AnesthesiaExam Podcast

Can platelet-rich plasma, the therapy we inject to heal tissue, cause scar tissue? After Dr. David Rosenblum's LinkedIn post on PRP for rotator cuff tears drew a wave of questions from colleagues, he went back to the literature: the cell studies, the animal models, and every human trial he could find on PRP concentration, total dose and formulation. The short answer: in the lab and in animals, high-concentration PRP can overshoot into fibrosis, and the mechanism (TGF-β1) is well established. In human patients, no study at any concentration has linked PRP to scar or arthrofibrosis. The documented human harms are short-lived pain, swelling and stiffness. If anything, the human data says the usual problem is too few platelets, not too many. Timestamps 0:00 Intro, the new Pain Medicine: High-Yield Review book (now also in Spanish) and upcoming courses 2:59 The question: does PRP cause scar tissue? 3:24 The short answer 5:11 The animal data: Harris 2012 6:14 LaPrade 2018 and the therapeutic window 7:35 The mechanism: TGF-β1 (Li 2016, Terada 2013, Sundman 2011, McCarrel 2012) 9:32 The human data: dose, not just concentration (Dernek, Boffa, Berrigan, Patel) 12:12 Practical takeaways for your next PRP case 13:44 From the NRAP Community: PRP vs. steroid for lumbar disc herniation (Sonkar 2026) 14:42 Why ultrasound guidance matters, plus the NYC hands-on workshop calendar 15:49 APP training, the APP Orientation course, observerships and private training 16:20 Close Key takeaways The dose response is an inverted U. The preclinical therapeutic window is roughly 0.5–1.5 × 10⁶ platelets/µL. At 5 × 10⁶/µL, PRP was toxic to human tenocytes in vitro (Giusti 2014). In a rabbit MCL model, higher concentrations did worse than saline (LaPrade 2018). PRP in healthy tissue can leave scar. PRP injected into normal rabbit tissue left persistent scar at 12 weeks while saline sites stayed clean (Harris 2012). TGF-β1 drives the fibrosis. Blocking it with a neutralizing antibody or with losartan reduced fibrosis and improved muscle healing (Li 2016; Terada 2013). Formulation is a dosing decision. Leukocyte-rich PRP delivers several-fold more TGF-β1, MMP-9 and IL-1β than leukocyte-poor PRP (Sundman 2011). No human study links PRP at any concentration to fibrosis or arthrofibrosis. In knee OA, total platelets delivered predicts success. More than 10 billion platelets per course was favorable (Berrigan 2024), and doubling the volume at the same concentration improved outcomes (Patel 2024). Practical takeaways Know your system's concentration, volume and total platelet dose. Respect the therapeutic window in tendon and ligament. Consider leukocyte-poor PRP for scar-prone tissue. Dose joints by total platelets, not concentration alone. Judge biologics at 6–12 weeks, not 2–3. Use ultrasound guidance. A well-prepared syringe in the wrong plane is just expensive plasma. Have a study that says otherwise? Send it to [email protected] or post it in the NRAP Community Regenerative Medicine forum. Train with NRAP Academy Hands-on ultrasound workshops in New York City: Sunday, November 8, 2026 · Sunday, December 6, 2026 · Sunday, January 31, 2027. For Anesthesiologists & Residents - AnesthesiaExam Board Review: Basic AnesthesiaExam Board Review - high-yield questions and explanations for residents preparing for the ABA BASIC exam. Advanced AnesthesiaExam Board Review - comprehensive review for ABA ADVANCED certification. MOCA AnesthesiaExam Comprehensive Board Review - question bank for ABA certification and MOCA. Book: Pain Medicine: High-Yield Review is available as an eBook and as a paperback on Amazon. A Spanish edition is also available. Virtual Pain Fellowship: nrappain.org/bundles/Virtual-Pain-Fellowship Advanced practice providers: APP pain training is available now, and the APP Orientation course is coming soon. Visit nrappain.org. Observerships and private ultrasound training, including sessions in Playa Grande, Costa Rica: nrappain.org References Harris NL, et al. The effect of platelet-rich plasma on normal soft tissues in the rabbit. J Bone Joint Surg Am. 2012;94(9):786–793. PMID 22552667. Giusti I, et al. Platelet concentration in platelet-rich plasma affects tenocyte behavior in vitro. BioMed Res Int. 2014;2014:630870. PMID 25147809. LaPrade RF, et al. Use of platelet-rich plasma immediately after an injury did not improve ligament healing, and increasing platelet concentrations was detrimental in an in vivo animal model. Am J Sports Med. 2018;46(3):702–712. PMID 29211969. Weibrich G, et al. Effect of platelet concentration in platelet-rich plasma on peri-implant bone regeneration. Bone. 2004;34(4):665–671. PMID 15050897. Yoshida R, Cheng M, Murray MM. Increasing platelet concentration in platelet-rich plasma inhibits anterior cruciate ligament cell function. J Orthop Res. 2014;32(2):291–295. PMID 24122902. Li H, et al. Customized platelet-rich plasma with TGF-β1 neutralization for tissue-engineered muscle regeneration. Biomaterials. 2016;87:147–156. Terada S, et al. Use of an antifibrotic agent (losartan) improves the effect of platelet-rich plasma on muscle healing. J Bone Joint Surg Am. 2013;95(11):980–988. PMID 23780535. Sundman EA, Cole BJ, Fortier LA. Growth factor and catabolic cytokine concentrations are influenced by the cellular composition of platelet-rich plasma. Am J Sports Med. 2011;39(10):2135–2141. PMID 21846925. McCarrel TM, Minas T, Fortier LA. Optimization of leukocyte concentration in platelet-rich plasma for the treatment of tendinopathy. J Bone Joint Surg Am. 2012;94(20):e143. PMID 23032594. Dragoo JL, et al. Comparison of the acute inflammatory response of two commercial platelet-rich plasma systems in healthy rabbit tendons. Am J Sports Med. 2012;40(6):1274–1281. PMID 22495144. Dernek B, et al. Effect of platelet concentration on the clinical outcome of platelet-rich plasma injections in knee osteoarthritis. J Phys Ther Sci. 2017;29(5):896–899. Boffa A, et al. Platelet concentration and platelet-rich plasma outcomes in knee osteoarthritis. Am J Sports Med. 2024;52(13):3223–3231. PMID 39397728. Berrigan WA, et al. A higher platelet dose may yield better clinical outcomes for platelet-rich plasma in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Curr Rev Musculoskelet Med. 2024;17(12):570–588. Patel S, et al. Same concentration, higher volume ("superdose") PRP in early knee OA: a triple-blind RCT. Orthop J Sports Med. 2024;12(2). Riboh JC, et al. Effect of leukocyte concentration on the efficacy of platelet-rich plasma in knee osteoarthritis. Am J Sports Med. 2016;44(3):792–800. PMID 25925602. Sonkar T, Yadav V, Singh S. A randomized controlled trial comparing transforaminal injections of platelet-rich plasma versus steroid for lumbar herniated disc. J Clin Orthop Trauma. 2026;81:103546. PMID 42404033. Patients: in pain in Brooklyn or NYC? Dr. Rosenblum treats patients with back, neck, joint and nerve pain in Brooklyn, NY, and offers virtual second opinions. Visit RosenblumPain.com or call (718) 436-7246. This episode is brought to you by NRAP Academy and AnesthesiaExam - visit www.NRAPpain.org for CME in neuromodulation, regional anesthesia, and pain medicine. This podcast is for clinician education only and is not medical advice for any individual patient. Study findings are discussed as reported by their authors. Clinical decisions remain the responsibility of the treating physician.

Dr. David Rosenblum sits down with Nora Rabah Rodden, founder and CEO of Nervana, a digital health app for people living with chronic pain and other persistent symptoms. During her senior year at Cornell, Nora was hit by a car, which led to five years of mid and low back pain. She tried radiofrequency ablation, PRP, steroid injections, chiropractic care, physical therapy and acupuncture, and none of them gave her lasting relief. While earning her MBA and MS in Biotechnology at Harvard, Nora enrolled as a participant in a clinical study of Psychophysiologic Symptom Relief Therapy (PSRT), led by Dr. Michael Donnino. The study combined pain education, graded exposure and journaling. Within weeks her pain dropped from a 7/10 to zero, and her insomnia and digestive problems improved too. Topics covered: How Nora went from a skeptical pain patient to building an app around the biopsychosocial model How Nervana works: pain neuroscience education, a voice-to-voice AI coach, journaling, meditation and somatic exercises. The app does not diagnose or prescribe. Why the app is "meant to be deleted," and how patients can export a one-page summary for their clinician The gap between how much the biopsychosocial model is emphasized in medical school and on the boards, and how hard it is to apply in a busy interventional practice A clinical story: a patient who asked for an injection for abdominal pain one month after losing her baby Why a diagnostic block is only a snapshot, and how life stressors can change pain scores How to bring up the emotional side of pain without making patients feel dismissed Why a pain physician should never tell a patient "there's nothing I can do for you" Bottom line: chronic pain is real, but the brain can turn the volume up or down. Understanding the biopsychosocial model helps clinicians offer patients more than procedures alone, and never leave them feeling there is nothing more that can be done. Guest resources: Nervana, https://www.trynervana.com. Clinicians can get free access at https://www.trynervana.com/for-clinicians For Anesthesiologists & Residents - AnesthesiaExam Board Review: Basic AnesthesiaExam Board Review - high-yield questions and explanations for residents preparing for the ABA BASIC exam. Advanced AnesthesiaExam Board Review - comprehensive review for ABA ADVANCED certification. MOCA AnesthesiaExam Comprehensive Board Review - question bank for ABA certification and MOCA. Ultrasound CME Course Calendar - live ultrasound-guided regional anesthesia and interventional pain workshops in NYC, Costa Rica and elsewhere. Conferences & Webinars: https://www.nrappain.org/pages/upcoming-pain-management-conferences Pain Medicine Fellowship-bound? Virtual Pain Fellowship: https://www.nrappain.org/bundles/Virtual-Pain-Fellowship About the Host David Rosenblum, MD is Director of Pain Management at Maimonides Medical Center and Co-Owner/Clinic Director of AABP Integrative Pain Care and Wellness in Brooklyn, NY. Dual board-certified in Anesthesiology and Pain Medicine, he is a co-author of the ASIPP Peripheral Nerve Stimulation (PNS) guidelines and a widely recognized educator in regenerative pain medicine (PRP, BMAC, amniotic therapies). As founder of NRAP Academy, he has trained 3,500+ physicians for board certification since 2008, and hosts the PainExam, AnesthesiaExam, and PMRExam podcasts. He has been named a New York Magazine "Top Doctor" from 2016–2026. Living with chronic pain? Dr. Rosenblum sees patients for interventional and regenerative pain treatment - including epidurals, nerve blocks, spinal cord & peripheral nerve stimulation, and PRP/BMAC - at his Brooklyn, NY office. Visit RosenblumPain.com for more information, or call 718 436 7246. This episode is brought to you by NRAP Academy and AnesthesiaExam - visit www.NRAPpain.org for CME in neuromodulation, regional anesthesia, and pain medicine. This podcast is for educational purposes only and is not medical advice.

It's the day before the pain boards, so Dr. David Rosenblum skipped the Zoom and recorded a rapid-fire, last-minute review of the high-yield keywords and "board traps" most likely to show up on the ABA Pain Medicine exam. Listen on your commute or at the gym. High-yield topics covered Neonatal pain: A-delta and C fibers and ascending pathways work before birth, but descending inhibition is immature, so neonatal pain may be exaggerated or prolonged. Board trap: incomplete myelination does not mean neonates can't feel pain. Dorsal horn anatomy: Rexed laminae I, II and V. Lamina II is the substantia gelatinosa. Peripheral vs. central sensitization: the "inflammatory soup" (prostaglandins, bradykinin, H+, ATP, histamine, serotonin, cytokines, NGF) causes primary hyperalgesia. NMDA activation, wind-up and expanded receptive fields cause secondary hyperalgesia and allodynia. Superficial cervical plexus (C2–C4): lesser occipital, great auricular, transverse cervical and supraclavicular nerves. Blocked behind the SCM, and useful for clavicle pain. Eagle syndrome: an elongated styloid process irritating the glossopharyngeal nerve. Pain scales: NIPS, CRIES, FLACC and modified FLACC, Wong-Baker FACES, FPS-R, NRS, VAS and PROMIS-10 Global Health. Statistics: sensitivity and specificity don't depend on prevalence, but PPV and NPV do. Type I error is a false positive (α = 0.05) and Type II error is a false negative. Acetaminophen toxicity: use the Rumack-Matthew nomogram at 4 hours or later (acute single ingestion only). N-acetylcysteine is the antidote. Buprenorphine: a high-affinity partial mu agonist and kappa antagonist, with a ceiling effect on respiratory depression. Drug toxicities: carbamazepine (SIADH, SJS with HLA-B*1502, CYP3A4 induction), methotrexate (leucovorin rescue), hydroxychloroquine (retina), TNF-α inhibitors (TB reactivation), JAK inhibitors (boxed warning for MACE, thrombosis, malignancy), NSAIDs, SSRIs/SNRIs and tramadol (hyponatremia). Muscle relaxants: baclofen, tizanidine, cyclobenzaprine, methocarbamol, metaxalone, carisoprodol (meprobamate), chlorzoxazone, dantrolene, diazepam and botulinum toxin (cleaves SNARE proteins). Upcoming events Coming up: the NY/NJ Pain Congress in November and the Latin American Pain Society meeting next year. Hands-on NRAP ultrasound courses in New York are coming up in October and November. See the calendar at nrappain.org. Taking the boards next year? Start here: More CME, board review and ultrasound training at www.NRAPpain.org. Patients: in pain in Brooklyn or NYC? Dr. Rosenblum treats patients with back, neck, joint and nerve pain in Brooklyn, NY, and offers virtual second opinions. Visit RosenblumPain.com or call (718) 436-7246 to book an appointment. For educational purposes only. Not medical advice.

Artificial intelligence is moving fast from buzzword to clinical tool — and pain medicine is no exception. In this episode, Dr. David Rosenblum breaks down how AI is already touching the field, drawing on "Artificial Intelligence and Pain Medicine: An Introduction" by Hagedorn, George, Aiyer, Schmidt, Halamka, and D'Souza (Journal of Pain Research, 2024;17:509–518). Topics covered: Why AI is expected to be a genuine turning point for healthcare, not just another tech trend Using machine learning to optimize clinical trial design and patient selection in pain research Natural language processing (NLP) tools that streamline physician workflow and improve doctor-patient communication Deep learning approaches to analyzing patient outcomes and predicting who responds best to a given treatment What better disease recognition and treatment selection could look like in day-to-day pain practice Practical implications for cost and time savings, product development, and clinical decision-making Where the evidence is still early, and what physicians should watch for as AI tools move toward the bedside Bottom line: AI won't replace clinical judgment in pain medicine, but it's already starting to augment it — from trial design to the exam room. Physicians who understand where the technology is headed will be best positioned to use it well. Reference: Hagedorn JM, George TK, Aiyer R, Schmidt K, Halamka J, D'Souza RS. Artificial Intelligence and Pain Medicine: An Introduction. J Pain Res. 2024;17:509–518. https://pmc.ncbi.nlm.nih.gov/articles/PMC10848920/ About the Host David Rosenblum, MD is Director of Pain Management at Maimonides Medical Center and Co-Owner/Clinic Director of AABP Integrative Pain Care and Wellness in Brooklyn, NY. Dual board-certified in Anesthesiology and Pain Medicine, he is a co-author of the ASIPP Peripheral Nerve Stimulation (PNS) guidelines and a widely recognized educator in regenerative pain medicine (PRP, BMAC, amniotic therapies). As founder of NRAP Academy, he has trained 3,500+ physicians for pain board certification since 2008, and hosts the PainExam, AnesthesiaExam, and PMRExam podcasts. He has been named a New York Magazine "Top Doctor" from 2016–2026. Living with chronic pain? Dr. Rosenblum sees patients for interventional and regenerative pain treatment - including epidurals, nerve blocks, spinal cord & peripheral nerve stimulation, and PRP/BMAC - at his Brooklyn, NY office. Visit RosenblumPain.com for more information. or call 718 436 7246 For Physicians & APPs - Continue Your Education: CME Course Calendar: https://www.nrappain.org/pages/upcoming-pain-management-conferences Virtual Pain Fellowship: https://www.nrappain.org/bundles/Virtual-Pain-Fellowship PainExam Board Prep: https://www.nrappain.org/pages/pain-management-cme-courses This episode is brought to you by NRAP Academy and PainExam - visit www.NRAPpain.org for CME in neuromodulation, regional anesthesia, and pain medicine.  

Ketamine clinics have exploded worldwide, offering low-dose intravenous infusions for chronic pain patients who've run out of options. But is this practice actually backed by evidence, or has off-label use outpaced the science? In this episode of the PainExam Podcast, Dr. David Rosenblum reviews the current literature on subanaesthetic-dose ketamine infusions (SDKIs) for chronic pain, drawing on the 2023 British Journal of Pain review by Harry M. Griffiths, "Low-dose ketamine infusions for chronic pain management: Does this qualify as evidence-based practice?" Topics covered: Why conventional analgesics (opioids, anticonvulsants, antidepressants) fail in 60–70% of chronic pain patients How ketamine works as an NMDA receptor antagonist, and why that mechanism is likely an oversimplification Typical SDKI dosing (~0.35–0.5 mg/kg) versus anesthetic dosing, and why the IV route dominates the evidence base What the meta-analyses actually show: modest, time-limited pain reduction (mean difference around -1.83 on a 0–10 scale) with higher efficacy but more side effects at higher doses Key trials — Corriger et al.'s 1-year follow-up (256 patients), Orhurhu et al.'s systematic review and meta-analysis, and smaller RCTs in CRPS, fibromyalgia, and ischemic limb pain Common side effects (nausea, psychomimetic symptoms) versus rare but serious adverse events (hepatic, cardiac, urogenital) — and how dose and premedication with clonidine/midazolam affect risk Why blinding failure (up to 93% of patients correctly guessing their treatment in one trial) may be inflating reported effect sizes The absence of standardized protocols, guidelines, or a clear "exit strategy" for patients on long-term SDKI therapy What needs to happen next: larger multicenter RCTs, ketamine clinic registries, and better outcome measures beyond simple pain scores Bottom line: SDKIs offer a promising but still under-evidenced option for refractory chronic pain — reserved for the right patient, with modest expectations and careful monitoring. Reference: Griffiths HM. Low-dose ketamine infusions for chronic pain management: Does this qualify as evidence-based practice? Br J Pain. 2023;17(5). https://journals.sagepub.com/doi/full/10.1177/20494637231182804 Show Image About the Host David Rosenblum, MD is Director of Pain Management at Maimonides Medical Center and Co-Owner/Clinic Director of AABP Integrative Pain Care and Wellness in Brooklyn, NY. Dual board-certified in Anesthesiology and Pain Medicine, he is a co-author of the ASIPP Peripheral Nerve Stimulation (PNS) guidelines and a widely recognized educator in regenerative pain medicine (PRP, BMAC, amniotic therapies). As founder of NRAP Academy, he has trained 3,500+ physicians for pain board certification since 2008, and hosts the PainExam, AnesthesiaExam, and PMRExam podcasts. He has been named a New York Magazine "Top Doctor" from 2016–2026. Living with chronic pain? Dr. Rosenblum sees patients for interventional and regenerative pain treatment — including epidurals, nerve blocks, spinal cord & peripheral nerve stimulation, and PRP/BMAC — at his Brooklyn, NY office. Visit RosenblumPain.com for more information. For Physicians & APPs — Continue Your Education: CME Course Calendar: https://www.nrappain.org/pages/upcoming-pain-management-conferences Virtual Pain Fellowship: https://www.nrappain.org/bundles/Virtual-Pain-Fellowship PainExam Board Prep: https://www.nrappain.org/pages/pain-management-cme-couåçrses This episode is brought to you by NRAP Academy and PainExam — visit www.NRAPpain.org for CME in neuromodulation, regional anesthesia, and pain medicine.

  *]:pointer-events-auto R6Vx5W_threadScrollVars scroll-mb-[calc(var(--scroll-root-safe-area-inset-bottom,0px)+var(--thread-response-height))] scroll-mt-(--sticky-padding-top)" dir="auto" data-turn-id="c3881c21-13af-4075-a5be-171053d37466" data-turn-id-container="c3881c21-13af-4075-a5be-171053d37466" data-testid="conversation-turn-3" data-turn="user">   *]:pointer-events-auto R6Vx5W_threadScrollVars scroll-mb-[calc(var(--scroll-root-safe-area-inset-bottom,0px)+var(--thread-response-height))] scroll-mt-[calc(var(--header-height)+min(200px,max(70px,20svh)))]" dir="auto" data-turn-id= "request-WEB:435fda1a-0142-445e-a974-3323f9f0ded7-1" data-turn-id-container= "request-WEB:435fda1a-0142-445e-a974-3323f9f0ded7-1" data-testid= "conversation-turn-4" data-turn="assistant"> PainExam Podcast Show Notes NAD+ Supplementation in Pain and Inflammation: Hype, Hope, or Emerging Science? Hosted by: PainExam Podcast Presented by: NRAP Academy (Neuromodulation, Regional Anesthesia & Pain) Host: David Rosenblum, MD Episode Overview In this episode of the PainExam Podcast, we explore the growing interest in NAD+ (Nicotinamide Adenine Dinucleotide) supplementation and its potential role in pain management, inflammation reduction, cellular recovery, and healthy aging. NAD+ is a naturally occurring coenzyme found in every living cell and is essential for energy production, mitochondrial function, DNA repair, and cellular resilience. As NAD+ levels decline with age, chronic stress, inflammation, and disease, researchers have begun investigating whether restoring NAD+ levels may improve outcomes in chronic pain conditions and inflammatory disorders. We review the current science, discuss potential mechanisms of action, and examine how NAD+ therapy is being integrated into regenerative medicine, wellness programs, and pain management practices. What is NAD+? NAD+ is a coenzyme involved in: ✅ Cellular energy production (ATP generation) ✅ Mitochondrial health ✅ DNA repair pathways ✅ Oxidative stress reduction ✅ Neuroprotection ✅ Cellular signaling ✅ Activation of longevity-associated proteins called sirtuins Without adequate NAD+, cells become less efficient at producing energy and managing inflammation. Why Might NAD+ Matter in Chronic Pain? Many chronic pain conditions involve: Mitochondrial dysfunction Oxidative stress Neuroinflammation Peripheral and central sensitization Impaired cellular recovery Researchers hypothesize that optimizing NAD+ levels may help address several of these pathways simultaneously. Potential areas of interest include: Neuropathic Pain NAD+ may support: Nerve repair Axonal recovery Mitochondrial function within neurons Reduction of oxidative injury Inflammatory Pain NAD+ influences inflammatory signaling pathways and may help modulate: Cytokine production Immune cell activity Cellular stress responses Fatigue and Recovery Patients with chronic pain frequently report: Fatigue Brain fog Reduced exercise tolerance Poor recovery Because NAD+ plays a critical role in energy metabolism, some clinicians report improvements in energy and recovery following supplementation. Potential Mechanisms of Action 1. Improved Mitochondrial Function Mitochondria generate ATP, the body's energy currency. Reduced NAD+ levels are associated with: Cellular aging Impaired energy production Increased inflammation Supplementation may help restore mitochondrial efficiency. 2. Activation of Sirtuins Sirtuins are proteins involved in: Cellular repair Longevity Metabolic regulation Inflammation control NAD+ serves as a critical substrate for sirtuin activity. 3. DNA Repair Support NAD+ is required for enzymes known as PARPs (Poly ADP Ribose Polymerases), which participate in DNA repair processes following cellular injury. 4. Reduction of Oxidative Stress Chronic inflammation often produces excessive reactive oxygen species (ROS). NAD+ may help maintain cellular antioxidant defenses and reduce oxidative injury. Routes of NAD+ Supplementation Intravenous (IV) NAD+ Most commonly marketed in wellness and recovery clinics. Potential advantages: Direct systemic delivery Avoids gastrointestinal absorption issues Allows higher dosing protocols Potential limitations: Cost Time commitment Variable evidence base Oral Precursors Rather than NAD+ itself, many supplements provide precursors such as: Nicotinamide Riboside (NR) Nicotinamide Mononucleotide (NMN) These compounds are converted into NAD+ within the body. What Does the Evidence Show? Current evidence remains preliminary. While preclinical and mechanistic studies are promising, large-scale randomized controlled trials evaluating NAD+ specifically for chronic pain are still limited. Areas under active investigation include: Neuropathic pain Neurodegenerative disorders Chronic fatigue syndromes Recovery optimization Healthy aging Patients should understand that NAD+ therapy remains an emerging treatment rather than a standard evidence-based pain intervention. Safety Considerations Reported side effects may include: Nausea Flushing Chest tightness during rapid infusions Headache Fatigue Lightheadedness Most adverse effects appear infusion-rate dependent and can often be minimized through slower administration protocols. Patients should discuss treatment with a qualified healthcare professional, especially if they have: Cardiovascular disease Active cancer Significant medical comorbidities Clinical Pearls for Pain Physicians ✔ Consider NAD+ as a potential adjunct—not a replacement—for evidence-based pain care. ✔ Continue emphasizing exercise, sleep optimization, nutrition, behavioral health, and appropriate interventional therapies. ✔ Discuss realistic expectations with patients. ✔ Recognize that evidence continues to evolve. ✔ Focus on patient-centered outcomes rather than laboratory markers alone. Key Takeaways NAD+ is essential for cellular energy production and repair. Declining NAD+ levels may contribute to aging, inflammation, and chronic disease. Early evidence suggests possible benefits in inflammation, recovery, fatigue, and nerve health. Robust pain-specific clinical trials remain limited. NAD+ therapy should currently be viewed as an adjunctive and investigational strategy in pain management. Resources for Physicians Pain Medicine Board Preparation Prepare for the ABA Pain Medicine Boards with: 🎯 Comprehensive Question Banks 🎯 Virtual Pain Fellowship 🎯 Flashcards and Mock Exams 🎯 Weekly Board Review Content 👉 Pain Management Board Prep at NRAP Academy Hands-On Ultrasound Courses – New York Learn: Peripheral nerve imaging Ultrasound-guided injections Regenerative medicine procedures Diagnostic musculoskeletal ultrasound Advanced pain intervention techniques 👉 NRAP Ultrasound Courses in New York Ultrasound & Regenerative Medicine Training – Costa Rica Join physicians from around the world for immersive training in: 🌴 Playa Grande, Costa Rica ☀️ Small-group hands-on instruction 🦴 Regenerative medicine applications 📡 Ultrasound-guided pain procedures 👉 Costa Rica Ultrasound Training Courses Connect With PainExam 🌐 NRAP Academy Website 🎙️ Search PainExam Podcast on your favorite podcast platform. 📚 Explore the Virtual Pain Fellowship, Board Review Programs, Ultrasound Training, and CME opportunities. References Hudson Health. NAD+ Infusion Therapy: Full Clinical Review and Background Paper. 2023. Verdin E. NAD⁺ in aging, metabolism, and neurodegeneration. Science. 2015. Covarrubias AJ, Perrone R, Grozio A, Verdin E. NAD⁺ metabolism and its roles in cellular processes. Nature Reviews Molecular Cell Biology. 2021. Rajman L, Chwalek K, Sinclair DA. Therapeutic potential of NAD-boosting molecules. Cell Metabolism. 2018. Katsyuba E, Auwerx J. Modulating NAD⁺ metabolism for health and longevity. Nature Reviews Endocrinology. 2017. Disclaimer: This podcast is intended for educational purposes only and should not be construed as medical advice. Always consult qualified healthcare professionals before initiating any treatment.

PainExam Podcast Show Notes Compression Fractures, Vertebroplasty, Kyphoplasty & Occipital Neuralgia for the ABA Pain Medicine Boards In this episode of the PainExam Podcast, Dr. David Rosenblum reviews two frequently tested topics on the ABA Pain Medicine Board Examination: Occipital Neuralgia and Vertebral Compression Fractures, including the indications, techniques, complications, and evidence surrounding vertebroplasty and kyphoplasty. Whether you are preparing for the ABA Pain Medicine Boards, ABPM, ABIPP, FIPP, or simply looking to strengthen your interventional pain knowledge, this episode covers essential board pearls, anatomy, diagnosis, imaging findings, and treatment options. Episode Highlights Occipital Neuralgia Topics discussed include: Anatomy of the greater, lesser, and third occipital nerves C2 dorsal ramus anatomy and clinical relevance Diagnostic criteria for occipital neuralgia Differentiating occipital neuralgia from: Cervicogenic headache Migraine Cluster headache Tension headache Physical examination findings Occipital nerve blocks Pulsed radiofrequency ablation Cryoneurolysis Peripheral nerve stimulation (PNS) Board Pearl The greater occipital nerve originates from the dorsal ramus of C2 and temporary pain relief following a diagnostic occipital nerve block strongly supports the diagnosis. Vertebral Compression Fractures Topics reviewed include: Osteoporotic vertebral compression fractures Thoracolumbar fracture patterns MRI findings STIR sequence interpretation Patient selection for vertebral augmentation Conservative treatment versus intervention Vertebroplasty technique Kyphoplasty technique Cement leakage and other complications Evidence supporting vertebral augmentation procedures Board Pearl Bone marrow edema on MRI STIR imaging is one of the most important findings suggesting an acute compression fracture. Kyphoplasty vs Vertebroplasty Vertebroplasty Direct injection of PMMA cement into the vertebral body Stabilizes micro-motion within the fracture Can provide rapid pain relief Kyphoplasty Balloon tamp creates a cavity before cement placement May partially restore vertebral body height May reduce risk of cement extravasation Often preferred in selected patients with significant vertebral collapse Commonly Tested Complications Cement leakage Pulmonary cement embolism Adjacent level fractures Infection Neurologic injury (rare) High-Yield ABA Pain Medicine Keywords Occipital Neuralgia Greater Occipital Nerve C2 Dorsal Ramus Third Occipital Nerve Cervicogenic Headache Peripheral Nerve Stimulation Vertebral Compression Fracture Kyphoplasty Vertebroplasty PMMA Cement STIR MRI Osteoporosis Cement Extravasation Upcoming Educational Meetings & Conferences 2026 ASPN Annual Meeting – Miami Learn more about the upcoming meeting hosted by the American Society of Pain and Neuroscience: 📍 ASPN Annual Conference & Miami Meeting Information PainWeek 2026 – Las Vegas Join thousands of pain physicians, APPs, nurses, and industry professionals at: 📍 PAINWeek Las Vegas 2026 Latin American Pain Society Meeting – Brazil For information regarding the upcoming regional pain meeting in Brazil: 📍 Latin American Pain Federation (FEDELAT) Information CME, Ultrasound & Board Review Resources NRAP Academy CME Courses, Virtual Pain Fellowship, Ultrasound Workshops, Regenerative Medicine Training, and Board Review Programs: 📍 NRAP Academy Website CME Calendar Upcoming Ultrasound Workshops, Regenerative Medicine Courses, Board Review Programs, and Conferences: 📍 NRAP Academy CME Calendar Virtual Pain Fellowship Comprehensive longitudinal pain management education: 📍 Virtual Pain Fellowship Program Pain Management Board Review Prepare for: ABA Pain Medicine Boards ABPM ABIPP FIPP 📍 PainExam Board Review Resources Connect With Dr. David Rosenblum Patients Seeking Care Appointments and consultation requests: 📍 AABP Integrative Pain Care & Wellness Physician Education CME, Ultrasound Training, Regenerative Medicine, and Board Review: 📍 NRAP Academy References Margetis K, Patel A, Petrone B, et al. Percutaneous Vertebroplasty and Kyphoplasty. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Updated April 6, 2025. Available at: https://www.ncbi.nlm.nih.gov/books/NBK525963/ Daher M, Kreichati G, Kharrat K, Sebaaly A. Vertebroplasty versus Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures: A Meta-Analysis. World Neurosurgery. 2023;171:65-71. Masala S, Fiori R, Massari F, Simonetti G. Kyphoplasty: Indications, Contraindications and Technique. Radiologia Medica. 2005;110(1-2):97-105. Headache Classification Committee of the International Headache Society (IHS). International Classification of Headache Disorders (ICHD-3). Cephalalgia. 2018. Bogduk N. The Clinical Anatomy of the Cervical Dorsal Rami. Spine-related anatomy and occipital nerve pain syndromes. Subscribe to the PainExam Podcast For weekly board review content, ultrasound-guided procedures, regenerative medicine updates, pain medicine literature reviews, and expert interviews, subscribe to the PainExam Podcast and visit: 📍 PainExam Podcast & Board Review Resources 🎓 Earn CME and advance your skills through the NRAP Academy and Virtual Pain Fellowship.

🎙️ PainExam Podcast Show Notes CRPS & Intrathecal Pain Pumps — High-Yield ABA Pain Board Review 🔥 Episode Overview In this episode of the PainExam Podcast, David Rosenblum reviews two essential ABA Pain Medicine Board topics: Complex Regional Pain Syndrome (CRPS) Intrathecal Drug Delivery Systems (Pain Pumps) This episode focuses on: High-yield board pearls Clinical decision-making Interventional treatment strategies Common exam pitfalls Whether you are preparing for the: ABA Pain Medicine Boards ABPM ABIPP FIPP —or looking to sharpen your interventional pain knowledge—this episode delivers practical and testable concepts. 🧠 Topic 1: Complex Regional Pain Syndrome (CRPS) 🔬 What is CRPS? CRPS is a chronic neuropathic pain condition characterized by: Disproportionate pain Autonomic dysfunction Sensory abnormalities Motor and trophic changes 📋 CRPS Types CRPS Type I No confirmed nerve injury Formerly "Reflex Sympathetic Dystrophy" CRPS Type II Confirmed nerve injury Formerly "Causalgia" ⚠️ Pathophysiology CRPS involves: Peripheral sensitization Central sensitization Sympathetic dysfunction Neurogenic inflammation Cortical reorganization 🩺 High-Yield Clinical Features Burning pain Allodynia Hyperalgesia Temperature asymmetry Skin color changes Edema Weakness and trophic changes 📚 Budapest Criteria (BOARD FAVORITE) Diagnosis requires: Continuing pain disproportionate to injury Symptoms in ≥3 categories Signs in ≥2 categories 💊 Treatment First-Line Physical therapy (MOST important) Early mobilization Medications Gabapentin Pregabalin TCAs Interventional Sympathetic blocks Spinal cord stimulation 🚨 Board Pearls Early treatment improves outcomes CRPS may spread beyond the initial site Immobilization worsens symptoms 💉 Topic 2: Intrathecal Drug Delivery Systems (Pain Pumps) 🔬 What Are Intrathecal Pumps? Intrathecal pumps deliver medications directly into the CSF, allowing: Lower systemic doses Better analgesia Reduced systemic side effects 🎯 Indications Failed back surgery syndrome Cancer pain Refractory neuropathic pain Severe chronic pain not responsive to conservative therapy 💊 Common Intrathecal Medications Opioids Morphine Hydromorphone Non-Opioid Ziconotide Other Baclofen (spasticity) ⚠️ Ziconotide — HIGH-YIELD BOARD PEARL Ziconotide: Blocks N-type calcium channels Does NOT cause respiratory depression Can cause psychiatric side effects ⚠️ Major Complications Infection Catheter malfunction Pump failure Withdrawal syndromes Catheter-tip granuloma formation 🚨 Granuloma Formation High-dose intrathecal opioids may cause: Catheter-tip inflammatory masses Cord compression Neurologic deficits 📋 Trialing Patients typically undergo: Bolus trial Continuous infusion trial before permanent implantation. 🎯 Board Pearls Ziconotide = no respiratory depression Pump failure can cause life-threatening withdrawal Granulomas are associated with opioid concentration 📝 High-Yield Board Takeaways CRPS Budapest criteria = critical Early PT = first-line Autonomic dysfunction = hallmark Intrathecal Pumps Ziconotide is highly testable Know granuloma risks Understand pump complications and withdrawal 🎓 Pain Board Prep Resources Prepare for your ABA Pain Medicine boards with: 👉 https://painexam.com 👉 https://nrappain.org 🏆 Why Physicians Choose NRAP Academy Comprehensive board prep High-yield MCQs Virtual Pain Fellowship Ultrasound-guided pain training Interventional pain education 🎤 Upcoming Training Join upcoming: Ultrasound-guided procedure workshops Regenerative medicine courses Pain board review sessions 📢Register today! If you're serious about: ✅ Passing your pain boards ✅ Mastering interventional pain ✅ Improving patient outcomes Subscribe to the PainExam Podcast and join the Virtual Pain Fellowship. 👉 https://nrappain.org 👉 https://painexam.com Reference  https://dontforgetthebubbles.com/complex-regional-pain-syndrome/ https://www.ncbi.nlm.nih.gov/books/NBK459151/

🎙️ PainExam Podcast Show Notes Corticosteroids & Contrast Agents in Pain Management + Evidence-Based Steroid Selection 🔥 Episode Overview In this high-yield episode of the PainExam Podcast, David Rosenblum breaks down a must-know board topic: 👉 Injectable corticosteroids vs contrast agents in interventional pain procedures This episode goes beyond basics and dives into: Particulate vs non-particulate steroids Comparative profiles of dexamethasone, betamethasone, triamcinolone, and methylprednisolone Contrast agent selection and safety Critical complications including embolization and neurotoxicity A recent study comparing steroid effectiveness in transforaminal epidural injections This is essential for physicians preparing for the ABA Pain Medicine boards and for clinicians performing spine interventions. 🧠 Core Concept Corticosteroids = therapeutic (reduce inflammation) Contrast agents = diagnostic + safety tools (confirm needle placement) 👉 Board pearl: Steroids treat pain — contrast prevents complications 💉 Corticosteroids — High-Yield Comparison 🔬 Mechanism Inhibit phospholipase A2 Reduce inflammatory mediators Decrease nerve root irritation ⚖️ Key Steroids Compared Steroid Type Particle Profile Key Advantage Major Risk Dexamethasone Non-particulate No aggregation Safest for TFESI Possibly shorter duration Triamcinolone Particulate Large particles Longer depot effect Embolic infarction Methylprednisolone Particulate Aggregates Strong anti-inflammatory Avoid in cervical TFESI Betamethasone Mixed Depends on formulation Potent Acetate = particulate risk 🚨 Major Steroid Risks Local: Tissue atrophy Depigmentation Systemic: Hyperglycemia Adrenal suppression Immunosuppression Catastrophic (Board Tested): Spinal cord infarction Stroke 👉 Caused by intra-arterial injection of particulate steroids 📊 Contrast Agents — High-Yield Review Common Agents Iohexol (Omnipaque) Iopamidol (Isovue) Iodixanol (Visipaque) 🎯 Purpose Confirm needle placement Detect intravascular injection Prevent intrathecal injection ⚠️ Risks Allergic reaction Anaphylaxis Contrast-induced nephropathy 👉 Board pearl: Shellfish allergy ≠ contrast allergy ⚠️ Critical Safety Topic: Gadolinium Gadolinium-based contrast agents are: ❌ NOT approved for epidural or intrathecal use ❌ NOT safe substitutes for iodinated contrast in spine procedures 🚨 Intrathecal Gadolinium Risks Encephalopathy Seizures Respiratory distress Death 👉 Extremely high-yield board concept 📚 Evidence-Based Medicine Segment Study Review: Steroid Selection in TFESI A recent study comparing: Dexamethasone Methylprednisolone Betamethasone 🔑 Key Findings Dexamethasone showed comparable or better outcomes No clear advantage of particulate steroids Similar rates of: Repeat injections Surgical progression 🎯 Clinical Implication 👉 Efficacy differences are smaller than previously thought 👉 Safety is driving practice change 🚨 Board-Level Takeaway Non-particulate steroids = safer Outcomes ≈ similar Technique matters more than steroid choice 👉 Best exam answer: dexamethasone for TFESI 🎯 Board Prep Summary Dexamethasone = safest for transforaminal injections Particulate steroids = embolic risk Contrast must be used before steroid injection Gadolinium = dangerous in neuraxial space Clinical outcomes often similar across steroid types 🎓 Pain Board Prep Resources Prepare for your ABA Pain Medicine boards with: 👉 https://painexam.com 👉 https://nrappain.org 🏆 Why Physicians Choose NRAP Academy High-yield board review content Thousands of MCQs Virtual Pain Fellowship Ultrasound + regenerative training Real-world clinical integration Register Today! 🎤 Upcoming Training Ultrasound-guided pain procedures Regenerative medicine courses (PRP, biologics) Hands-on workshops Register Today! 📢 Call to Action If you're serious about passing your boards and practicing safer interventional pain medicine: ✅ Subscribe to the PainExam Podcast ✅ Join the Virtual Pain Fellowship ✅ Visit https://nrappain.org   References Calvo N, Jamil M, Feldman S, Shah A, Nauman F, Ferrara J. Neurotoxicity from intrathecal gadolinium administration: Case presentation and brief review. Neurol Clin Pract. 2020 Feb;10(1):e7-e10. doi: 10.1212/CPJ.0000000000000696. PMID: 32190427; PMCID: PMC7057078. Moreira, Alexandra M., et al. "Comparing the effectiveness and safety of dexamethasone, methylprednisolone and betamethasone in lumbar transforaminal epidural steroid injections." Pain physician 27.5 (2024): 341.

🎙️ AnesthesiaExam Podcast & Video Show Notes Spine Pain, Facet Syndromes, and Interventional Concepts for the Anesthesia Boards 🔥 Episode Overview In this episode of the AnesthesiaExam Podcast, David Rosenblum delivers a high-yield, board-focused review of spine pain concepts every anesthesiologist must know: Lumbar, cervical, and thoracic facet-mediated pain Key anatomy and spinal innervation patterns Medial branch blocks and radiofrequency ablation (RFA) Important clinical correlations for anesthesia and pain boards This episode bridges the gap between anesthesiology board knowledge and real-world interventional pain practice. 🧠 Key Topics Covered 🦴 Facet-Mediated Spine Pain Common cause of axial back and neck pain Mechanical pain pattern: Worse with extension Improved with flexion 🔬 High-Yield Anatomy for Boards Dual innervation of facet joints L5–S1 facet → L5 dorsal ramus (classic exam question) C2–3 facet → third occipital nerve 💉 Diagnostic & Interventional Concepts Diagnosis via medial branch blocks (MBB) RFA for longer-term pain relief Understanding procedural anatomy is key for: Regional anesthesia Pain procedures Board exams ⚡ Why This Matters for Anesthesia Boards Even if you don't perform interventional pain procedures, these concepts are critical for: Spine anatomy questions Regional anesthesia understanding Pain management scenarios Oral boards and OSCE-style cases 🎯 Board Prep Takeaways Facet pain = axial, mechanical Dual innervation = high-yield test concept L5 dorsal ramus = commonly tested Understand difference between: Radicular vs axial pain Facet vs discogenic pain 🎓 Anesthesia Board Prep Resources If you're preparing for the ABA Anesthesiology boards, start here: 👉 AnesthesiaExam Board Review Platform: https://nrappain.org 👉 Full Question Bank + Lecture Series: https://nrappain.org 👉 Pain + Anesthesia Integrated Learning: https://painexam.com 🏆 Why Anesthesiologists Choose NRAP Academy Comprehensive ABA anesthesiology board prep Integrated pain + anesthesia curriculum High-yield MCQs and rapid review lectures Ultrasound and regional anesthesia content Real-world clinical correlations 🎤 Live Courses & Advanced Training Enhance your skills beyond the boards: Ultrasound-guided regional anesthesia courses Pain + regenerative medicine workshops Hands-on training for real clinical application 🔗 Connect & Learn More 🌐 NRAP Academy: https://nrappain.org 📚 PainExam: https://painexam.com 🎥 YouTube: NRAP Academy 🎓 Courses: Ultrasound + Regional Anesthesia 📢 Call to Action If you're serious about passing your anesthesia boards and mastering pain + regional techniques: ✅ Subscribe to the AnesthesiaExam Podcast ✅ Join the NRAP Board Review Platform ✅ Explore advanced training courses