• What is chronic pain?
• Overview of your treatment options
• How does spinal cord stimulation work?
• Who is a good candidate for spinal cord stimulation?
• Clinical evidence & patient testimonials
• Insurance coverage
• Q+A with Dr. Hoelzer
welcome everyone thank you all for joining us today if you’re experiencing chronic pain and
are looking for a long-term solution you’re in the right place there will be live q a with dr holzer at
the end of the event to answer any questions you have if at any time during the event you do have a question please
use the q a feature located at the bottom of your screen next slide
before i hand it over to dr holzer i wanted to quickly introduce myself my name is kayla and i’m a team member at
nevro nevro is a medical device company in california and the creator of a chronic pain treatment option called hfx this
helped over 80 000 people worldwide find pain relief next slide
as you listen to the presentation you may wonder where you can find a physician and luckily there are thousands of physicians across the u.s
that offer hfx and will provide instructions on how to find a physician at the end of the event
next slide i’m excited to introduce dr holzer he
practices pain management in the utah area and has taken the time today to answer
your questions and share his expertise about chronic pain and spinal cord stimulation
he’s double board certified has over 19 years of experience in the medical field and served as the director
for the pain medicine fellowship and the director of neuromodulation at the mayo clinic in minnesota he has also authored
over 36 peer reviewed medical articles and book chapters dr holzer’s guiding philosophy is to
view each patient as his own family member listen to his patients and improve not just their pain but all
areas of their life like their ability to work and spend time with family and with that i’ll hand it over to dr
holzer good evening thank you it’s a pleasure
to be here with you tonight and thank you for taking the time out of your life and your schedules to spend a little bit of time with me talking about what i think is an incredibly important topic and one that’s maybe not talked about enough uh in the medical field and
certainly not in our everyday societies uh i appreciate that very warm and
positive introduction as caleb pointed out the majority of my career in medical practice was actually spent in the
academic world where i was involved in education of fellows and i served as a fellowship director
and i was involved also in clinical research and had a lot of research to kind of function and centered around the very topic we’re going to discuss
tonight about four years ago my wife and i decided to make a transition out to the state of utah
where a number of the people in the practice i’m in now have been my former fellow so i had a chance to train them and work with them and so i decided to transition to a place with just a little better weather than minnesota and it’s been a great adventure uh ever
since then tonight i hope you’ll leave this talk with hopefully any question that you
might have regarding the topics we’re discussing will get answered because we have plenty of time at the end for questions and answers and hopefully I’ll add some value to the things that you’re um struggling with right now and give you some what i hope is some hope uh in
the future of potential ways of managing your pain in a better way next slide please
so if you’re sitting there on this on this zoom call or if you spent a good portion of your today day-to-day
feeling like you’re on the sideline and not really participating in life especially the way you always envision
i want you to know that you’re not alone so today i saw i think 33 or 34 patients in my clinic and almost all of them have
a similar story to probably the story that you have i’m not trying to say that you’re not special but you’re not unique
and what i mean by that are there others that are suffering from this problem as you can see from the bottom part of the slide it’s estimated that a minimum of 50 million americans suffer from chronic pain in one form or another and that that number is often considered to be an
underestimate of what the actual number is because some just kind of lose hope and stop seeking any kind of treatment
but if you suffer from chronic pain you find yourself not living the independent life that you want to live not having
dinners trips with your spouse or loved ones and we hear that every day in my practice
next slide what i do want to say is that while you’re not alone you’re also not stuck
and i know you probably feel stuck right now or at least if you’re normal you have felt stuck during this process but
i can tell you that with you can find the right provider and get the right answers to your questions and then have
the problem investigated the correct way there is certainly hope for having an improvement in your everyday life and in
your in your overall pain management and i can think of many many patients that have had felt like they’d run out
of options whether it’s because medications weren’t working anymore or procedures have been tried
that they thought had a lot of hope didn’t end up turning out to give them the relief they wanted or because it started to affect their mood or their
emotion and by intervening with the proper therapy at the proper time they’ve really gotten a lot of that hope
back and so much of their life back and so i hope that while you’re not alone in your pain you’re also going to be part
of this group of people that find relief with some of these newer and exciting treatments that are now available for
patients next slide so tonight we’re going to talk about a
number of topics we’ll talk a little bit about what chronic pain is what the options are for treating it then we’re
going to delve into one of the what i think is one of the more important options that has had some of the most significant improvements over the last
several years and that is the treatment of spinal cord stimulation we’ll talk about who’s a good candidate for that
why i think it’s such a great therapy for patients is it covered by insurance and then more importantly i think we’re
so what is chronic pain or what is pain in general well pain is the way that your
body interprets sensory information acute pain usually means that something is wrong and needs to be fixed chronic
pain is often a situation where while the problem is either resolved or is as good as it’s going to get the body
continues to send those signals of pain and so you think of acute pain as a broken bone or a surgery that you’ve had
or a cri or an acute illness that happens it typically is going to last a short period of time weeks to maybe six weeks
or even a couple of months but then it improves slowly and you get over it chronic pain sadly lasts longer than six
months and continues despite you following the treatments that your doctors have offered
and as i mentioned to begin with many many patients have chronic pain and there are many that thought they were
under an acute pain process then progresses into a chronic pain situation
versus nerve pain and mechanical pain is the things that you think of like bone pain like a fracture or a torn ligament
or torn muscle those are mechanical kind of pains nerve pain is when the nerves
themselves have either become damaged or irritated and then continue to assemble
a signal of pain that is quite different from mechanical pain mechanical pain is
often dull sometimes it’s described as sharp it’s usually localized where nerve pain people use terms like pins and
needles numbness electric sensation burning sensation those are things that give people a clue your doctors and you
as a patient that maybe this is more of a nerve pain process one thing to point out is a pain can
start as a mechanical pain and then turn into a nerve pain and the reason why that is is because the body
acts like an incredible super computer so if the nervous system has been transmitting the signal of pain from
your arthritic knee for a prolonged period of time eventually those nerves just kind of rev up and continue to send
that signal and some of you on this call probably are shaking your head thinking oh yeah that’s exactly what happened to me so it can transition from mechanical to nerve pain next slide when patients have pain that doesn’t go
away with just time and the basic treatment options then we start to look at ways to try and intervene on that
pain and there’s kind of a step fashion to it you can see on this slide step one
are things like over-the-counter medications ibuprofen tylenol the leave those types of things lifestyle changes
maybe modifying your activities stretching exercises physical massage therapy
typically at that point you’ll go in and see a physician who might prescribe physical therapy they may recommend or
perform a nerve block or an epidural steroid injection or a joint injection depending what the problem is
they might try things like a tens unit to try to improve your pain and then there’s other medications that are more
prescription and not all of those are opiate medications things like muscle relaxers or nerve pain medicines like gabapentin
or pregabalin some i’m sure some of the folks that are listening in are on those medications now
and then really when it comes to the medication options the last resort are those opioid medications and that’s
the reason why those are really a last disorder for two reasons one is because many pain that is
many pains that are chronic in nature are neuropathic or nerve driven and research suggests that nerve pain
doesn’t really respond very well to opioid medications and then two uh everyone that listens to the news or
to 60 minutes or to any of those kind of programs know that as an as a society in america we’re in an opioid epidemic or
treating their pain was opioids and so they were prescribed maybe too frequently and as a result patients
became tolerant to them and dependent on them and even in some cases addicted to them and so we try to be very very
careful now with the opioid medications not to say that they’re not potentially an option for patients however there’s
got to be a great deal of caution when prescribing them step three is what i would call the
advanced treatment options and those include things like surgery or pain pumps or spinal cord stimulation which
is where we’re really going to focus a lot of our talk from here on out next slide please
so how does spinal cord stimulation work well it’s best for chronic nerve pain it’s really never used for acute pain
and really it’s not super effective for mechanical pain again i described just a few minutes ago that there could be that
transition between mechanical and nerve-based pain and in those situations it might be just the right thing to do
essentially what spinal cord stimulation is is it delivers an electrical impulse to the spinal cord to change the
signsling of pain in the spine and particularly chronic pain the way i describe it when i’m sitting
of a pacemaker well a pacemaker uses electrical impulses to control the way
the heart is beating a spinal cord stimulator is based on similar technology it’s not the same technology
but it’s a similar technology but it uses electronic electrical signaling to
pace the signaling in the spinal cord to change that pain pathway so that the patient doesn’t suffer from that pain
anymore next slide so who’s a good candidate we just
mentioned before that nerve pain is really the pain that responds to it best however you may be unsure and your clinician may
be unsure whether or not what component of your campaign is mechanical and what component is nerve driven there’s not a
really clear study to figure that out so sometimes it takes a little bit of thought and asking the right questions
and even what i call a trial that we’ll get to in a moment to help figure that out the pain really should have been present
for more than six months if it’s been under six months things to try to get it to go away are more the approach to take
if it’s located in the back the trunk or the limbs those are areas that respond well to spinal cord stimulation
and if you’re still having pain after trying other things then spinal cord stimulation is really an excellent
treatment option and you can see the graph or the picture to the right showing a lot of different areas that
have been successfully treated with spinal cord stimulation next slide
so who’s not a good candidate that’s always important to point out well i just said if you haven’t had pain for
more than six months your focus should not be on spinal cord stimulation i’m guessing if you join this call in the
evening and you’re taking time away from your family and loved ones your pains probably lasted longer than six months
or you would have taken the time to be on this call if your pain is primarily bone or tissue
or muscle pain or cancer pain although there are cancer patients that i treat
with spinal cord stimulation and we can get into that later on um if your pain is recent or from a
strain it’s really not a good idea to do stimulation or if it’s really arthritis related or
fibromyalgia related those are pain processes particularly the fibromyalgia that doesn’t really seem to respond well
to spinal cord stimulation now that doesn’t mean it’s not a real problem and there are many people that suffer from fibromyalgia we just need to do a better jobs healthcare providers are figuring out ways of treating that and at this point spinal cord stimulation we still
haven’t quite figured out how best to apply it to that particular disease state next slide
so what is spinal cord stimulation i already kind of mentioned the fact that it’s an electrical impulse that changes
the signaling in the spine it’s actually been around for a long long time it was developed in the 1960s it’s interesting
because i just said on the slide before that it was it’s not really used for cancer pain well the first patient that had spinal cord stimulation applied to
him actually were suffering from cancer pain that was causing compression of nerves so it can be applied in that way
but it’s just not the typical way traditionally it used a paresthesia technique which means the electrical
impulse in the spine stimulated the nerves in such a way that the patient experienced a pleasant warm tingling sensation in
the air that they used to have pain so if they used to have pain kind of along their right leg on the outside part of it the goal of the stimulation was to
replace that with a tingling sensation historically spinal cord stimulation has
made it very difficult for patients to get mris and many of the battery systems that were older were non-rechargeable so
they had to be replaced in a somewhat frequent manner of course over the course of the last 20 years just like
your cell phone has gotten smaller and smaller and more sophisticated the spinal cord
stimulation systems have gotten smaller more sophisticated and have become
really made really great improvements in 2015
the entire field of spinal cord stimulation was turned on its head for 30 years spinal cord simulation was
done in a certain way with a certain goal and that goal was to create a tingling sensation where the pain was at
and that was all we really had and then in 2015 uh studies began to be done on
high frequency stimulation a way that was it would cause stimulation in such a way that patients actually didn’t experience any of that tingling
sensation where the pain was out they just received the pain relief in addition these newer stimulation systems
were mri compatible or conditional which means if the conditions are right they can still get an mri and the batteries
became smaller and rechargeable where now they could last 12 years 10 plus years for many of them and some of them
12 or 15 years so really great advancements in order to help patients better manage their pain
next slide there are about four companies currently
that have commercially available spinal cord stimulations of which nevro which provides the hfx stimulator
is one of several so if you’ve researched this at all hopefully you’ve looked into these companies some and
looked at what the potential benefits and maybe downsides of these different systems are one thing i’ll
point out is that i mentioned that in 2015 the fda approved this new way of doing stimulation where the frequency of
the stimulation had always been somewhere between 30 and 150 was the standard frequency
and they started studying 10 000 as the frequency and found that it was more
effective in treating pain and that was a proprietary way of doing stimulation and so there’s only really one company that can
offer that high frequency or 10 000 kilohertz um stimulation and that’s the nevro system
with hfx that you can see on the slide there but what’s nice about it is it also allows for the low frequency or the
older way of doing stimulation to be paired with it so it just gives patients the most options as far as programming
goes and trying to manage their pain better i tell patients that if they’re looking into a spinal cord
stimulation stimulator they would be wise to do a couple of things one research what the differences are in the
systems and then two ask your clinician or ask yourself well what is the data
and what i’ll tell you is that the largest studies that have been done on spinal cord stimulation comparing it to
other treatment options and comparing it to other ways of doing stimulation have been done with
hfx with high frequency stimulation and it’s shown superior outcomes so if you want to be data driven if you want to
use what we call medical evidence then the nevro has that medical evidence which i think is really important
because we want to improve the field by offering more options for patients
next slide so here are some of the reasons why people might choose high frequency
stimulation well one it’s been around for a long time it’s been proven to help patients there’s been remarkable
advancements in the last 10 years that have made that treatment even better it’s a drug free option and we know that
every medication that we offer patients has some sort of side effect and it’s just a matter of trying to find
medicines that maybe have enough benefit to outweigh those side effects and so if we can find drug-free options that can
be a great thing i was involved in a study that looked at spinal cord stimulation and we found that in our
patients the majority of patients came off somewhere between 60 and 80 percent of
their medications after undergoing a spinal cord stimulator implant which tells me that then they were free from
those side effects they were free from all those doctors visits from the constipation from the clouded mind so
that’s really an important thing one of the key things that i love about spinal cord stimulation
is it’s one of the few things in medicine that you get to try it before you buy it so to speak what i mean by
that is say you’ve had back surgery before and you have continued problems and
you’re thinking about maybe getting another back surgery well if you decide to do that you’re you’re going to go to sleep under anesthesia and you’re going to wake up from that back surgery and you’ve got what you’ve got what i mean by that is if you’re better great if you’re not better that’s a possibility and if you’re worse that’s also a possibility well with spinal cord stimulation before you ever go undergo
the implant you can undergo a trial of that what that means is you come into the office or the surgical center depending
on where your doctor performs these tests and under x-ray guidance they can place
those needles are then removed and those electrodes are just left in place and they’re just taped in place kind of like an iv would be so the treatment portion of it is in the spinal area but the electrodes come out of the skin and are just taped into place and you get to
test it out for about a week and so you really get an opportunity to see what kind of improvement do i get in my pain
am i taking less medications am i more active am i sleeping better you get a chance to really see if i undergo this
implant how’s my life going to actually be different and how’s it going to be better because of the spinal cord stimulator so i love it because
i don’t ever have to convince a patient to do this and in fact one of the things that i find uh interesting is that
sometimes a patient will maybe be a little unsure about doing the trial to start with and so we’ll kind of work through their questions we’ll do the
trial and they’ll finish the trial and they’ve had such great relief that they’ll want me to schedule the implant right away
and i thought well it’s going to take me you know a few weeks to get things situated and they’re kind of annoyed because they’ve had such great pain
relief they want it back right away and i always know that that’s a great sign that when we do the permanent implant they’re going to do really really well but i kind of chuckle a little bit in my mind because i sort of had to convince them to do the test and now they’re sort of mad at me that i can’t do the permanent one fast enough for them but we always try to do everything we can to get them in and get taken care of as quickly as possible
and of course this what we’re talking about is safe and fda approved and clinically proven
to be effective for patients and that’s important next slide
so i just talked about clinically proven and i talked about the data that we’re looking at here as far as when you’re
picking a system how do you know the right system so if you look at this this was done from a large national study uh and i can
still remember when this data was first reported it was a very exciting time in our field because up until then
generally speaking people felt that spinal cord stimulation was good at treating leg pain but not back pain so
often when i saw a patient if most of their pain was in their back but not their leg i would tell them well you might not be a great candidate for this
therapy well this new way of doing stimulation with this 10 kilohertz or hfx actually showed that you could treat
back pain as you see on the slide quite effectively and you could treat leg pain quite effectively and in fact in this
study it wasn’t just that they used hfx half of the patients got hfx half of the
patients got the old way of doing spinal cord stimulation and the ones who had the new way of doing it the hfx by far
did better so it was really an exciting study for us to review next slide
and you can kind of see that here on this slide here that the traditional stimulation we always knew it was
helpful to patients we were doing it and you can see that it was about a little less than 50 improvement where with um
hfx we saw a much better improvement rate and patients were very happy with that next slide
so here are the goals of spinal cord stimulation more independence improve sleep improve quality of life and improve
social life because you can interact you can go to that that birthday party you can go to that grandchild’s baseball game you can do
lot of pain and you don’t want to be caught outside of the house in a difficult spot as far as pain goes well
with spinal cord stimulation the hope is to give you that freedom again where you can go out and do those things next slide
so what’s the process if you if you’re sitting here listening and you think well maybe this is for me then then
there is a process to it the first thing is that you need to meet with a pain management physician
who’s experienced in spinal cord stimulation and particularly utilizing the hfx
system and and treating patients once you’ve done that and by the way at the end of this you’ll see that
there’s websites that you can go to to find those positions they’re not hard to find and we can make sure you get into the
kind of people that have the experience needed to help you once you’ve done that then you go through that temporary trial that i
talked about the testing of the spinal cord stimulator it’s generally five to seven days on that the typical is seven
days occasionally we’ll see a patient that’s doing just so great after five days it seems silly to continue to do
the stimulation trial um it’s a quick simple thing to do and then you can move forward with the
permanent implant depending on how you did the permanent implant is usually done in a surgical center
it doesn’t typically require a general anesthetic it’s done under sedation there are two small incisions that are
made but those those are just made so that the components that are used for the stimulation can go under the skin so no
muscle is cut no bone is cut and your anatomy isn’t changed so one of the things i love about this is it’s
completely reversible so say you did this and for some reason it just didn’t give you the relief you needed which is
which is rare but could happen unlike almost any other surgery you can go back and take those components out
and the person’s body is just how it was before because the bone and muscles stay completely intact for this procedure
next slide so this is kind of what the system looks like and i actually have one of the
batteries here that i kind of show to my patients you can see this is the battery that goes kind of under the skin and the flank that powers the system it’s really silver dollar about three silver dollars stacked on top of each other and that’s the size of it the electrodes are very
malleable soft electrodes the ones placed in the the spinal area have the ability to move with the spine and not
really irritate the area at all after it’s healed in next slide
so there’s questions that often come up with these devices when i’m first talking to patients about them one is
can it be turned off and the answer is yes you actually have a controller you can turn it off and on and even change
some of your programming after you’re after the folks that are in uh responsible some of the programming have
locked in some programming options for you you can fly with this system in you can swim in fact i had somebody that was on
a swim team actually going back to flying i had a patient that was a commercial pilot for a major airline
that had actually not been able to fly for a period of time because he’d been in a pretty horrific accident that caused very severe chronic pain uh and
as a result of that very severe chronic pain he was actually on a number of medications that then made it so that he could not be a commercial
pilot so of course he came to me this was when i was at mayo so he came from a long distance away across the country to
see us and we were able to do a spinal cord stimulator for him and within about two months he was off of all of his medications he had completely normal nerve function restored and so he was able to pass all of the tests with the faa and so not only can you fly you can
actually be a pilot with this not that if you’re not a pilot yet i’m not saying that uh but you can actually get back to
the things you want to do and yes you can have an mri with this device anywhere in your body including your
spine ct scans are never a problem next slide
almost all and really all insurance companies cover this procedure some cover it for very specific conditions
and so you have to work with your doctor to be certain that you are that you that you qualify under those conditions but
that’s something that we do every day uh and even medicaid policies and workmen comps with the exception of washington
cover this this therapy for treating pain because it’s been proven to be helpful and is really a minimally
invasive way of giving people their function back and freeing them from some of their medication burden
next slide so when should you talk to your doctor
about spinal cord stimulation well i always tell people it’s very easy to decide if you want to go on with the
procedure if you have pain in your life that’s a nuisance like it bothers you but it doesn’t keep you from doing the
things you need to do it doesn’t keep you from sleeping it doesn’t keep you from working it doesn’t keep you from being active the way you want to be
active from going to the different social events you want to go to if it’s not keeping you from doing those things
then you should just continue to let it be a nuisance in your life but the minute the pain becomes so problematic that it’s keeping you from doing those important things whether it’s sleep or activities or social things or exercise
then that’s when you should start to say well maybe this is a therapy that could help me get those things back
your pain regardless of what path you go down for treating your pain just a couple of things you want to be specific
talk to them about where the pain is where it radiates from there what things make it worse you want
to use those descriptive terms like is it sharp is it stabbing is it burning is it electrical because that helps the
doctor or the clinician figure out maybe what the source is making comparisons can be helpful
because that helps the your clinician kind of think about what area in the body it
might be affecting and just how severe the pain is and then you want to give details about how it affects your life
what kind of functional problems does it cause when is it worse what things make it better
what the progress is in other words if i see a patient and they say you know i’ve had pain for 20 years my question for
them is okay well why are you here now what’s different about it has it become more constant has it become more intense
what what’s changing in a way that makes you worried and needing to get some additional care for that
and then of course you’ll want to make sure they know your treatments and you’ll be surprised a lot of patients
will come in and say well you know i had i had some injections well there are a number of different injection things
that can be done for pain and so if you can have detailed records of those of the dates they were done what exactly
was done and what the outcome was on a paper for your physician that will speed that process along because then
they won’t start reinventing the will they won’t go back to things that have already been tried that weren’t helpful
and that will move you along the pathway of something that might be helpful to you next slide
back on and we’re gonna start to work on some of those questions that some of you have thank you dr holzer for sharing your
knowledge and expertise with us so like dr holzer said we now like to open the floor to the audience answer any
questions you have about chronic pain spinal cord stimulation and hfx go ahead and just use the q a feature located in
the bottom right corner of the screen to ask your question and we will get started
okay dr holzer so we have an attendee here who was wondering what a tens unit is and how is that different
to hfx you know that’s an awesome question you’ve ever asked that question because i get asked that question
probably eight times a week in my clinic a tens unit strength stands for
transcutaneous electrical nerve stimulation the end part of it that nerve
stimulation is a little bit of a isn’t really proven as far as what it does
what it is is you place pads on the area that hurts and it gives electrical impulses to the superficial structures
so it doesn’t truly stimulate nerves necessarily it stimulates the skin and it stimulates the muscles that are
just slightly deep to the skin the reason why it’s um sometimes patients will say well if i do the tens
unit and it helped does that mean spinal cord stimulation is going to help or they’ll ask me the opposite if i did a
tens unit and it didn’t help does that mean a spinal cord stimulator won’t help and they’re actually completely
different therapies with a completely different target you have to remember that the tens unit goes on top of the skin
and the skin is one of the greatest impedances to electrical current that we know of in other words our bodies are
designed to not let electrical current in or electrical current out and so when you apply a tension it really is only
stimulating the superficial structures and maybe the most superficial nerves it can help kind of as a distractor for
pain and so if you’ll think back to the time that you hurt your you know you got an owie when you were a kid and your mom
said well do you want me to kiss it better or she would rub it better well the way that was working was by stimulating some of those what we call
proprioceptive nerves or those nerves of of gentle stimulation along the hand because that helps block some of the
pain signal and that’s probably what a tens unit is doing it might also cause a
little bit of release of like neurotransmitters that help with local inflammation but it’s not actually causing an effect
at the spinal cord level where most of pain is processed and that’s the big difference is that spinal cord
stimulation is targeting that what we call the the central station of pain processing where the tens unit is more
of a distractor on the skin it can be helpful and i talk to patients about them all the time but it’s just not
quite as potent we have an attendee here and they’re experiencing pain in two different
locations and they’re wondering if hfx can relieve both areas of pain
so great another great question and one that i get asked quite a bit my clinics it so it’s like you guys are all my patients here i love it
so the answer to that is generally when i talk to a patient it depends on how spread out that pain is in other words
if somebody says you know doc i’ve got pain in my back and in my knee my low back and my knee that’s very easy to treat with hfx if
they say well really my pain doctor is in my knee and in my shoulder well those are two different regions that require
stimulation in different areas of the spine they still both can be treated with hfx it just changes the process
so if the areas are in the same region so in other words what i mean by that is below the waist
or kind of mid-body up then then absolutely the answer is yes
they can be treated if there are more than one region i ask the patient to try to focus in on
which area is most problematic to them and we will focus the trial to test on
that area once we know we can cover the pain in that area we can often still treat both
however you don’t want to miss a spot first so you always want to make sure you’re honed in on the most most
problematic area first to make sure you’re treating it so the quick answer to that is yes you can treat more than
one area it’s easy it’s easier if they’re in the same region but even if they’re in different regions it can be
done it just adds a little complexity to the procedure in the case we have a few questions here about the
type of pain that hfx could help so i’ll start with um does hfx help neck pain
yes again what that neck pain is from matters so if it’s more of a disc focused pain or a
nerve irritation pain then yes for sure and in fact nevro was one of the first
companies to do studies on neck pain and stimulation and there’s some very interesting studies that came
out about that if the pain is primarily arthritic in nature or muscle related which can be
problems in the neck that it’s not going to be quite as effective so it takes a little bit of teasing it out but the
answer is yes and then when you’re saying like arthritic we have a patient here who’s
wondering if uh hff could help with osteoarthritis
so when people say arthritis or when i say arthritic pain 90 of that is osteoarthritis there are
other forms of arthritis like the most the second most common being rheumatoid arthritis and the quick answer to that
is it’s generally not helpful for osteoarthritis with some caveats in
other words where is that osteoarthritis and what are some of the aspects of that
osteoarthritis so i mentioned at the beginning of my talk of where patients have pain in their knee for a long time
and the body starts to develop sort of a hypersensitivity to that knee arthritis and starts to ramp up or amplify that
signal which is what the body does in that case then that situation may be treated by spinal cord stimulation but if it’s
still primarily just a mechanical pain then stimulation usually isn’t helpful
for osteoarthritis so that situation really requires the doctor to kind of tease through some things
the other caveat to that is patients are often told oh you have osteoarthritis in your spine
well it’s rare to see a patient who has only osteoarthritis in their spine it’s a generic way for doctors and
radiologists to sort of describe hey there’s a problem there but typically if somebody has arthritis in their spine
they also typically also have disc degeneration and neural for animal stenosis and other
things going on that do respond to spinal cord stimulation
would hfx help with painful diabetic neuropathy
yes in fact one of the best studies ever done on diabetic neuropathy was just published
this last year and the fda just approved hfx4 diabetic peripheral neuropathy in
fact it’s one of the things that i’m the most excited about treating patients for because up until now the only option for
those patients were a handful of different medications the studies that have just come out on this hf x10 for diabetic neuropathy are
really quite compelling not just from a pain relief component but many of the patients in this study actually had an
feel the bottom of their feet their feet better which made it so they could be more active so not only are we finding that hfx is helpful for the pain related to diabetic neuropathy but we’re also finding this actually improves the neurologic
problem that’s associated with diabetic neuropathy which to me is incredibly interesting and is actually right now
being studied more does hfx help with si joint pain
probably not so again si joint pain is a complex process
and is sometimes misdiagnosed if the pain is truly just pure si pain which
can happen then typically hfx is not helpful for it if there is a mixed pain pattern of s-i
pain along with some nerve issues which is also common then it can be helpful
which is why if it’s unclear which it often is the trial of stimulation can be so
valuable because if you do the test trial and it’s very helpful then that tells you that it’s a mixed pain pattern
and will respond if you do the trial and it doesn’t help then that tells you really it’s a mechanical pain that has
to be addressed in another manner does hfx help with conditions like
degenerative disc disease and degenerative faucets
so degenerative facet disease is like si pain and what i mean by that that’s
exactly the heart of what i’m getting at with that osteoarthritis so if it’s purely just an
arthritic pain probably not but the spine functions in a very dynamic manner and so if there’s
arthritic pain there’s often also other dynamics in the spine that are off that spinal stimulation can help with
particularly degenerative disc disease so we know that in degenerative disc disease conditions depending on where
the disc is and what kind of pain processing it’s doing spinal cord stimulation can be helpful to those patients
and what about herniated discs yeah so absolutely so by definition a
herniated disc is a nerve related problem and so that’s that cause
herniated disc causes nerve irritation so it’s a nerve pain certainly you’ll want to have a a
some so it’s not causing nerve irritation or compression anymore but it it is helpful to that for sure
we’ve got a few more just kind of helping you know attendees understand it could potentially work for them what
about spinal stenosis yes so there are a number of treatment options for spinal stenosis some of
which are more invasive and more surgically related like a decompression surgery or a fusion
surgery however spinal cord stimulation can help with spinal stenosis because by
definition spinal stenosis is a condition where the nerves are getting irritated and if you can
change some of that pattern of irritation then you can have an improvement in their symptoms patients can stand longer
and walk longer that’s another one and you’re hearing me say this often that needs to be carefully evaluated by the
doctor because you need to look and see what’s causing the spinal stenosis there’s different types of spinal stenosis how many levels are involved in
this spinal stenosis because that helps derive what the decision might be for treating it but spinal cord stimulation is one of
the treatment options i may not pronounce this right but would
hfx help with moralia parasites
mirage of parasitica or lateral femoral cutaneous neuralgia is helped by spinal cord stimulation so
that’s a nerve entrapment syndrome for those that are kind of wondering what just what word they just heard that’s a
nerve entrapment syndrome that happens in the anterior hip that causes a numbness and burning
sensation down the anterior lateral thigh so it kind of mimics like what a herniated disc might look like in the
back it can be very difficult to treat but yes spinal cord stimulation can
capture that pain and be quite effective at treating it we have an attendee who’s wondering um
if a spinal cord stimulation can help with improving sensations for example they’re experiencing weakness does it
help with any sensations so the first study we had that showed it
can help with the neurological exam was that one that was published in july on the diabetic peripheral neuropathy and
in those patients it was helpful to some of their numbness and tingling and to
some of their ability to fill and perceive where their feet were at which is very hard for a diabetic
neuropathy patient to do that doesn’t necessarily correlate to all nerve conditions because all the
studies haven’t been done and we haven’t had any evidence to date that shows that it helps with weakness what i will say
is i’ve seen many patients that have had an improvement in their weakness and it depends on what’s causing the weakness
so pain can become so severe that the body starts to develop weakness because the limit the limb or extremity or foot
isn’t being used properly or because the body processes that pain in such a way that it starts to develop a weakness type of
sensation but it’s not a true motor problem a motor neuron problem so in those situations if you do
stimulation where you then improve the pain the weakness can improve if it’s truly a damaged motor neuron
that’s not just being weakened because of pain then it may not help that weakness
and tani’s kind of wondering what does are there any restrictions what does the recovery look like like are they able to
still kind of go about their day and go to work if they’re trying hfx yes so
the electrodes come sticking out the skin and the way i describe it to my patients there is it’s a little bit like an iv coming out of the arm like you
tape it into place and you can kind of forget about it so it’s covered up and so it is there you we want you to
try to keep that area dry and clean so it limits some of your showering and soaking in tub options you can’t soak in
a tub you have to kind of do a sponge bath during that time or or something that allows you to keep that back
part of your back dry and clean and intact but other than that the restrictions are
go live your life that’s actually what we want to do we want you to go to work we want you to do activities that you normally are having a hard time doing so that you can get a sense for what the system will do the worst trial in the world would be the patient that came back to me and
said well doc i’m not sure because i actually just decided to take it easy this whole week and i didn’t do any of the things that normally bother me
because we actually want you to test it out and figure out what’s different one thing that’s kind of nice about this trial is i also i try really hard
to engage loved ones because they often can see the way you’re doing things different because of your pain
so sometimes it’ll actually be the spouse that’ll come in and say oh my gosh they’re standing straighter they’re walking better they’re moving more kind of fluidly or smoothly than they used to move not quite so tense and jagged and so it’s kind of interesting sometimes
you get a loved one’s perspective because they see it from a perspective that you don’t see as the patient
and how long is it typically between the trial and the implant often will depend on your
uh your physician’s schedule and their access to a surgical center i tell my
patients that i like it to be about two weeks between because there’s always the biggest risk with
this procedure is infection and the infection rates are very very low but nobody wants to have an infection and of
course right that i guess i shouldn’t even have to say that but the worry is is that if you’ve pierced the skin with
the trial electrodes and then taken them out well that you’ve caused a little bit of loss of integrity in that skin and so
i like to have a little bit of time for that area to heal up to make sure the body has handled any kind of bacteria that may have been there so that when we go into the permanent implant we’re not into a situation where the area is irritated or inflamed at all so about
two weeks but it can be six weeks or longer if you have to go through you know an
insurance process and then get listed at the surgical center and then say that date’s full so there’s there’s some
some subtleties there with just getting it on the schedule that can make it a little bit of a difference so no sooner than 10 to 14 days and
hopefully no later than four to six weeks depending on some of those scheduling conflicts that might come up
and then for the implants we have an attendee who’s wondering what kind of activity restrictions are there so first
short term you know after the implant procedure and then is there anything long term that they need to be aware of
so the recovery afterwards is usually pretty simple it’s not a big deal like i
mentioned it’s an outpatient procedure it takes about an hour to two hours depending on the process uh
and frankly your doctor’s experience and things with it the main goal in the initial recovery
art is there’s two main goals one is to get your incisions to heal up in a nice way and two is to have those electrodes
kind of what we call scar in or adhere in so they won’t move in the future
so the restrictions i give my patients are they can’t shower for 72 hours afterwards while we let those incisions
heal even after those incisions chilled we don’t want them to soak in a pool or tub
or hot tub for 30 days after because again we just want to be certain that we have a perfectly healed incision
in addition i tell them for about six weeks after four to six weeks i want them to be careful with their body that
doesn’t mean they can’t do things they can be out walking they could do the elliptical for example but what i’m asking them to do is avoid any extreme twisting or bending so we don’t want them to just bend straight down to the ground to pick something up we don’t want them to reach way above their head to get something out of the cupboard and we try to have them restrict to about 10 pounds of weight carrying because we
don’t want them to strain their back where those electrodes are healing into place
we have an attendee here who’s on pain medications and they’re wondering if you’ve seen any of your patients with
hfx reduce their pain medications the majority do in fact that’s the goal that’s one of the goals i have with them
is i tell my listen i don’t know what’s going to happen but my hope is is that we can reduce your
the pain medications that you’re taking to a much lower dose or maybe not even at all if that’s possible and and my
experience is about half the patients are able to come off their medications altogether
about a fourth of the patients are able to significantly reduce their medications
and about a fourth of them stay on about the same dose as they were on yet they have better function and better pain
improvement so they’re in a better spot but they still need some medications
and we have an attendee here who they’ve actually tried a simulator before so they’re kind of wondering would this
even be an option for them yeah so absolutely in fact this is a whole
different way of doing stimulation and in fact it used to be that insurance companies many of them would say
your insurance policy will allow you to try stimulation one time and then after that you can’t do it again
well when this new way of doing the stimulation came out most of the insurance companies revised their policy to say well
if they’ve tried the old way of doing stimulation and didn’t have a good response to it they can actually still
try this one because it’s a whole different mechanism of action a whole different way of doing the procedure so
absolutely and then we have i know we did brush on insurance so we do have a few questions
here about insurance so one attendee is wondering if medicare covers spinal cord stimulation
absolutely yep they do and what about the va if they have
tricare and they go to their local veterans affairs yes usually they do it typically
requires um going through a couple of checking the right boxes and jumping through a few hoops but generally speaking the answer
to that is yes they do and then circling back to the attendee who’s had um
a you know more traditional spinal cord simulator they’re kind of wondering you know they just want you to go over like what is the difference again like why even you know try if they’ve it’s failed them before so that’s a great question and first off
i would always and i would say this to any patient that i’m seeing everyone is individual so i tell every
patient that i’m approaching you as what i call a study of one like in other words let’s see what’s going to work for you so i can’t tell any patient oh you failed this other stimulator from brand x you’re absolutely going to do better with this new stimulator we don’t know
that until we try but it’s a different mechanism of action that’s actually been shown and to not
get into too many big details by stimulating at a higher frequency you’re actually affecting different
neurons in the spine than this this traditional stimulation now i did mention that you can actually do both
kinds with the nevro system but high frequency or hfx or the 10 000 kilohertz actually
causes a different stimulation of different neurons than traditional stimulation so it’s a different process
or target altogether and just an example i have right now there was a patient that came to me that was actually referred to
me by another pain doctor that does spinal cord stimulation that patient had actually had two other spinal cord stimulators both of
which had failed but it was sort of at his wit’s end he said boy i just don’t know what else to do and so he came to me specifically
for a trial of this kind of stimulation and i said to him i said well golly you have failed two other stimulators i’m
absolutely willing to try but it might work and it might not now he’s out he’s been implanted now for a number of
months and is doing really really really well so he’s thrilled that i was willing to try uh but that’s just one patient
that doesn’t mean that’s going to be you but to try it would be a reasonable thing to do
and um circling back so one of the attendees thanks you for your answer about the long term or the short
term restrictions but they’re kind of wondering is there anything in the long term like oh yeah you asked them and they yeah
it’s okay like can they die like they’re just kind of curious to see you know is there anything to look out for no you can the restrictions are very
minimal once the thing is healed into place at six weeks at that point the number one risk is what we call lead
migration so i’m just i’m gonna use my little pen here to show you the leads placed here and something happens and it
moves a little bit up or it moves a little bit down that’s not dangerous when that happens but the patient may not have the same pain control anymore it’s fixed quite simply by getting an updated x-ray seeing where it’s moved and adjusting the programming because
each of those electrodes have eight separate contacts that can be programmed so if it moves a little bit you can actually reprogram it and be in a great
spot again so that’s the biggest risk but once it’s healed in that risk is very very low and so i tell
patients we want you to do things so i’ve had patients that are on the competitive swimmers that are doing flip
turns now if you know what a flip turn is that means you kind of bend at 90 degrees in an extreme way and flip your legs over and push off the wall well there’s not a lot that’s more stressful as far as on the spine than a flip turn but they were back
competitively swimming and doing flip turns i i made them wait a little longer than the six weeks because i wanted to
be sure there are people that have very manual labor jobs painting and construction that that do those jobs
with the spinal cord stimulator and so there’s really not many restrictions you can swim you can hot tub you could
skydive you could uh any hobby you could think of you could do with a spinal cord stimulator in
all right we are coming up at the hour and i think that that’s a great way to end the the lightning round of questions
so thank you dr holzer for answering all those really great questions today and thank you to the audience for your
participation before we end i do want to share some resources and next steps for everyone on this call
next slide please so there are resources available for you if you’re interested in learning more on
nevrohfx.com this is a great place to start your research you can learn more about how hfx works to manage your pain
you can find out more information about spinal cord simulation i also recommend visiting the patient stories section to
hear from people who use hfx to see what their experience has been like next slide
or if you’re ready to take the next step there’s two things you can do first you can see if you’re a candidate for hfx by
taking a short questionnaire on our website and if you provide your phone number we’ll personally assign a hfx
coach who can answer any more questions you have and help you find a physician in your area or if you’d like to talk to a physician
sooner you can use our position finder tool to find a position offering hfx near you dr holzer is in the provo area
of utah and is listed on our position finder if you’d like to see him and we’ll send you these tools in an
email after the event again thank you everyone on the call and thank you dr holzer for your time today
i hope you enjoyed the event and have a great rest of your evening good night everyone take care you