as well. So this has shown some incidence, a reduction in incidence of chronic pain when performed pre-surgery. Not a whole lot after surgery outcomes that we know about. So I personally like to use flora with most of my procedures. I find it easier and less cumbersome than ultrasound, able to do more procedures this way. So you can also perform an erector spinae block fluoroscopically, just targeting the T4 transverse process and injecting a fairly large, between 20 to 30 cc, volume of bupivicane. And again, the spread of anesthetic goes into that paravertebral space. So these are kind of the fun things that we can start doing. So stellate ganglion block, you've got your stellate ganglion that sits around C7, kind of near the vertebral artery. So indications for performing this procedure is CRPS-like pain into the arm, which you can sometimes see after post-mastectomy, phantom breast pain, as well as some lymphedema pain. So using x-ray, we go at the C6, and then using x-ray, we go at the C6 level and go right down onto os, and you'll see spread actually all the way down to C7 T1 here. It's going to hit that stellate ganglion. For CRPS, it actually vasodilates. You can do this to heal mixed connective tissue disorder, like ulcers on the fingers that don't heal. So there's some outcomes. I was actually looking at some literature that Eric sent me to about utilization of this. Intercostal nerve blocks is probably what I perform the most. So you could do the intercostal brachial nerve blocks, but really thinking about kind of when they do a mastectomy, what you're cutting through. The intercostal brachial nerve comes off of the lateral branch of the intercostal nerve around the second level. So these are somatic nerves that arise T1 all the way to T11. They're actually a lot deeper than you think. So you can perform this with ultrasound, but when you do it with fluoro, you go quite a bit under the rib farther than you think. And so I found with ultrasound, I don't have the same outcome that I want than when I do it with fluoro. So you can target multiple levels. You could target T2 to T4 if you want, based on the dermatomal plane of their pain. Their very rarest risk would be a pneumothorax. I've never actually seen that happen. All right, and then getting into neuromodulation. So when we think about spinal cord stimulation, really the FDA approvals are for CRPS and post-laminectomy or failed back syndrome. But you can use this off-label for neuropathic pain in other places. So post-mastectomy syndrome could be one. Post-thoracotomy syndrome could be another. So really how spinal cord simulation works is that we're inhibiting the dorsal horn neurons, going back all the way to kind of the gate control theory. We also don't know all the ways that it works, but we do know that it can activate the descending inhibitory pathways. It increases GABA, acetylcholine, also increases glycine and decreases substance P. So you can have a surgically placed platyle lead or a percutaneous lead. Your percutaneous lead is placed in the epidural space and then tunneled into a small generator. You have chargeable and non-rechargeable. The rechargeable lasts about 9 to 10 years. And so often, if you have somebody who's younger who doesn't have any problems with range of motion on their shoulder, often we'll use a rechargeable. Older patient who maybe doesn't want to do that, might have difficulty doing it, we would place a non-rechargeable battery. So here's just a couple of pictures of patients that I've placed stimulators for for differing things. Something we didn't touch on as much today, but I have seen fairly often recently in my breast cancer patients after radiation is radiation induced brachial plexopathy. And I feel like this is something that we see often and is often missed, just because it can overlap. It could look like a cervical or a dick. It could look like just hypersensitivity of that arm, not even a muscle. Or hypersensitivity of that arm, not able to pinpoint it to a dermatomal pattern. And so often, I will get an MRI of the cervical spine and the brachial plexus. And more often than not, actually, the plexus is lighting up with some radiation-induced changes, which kind of makes sense sometimes based on where radiation is targeted. So for this patient, actually threaded the percutaneous lead all the way up to C2, as high as I could go, and got really good coverage of that entire arm with this. This patient had some kind of intercostal neuralgia a little bit lower than expected of post-mastectomy, but she also had chemotherapy-induced neuropathy of her feet. So was able to put two leads in and stagger them to get coverage of the chest wall with one lean and her legs and feet with the other. There's multiple companies, medical sales device companies, that make stimulators. You've got your kind of big three, Boston, Scientific, Medtronic, Abbott. And then you've now got Saluda, Nevro, and some other up-and-coming companies. The most important thing to know is that Medtronic is full-body MRI-compatible, and the rest are MRI-conditional. So depending on your patient, with my cancer patients, I lean towards the fact that they'll likely need an MRI at some point in time. So I use primarily Medtronic for my patients that do have a cancer diagnosis. There's a lot of data kind of for utilizing these and other things with the different companies. But for me, I don't want to have someone not able to get an MRI. We have to go take the system out for them to get something. It causes a lot of worry and concern for them. And so this way, you don't have to deal with that. And then when we talk about dorsal root ganglion stimulation, so this is a little bit newer. It was approved in 2016 by the FDA for CRPS type 1 and type 2. And it is only approved for lead placement at T10 and below. So this is where you're actually going to make a loop and thread your lead out the foramen, targeting that dorsal root ganglion. It works very, very well, but it is also not MRI-compatible. So if your patient needs an MRI, they can't have this. There's actually a little bit higher of an incidence of complications with this. You can have lead migration. You can actually have damage to the nerve or the dorsal root ganglion, which I've seen a few times. And it's quite painful for patients. If we were to place it for post-mastectomy syndrome, it's going to be used off-label. And so you're going to have to put it up pretty high there. I personally haven't done it for that indication. But I would imagine soon the approval for lead placements is going to go higher than T10. So then when we think about intrathecal drug delivery, those of you who may manage baclofen pumps, it's the same pump through Medtronic that we use for that, except we use it for opioid medication. So I see a lot of palliative patients that have significant metastatic disease in various cancer states. And so when we're looking at placing a pump, I think the most important thing is to make sure that the pain is opioid sensitive, that the patients aren't on exorbitant amounts of opioids, and their pain is not improving. So for patients that are on higher dosing, that they're a little worried they may have hit their max for oral medications, or they're having side effects like fatigue, constipation, nausea, then really an intrathecal pain pump would be a really good choice. As long as the prognosis is at minimum three months, data has shown at six months that it is worth the cost of implantation for this when you actually look at a cost analysis. So first-line agents, you have morphine, Dilaudid, fentanyl, and Prealt. The FDA-approved medications are morphine and Prealt. Prealt is snail venom. Second-line agents would be bupivacaine or clonidine. And then third-line, you can actually put all three in a pump. I personally, I use morphine or Dilaudid mixed with a very high concentration of bupivacaine, 30 milligrams per ml. I find that the bupivacaine is actually what improves pain the most, more so than opioids. When you do a conversion, 300 milligrams of oral morphine equals one milligram in the intrathecal space. And so for my patients, I actually use a fairly low, like maybe three milligrams per ml of morphine and then 30 milligrams of bupivacaine and run it. Sometimes I have patients on maybe 0.3 milligrams a day of morphine, but the much higher concentration of bupivacaine. I'm able to titrate them off of other oral medications, and they do really, really well. So if we're thinking about a post-mastectomy syndrome and placing a pump, you're going to put your catheter up probably around T2, T3 to get coverage of that chest wall. In these patients, bony metastases, I don't find, respond as well as neuropathic pain complaints. The nice part about this is you can put a 20 or 40 cc pump in, and often these patients can go sometimes three to six months and decrease their visits, at least for pain complaints, as they have so many other visits for all of their oncological care that it really does help improve the burden for these patients. And so overall, when I get people that call a lot to say, like, can you do anything for somebody? And my first response is, well, just send them over. We'll evaluate and see. But kind of contraindications are, for me, if you're doing a neuroxial procedure, if you cannot come off of blood thinners ever, then unfortunately I can't do any of these procedures. Platelet count under 100. And any skin issues, open wounds, you can't do an implantable device due to the risk of infection. Or if someone's getting active radiation in that area, the tissue can be friable, so you want to wait a certain amount of time after to think about an implantable device. And then really, a relative contraindication, right, is the need for future MRIs, which could limit peripheral stimulators, you know, or specific kinds of spinal cord stimulators. The pump, you know, if you have an MRI, it just has to be evaluated by your rep so that they can make sure that it restarted. Same as a baclofen pump. So I really love my job. I can offer a lot of things to some of our patients that maybe have maxed out other options. And so I think it's really, you know, wherever you're practicing, if you can partner with someone who can maybe provide some of these procedures, put your heads together. One of the most beneficial things that we've started where I practice is once a week, our inpatient palliative team, myself, our radiation oncologist, and one of our neurosurgeons who specializes in like only cancer spinal procedures meet once a week and talk about patients in the hospital that they're having challenges controlling their pain or they think they may have challenges outpatient and they refer over to us. So really, multidisciplinary management is what these patients need. And I think sometimes PM&R is one of the best referrals so we can often sometimes get them to where they need to be. So. There's some references and I think we'll welcome any questions at this time. Thank you. Hi, this is for our last speaker. When you say MRI conditional versus compatible, what's the difference and does the compatible necessarily mean that it doesn't have to be rechecked to get it started after the MRI? Thank you. So it's kind of what's approved. But full body MRI compatible means they can have an MRI anywhere on their body. MRI conditional is often there's a condition to it. So they may be able to get an MRI from the shoulders up and the waist down. But if there is any impedance in the leads, then that means you can't get an MRI anywhere, which often happens. Or a lead can break, right? Or wherever the impedance is, it's not fixable unless you switch it out. So then you really can't get an MRI. This is for Dr. Luke. So at our institution, intrathecal baclofen pumps are punted to PM&R. I'm just curious, as intrathecal pain pumps, who would manage that call if it's consulted in the ER? Is it your team? Is it neurosurgery? Do you all collaborate? Because certainly, if I want to encourage more pain pumps, I've got to be careful about who I'm going to give that consult to. So I personally manage all of mine, but our chronic anesthesia pain team manages the opioid pumps at our hospital system. Our baclofen is our PM&R and neurology. Neurosurgery, we would love to train, but that's been a little bit challenging. Hi, great talk. Thank you so much. So just two questions. So first, if you suspect a neuroma and you look under ultrasound, how often do you see one? And if you don't, do you inject anyway? And then second question, when you identify spiritual distress as a major contributing factor, what interventions do you recommend for that? Thank you. So spiritual distress can be kind of tricky. You need to have a chaplain there who does a real good spiritual history, but you could still start by saying how are your spirits doing, what gives you meaning in life to kind of open the door to that, and then find someone to help them further along with that as well, whether it's going to be your chaplain or social worker doing that. So the neuroma question is tricky. So I can't say I feel that I have confidently visualized a ton of chest wall neuromas when I look in that area. So if I don't see something that, to me, is definitively a neuroma and I want to inject it, I'm really using my ultrasound more for safety of kind of guiding the needle into the area. I don't think Sean Smith's here, but I know I've had a million philosophical conversations with Sean Smith about this issue. I think he injects a lot more of these than me. So he may have some stored images or some thoughts about what he thinks they look like when he sees them, but I haven't seen a ton. Thank you. Great talk. Thank you. I was hoping you could talk about how do you decide who gets an intrathecal pump versus a spinal cord stimulator? What's the criteria? So that's a really good question. So if someone is cured of cancer, then I would lean towards non-opioid treatment options. So that would be a spinal cord stimulator for me. And I would usually do that after we've tried so many other things. And it is off-label, so it isn't always approved by insurance. And it does all now, every insurance, including Medicare, now requires a psychological evaluation. If we're thinking about an intrathecal pump, then if the patient has a shorter prognosis or already has recurrence of disease somewhere else and we think it may metastasize again, then that's when I would lean towards a pump. And if they do have cancer-related pain, like metastatic disease, you can also usually bypass the psychological evaluation for the pump in an intrathecal trial because they are usually on a higher dose of opioids. If you were doing it, and you couldn't select patients, and everybody practices differently, somebody somewhere else may say, even if they're cured of cancer, I'd put a pump in to minimize the opioid use. For me, it would be a select number of people I would do that in that are technically cured of cancer. And you would then have to actually do a trial and then get insurance approval with a psychological evaluation usually for that. So both are expensive pieces of equipment. And so really picking the right person. If someone is having a lot of emotional distress, psychological distress, they're not going to pass the psychological evaluation for a spinal cord stimulator, likely. Hi, thank you so much again for the talk. Also, this is for Dr. Luke. I'm curious from your experience in terms of some of the interventional blocks that you've been doing, is this something that you have developed given the population and your passion for what you do over time? Or is this, if I were to make these referrals to a general anesthesia pain physician, would they understand what I'm asking and kind of make the right block decision? I think dependent on where you practice, too, I think a lot would be able to do most of these, yes. Not everyone manages pumps. And I think sometimes they may be a little over-reliant on certain things, right? Our physical exam really is the big key, right? So it's like radiation fibrosis. I've seen some wonky things done even where I practice. And no one noticed that they have thoracic outlet from radiation-induced changes of the PEC. And so you can, yes, wherever you are, you can definitely refer. Some places, I think like Sloan Kettering, there's more being done there than maybe other places. When I returned after training, I set this, I kind of built it from the ground up with the pieces I wanted. And I'm lucky that our Comprehensive Cancer Center pays my time, pays my pain psychologist time. So we're able to practice in this format because the billing, you can't see enough patients to do this in like a private practice setting and only do cancer-related pain. Thank you. Thank you. So my daughter at 24 had. What is her main pain complaint? Is it range of motion? Chest wall, chest wall. Just chest wall pain anteriorly? Yeah. On both sides? Yeah, well, mostly on the right side. On both sides, mostly on the right side. So I think I'd try interventional blocks, try intercostal blocks probably, and then I would try spinal cord stimulator for her. Wonderful talk, appreciate the insight from all the different perspectives. My question had to do with acupuncture, mind-body techniques, mindfulness, things like that. I'm not sure, to the best of your knowledge, is there a literature base for this? Is there a rationale? When would you use it, if you use it, that kind of thing? I'm not specifically aware of studies for this pain syndrome, and if there are, I apologize, I'm missing that, but I think there certainly can be a role. There's no specific studies, but just in cancer in general, all CBT integrative medicine can be beneficial, so I'd also include that in post-mastectomy pain. As long as there's no contraindications for doing those things, they're not financially toxic to the patient, I say go after them and do them. We do a lot of Reiki therapy and other types of integrative medicine through my palliative group in Mayo, so they have really good results from it, so if it's something you want to do and explore, and there's nothing that's going to cause any harm, I recommend you go ahead and do that. Are you aware of anybody using peripheral nerve stimulation for this type of pain? So you could, potentially, I mean dependent on if you have shoulders function, you could do super scapular peripheral nerve stimulator, you could drop it into the intercostal nerve. They're not MRI, right, so if you need an MRI, you can't have one. You could try Sprint, which is 60 days, which is probably what I would actually do for patients like this. I've done it for patients that have scapular lesion, drop it down there, leave it in for 60 days, and actually, it lasts, I have one that's over a year with significant pain relief, you think neuroplasticity is part of it. I didn't talk about it here specifically, it's just you have to find the right patient in a cancer patient population for that to be an appropriate use for, and then it's still fairly difficult for insurance coverage for those. I had a question back here, yeah, I don't know. But my question to you guys was, one of the things I noticed was, I've seen in my clinic and with some of the training I've gotten from Dr. Wazowski too, looking for patients and trying to get to the bottom of what's going on with the PNPS is almost like this dystonic type of reaction in the serratus anterior. I know that I've had a few patients that I've injected, and I was curious to get the panel's thoughts on if you felt like that was anything that you've seen in your clinic, or if there's any kind of physiologic basis that you've seen for that. Yes, yeah, I definitely have seen that, and if it is more of kind of, I guess, a spastic picture, I think that's where botulinum toxin, muscle relaxant medications, obviously therapy, all of those can be helpful. I think the way a lot of people have explained that in the literature is kind of loss of inhibitory control of the muscle due to some type of denervation, whether it's surgical nerve injury, radiation nerve injury, et cetera. I really enjoyed the talk. I just have two questions open to the whole panel, the first being maybe a naive question, but for neuromas, is what either in your practice or what's described in the literature are those intraneural injections into the neuroma or more perineural with the thought processes like the compression of the soft tissues as part of the pain genera as well as being my first question. Second question, again, open to the panel, but maybe for Dr. Luke as well, in your experience in the neuromodulation space, are you finding that habituation maybe to the waveforms in the patients that you're seeing are maybe more prevalent or maybe reprogramming needs more prevalent in the cancer patient population versus the non-cancer or are they about comparable? So I think you can do either for the first question. I don't think there's a right answer per se of where to inject or how to inject. For the second question, there could be. I recommend that they turn their spinal cord stimulator off for about eight hours a day to prevent habituation. And then sometimes we can do a combination of high frequency depending on, some people like to feel it and that's how they feel that it's working for them, some don't. So I think you could do a combination of that. Abbott makes burst therapy and so that is kind of based on that habituation thought process. So I haven't seen a lot of problems with it, like people. Hi, thanks for the talk. I have just one quick question. On one of the slides earlier, I saw it listed as lymphedema pain as an indication, I believe it was for one of the blocks. Forgive me if I'm wrong. It might have been one of the, like, stalaganglion, I think. I was curious, what are you defining as lymphedema pain? So I have a lot of patients, right, it's more just pain from kind of that large sensation or vascular changes after, like, lymphedema has gone on for a while. So how it works is, since it kind of blocks the sympathetic, does block the sympathetic fibers, can vasodilate, it can improve that. I don't use it for that a lot, but it is in the literature as one of kind of the indications for it. Thank you. And just to comment on that, too, I think it's an important distinction as we think about our sort of common, you know, iatrogenic post-lymph node dissection lymphedema versus what we call malignant lymphedema, which is the type of edema you see due to tumor burden in the axillary nodes itself. For our patients who are metastatic, you know, that type of lymphedema presents much more severely with a lot more pitting edema, may have kind of that CRPS kind of picture that you just mentioned. So for those patients with that more malignant type of lymphedema, it is extremely painful. And I think a procedure like that could be very helpful. But, you know, for the majority of our patients who are having that iatrogenic edema due to lymph node dissection, it's typically, you know, less painful, I guess is probably the safest way to say it.

post-mastectomy pain

assessment

management

education

neuropathic causes

musculoskeletal causes

clinical assessment

nerve blocks

psychological factors

chronic pain management

multidisciplinary approach