AnesthesiaExam Podcast

What is Kratom? Effects, Side Effects and Benefits in Pain Reduction

🎙️ PainExam Podcast Show Notes Kratom (Mitragyna speciosa): What Pain Physicians Must Know for the Boards In this episode, Dr. David Rosenblum reviews the current science, pharmacology, risks, and clinical relevance of Kratom — an herbal substance widely discussed by pain patients and increasingly appearing on pain-medicine board exams. The discussion focuses on evidence-based mechanisms, safety considerations, and counseling points essential for ABA/ABPM/ABIPP/FIPP board preparation. 🔍 Key Board-Relevant Takeaways 1. Pharmacology & Mechanism * Kratom's primary alkaloids are mitragynine and 7-hydroxymitragynine. * They act as partial mu-opioid receptor agonists and demonstrate G-protein biased signaling, which may reduce β-arrestin–mediated respiratory depression seen with full opioids. * No FDA-approved medical use; pharmacokinetics and dose-response remain inconsistent. 2. Reported Effects Potential Benefits (mostly anecdotal or preclinical): * Analgesia for chronic pain * Mood elevation and increased energy * Reduction of opioid withdrawal symptoms Major Limitations: * No high-quality randomized controlled trials * Not a recommended analgesic for evidence-based pain practice 3. Adverse Effects & Safety Concerns Commonly reported: * Nausea, vomiting, constipation * Tachycardia, palpitations * Hepatotoxicity in some users * Dependence and withdrawal syndrome similar to mild-moderate opioid withdrawal Serious risks: * Product variability and contamination * Potential interactions with CNS depressants * Unpredictable potency of alkaloids 4. Regulatory Status * Kratom is unregulated, with significant variability in purity and composition. * FDA and multiple public-health agencies caution against its use due to safety concerns. * Not recommended as a first-line or adjunct pain therapy. 5. What Boards Like to Test Expect questions on: * Mechanism: partial MOR agonist, G-protein bias * Differences from classical opioids * Adverse effects and withdrawal * Toxicology and contamination risks * Counseling patients who self-medicate * Lack of clinical trial data and regulatory approval 🎓 Board Prep Resources Prepare for the ABA, ABPM, ABIPP, FIPP, and AOBPM exams with the PainExam Board Review and full curriculum at the NRAP Academy: 👉 https://www.NRAPpain.org [https://www.nrappain.org/] 🫁 Hands-On Ultrasound Training for Pain Physicians Boost your procedural skills with live ultrasound-guided interventional pain and regional anesthesia workshops: 👉 https://www.nrappain.org/pages/ultrasound-training [https://www.nrappain.org/pages/ultrasound-training] 📚 References (Condensed) * Kruegel AC, Grundmann O. Neuropharmacology of kratom alkaloids. Neuropharmacology. * Eastlack SC et al. Kratom: Pharmacology & clinical implications. Phytother Res. * Striley CW et al. Health effects of kratom. Front Pharmacol. * FDA Public Health Advisory on Kratom. Educational Offerings & Learning Opportunities PainExam / NRAP Academy Training & Programs: * Neuromodulation & Regional Anesthesia Workshops * Ultrasound-Guided Pain Procedures * Regenerative Pain Medicine Training * Virtual Pain Fellowship * Pain Management Board Review & Question Banks Learn More / Register: 🔹 https://PainExam.com [https://painexam.com/] 🔹 https://NRAPpain.org [https://nrappain.org/] Board Prep & Certification Support Prepare for: * ABA Pain Boards * ABPM * ABIPP * Pain Management Board Certification Exams * (No reference to FIPP included, per request) Access Board Prep Courses & Q-Banks: ➡️ https://PainExam.com [https://painexam.com/] ➡️ https://NRAPpain.org [https://nrappain.org/] Clinical Practice AABP Integrative Pain Care (Brooklyn & Great Neck, NY) To schedule a consultation or referral: 🌐 https://AABPpain.com [https://aabppain.com/] 📞 Brooklyn: 718-436-7246 About the Host – David Rosenblum, MD Dr. Rosenblum serves as Director of Pain Management at Maimonides Medical Center and Managing Partner at AABP Integrative Pain Care in Brooklyn, NY. He is recognized as an early adopter and leading educator in ultrasound-guided pain procedures, neuromodulation, and regenerative medicine. He has: * Developed regional anesthesia training programs * Published widely in pain medicine literature * Lectured nationally and internationally through ASIPP, ASPN, NANS, IASP, and more * Helped over 3000 physicians pass pain board exams * Hosted the PainExam, AnesthesiaExam, and PMRExam podcasts Awards (Selected): * New York Magazine Top Doctors: 2016–2025 * Top Doctors NY Metro Area: 2016–2025 * Schneps Media Honors: Multiple Years Connect with Dr. Rosenblum * LinkedIn: https://www.linkedin.com/in/davidrosenblummd/ [https://www.linkedin.com/in/davidrosenblummd/] * Instagram: https://www.instagram.com/painexam/ [https://www.instagram.com/painexam/] * Facebook: https://www.facebook.com/david.rosenblum.16 [https://www.facebook.com/david.rosenblum.16] * X (Twitter): https://x.com/AlgoSonic [https://x.com/AlgoSonic] Episode Call-to-Action ✅ Join the NRAP Community ✅ Register for an Upcoming Workshop ✅ Access Pain Board Review Training Start here → https://NRAPpain.org [https://nrappain.org/] | https://PainExam.com [https://painexam.com/]

Caudal Epidural Steroid Injeciton with PRP

Caudal Epidural Steroid Injection with PRP Case Reports and a Testimonial! Upcoming Training Courses and Services * Regional Anesthesia [https://www.eventbrite.com/cc/ultrasound-guided-regional-anesthesia-pain-med-351559?utm-campaign=social&utm-content=creatorshare&utm-medium=discovery&utm-term=odclsxcollection&utm-source=cp&aff=escb] and IV Vascular Access Courses [https://www.eventbrite.com/cc/ultrasound-guided-iv-access-courses-3322109?utm-campaign=social&utm-content=creatorshare&utm-medium=discovery&utm-term=odclsxcollection&utm-source=cp&aff=escb]: * New York and Detroit locations scheduled * Pain Management Board Preparation [https://www.nrappain.org] Private Coaching Services: * Ultrasound guidance Preceptorship * Board preparation coaching * Contact available via email Info@NRAPpain.org [Info@NRAPpain.org] for interested physicians PRP Caudal Epidural Research Review * Study Overview: Randomized double-blind controlled pilot study comparing leukocyte-rich PRP versus corticosteroids in caudal epidural space * 50 patients randomly assigned to two groups * Treatment options: triamcinolone 60mg or leukocyte-rich PRP from 60ml autologous blood * Follow-up assessments at 1, 3, and 6 months using VAS and SF-36 surveys * Key Findings: * Both treatments showed significant pain reduction compared to baseline * Steroid group had lower VAS scores at one month * PRP group demonstrated superior results at 3 and 6 months * PRP group showed significant improvement across all SF-36 domains at 6 months * No complications or adverse effects in either group during 6-month follow-up Personal Treatment Experience * Dr. Rosenblum received transforaminal PRP injection 9-10 weeks ago * Gradual improvement noted from weeks 4-8, with more noticeable benefits from weeks 8-10 * Current status: minimal pain (0.5/10) only during weather changes Clinical Practice Philosophy * Treatment Approach: Minimalist philosophy focusing on turmeric, PRP, and Pilates * Medication Strategy: Low-dose naltrexone as go-to medication, avoiding long-term drugs with side effects * Surgical Avoidance: Prioritizing conservative treatments over unnecessary surgical interventions Emergency Department PRP Implementation * Case Study Results: Ultrasound-guided caudal epidural steroid injection in ER setting * 100% pain resolution achieved * Patient discharged directly from ER * Cost savings: reduced from $33,000 to $4,800 (approximately $28,000 savings) * Training Opportunities: Private training sessions available for ER physicians interested in ultrasound-guided procedures Patient Testimonial Highlights * Case Background: Nurse with herniated disc from March, previously considering $30,000 surgery * Treatment Outcome: PRP injection completed two months ago with nearly complete pain relief * Reduced from multiple pain medications to one Advil daily * Eliminated antalgic posture and muscle spasms * Returned to full 12-hour hospital shifts without difficulty * Overall quality of life restored to normal levels David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures. Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023 Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more! Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques. Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call Brooklyn 718 436 7246 Reference Irvan J. Bubic, Jessica Oswald, Ultrasound-Guided Caudal Epidural Steroid Injection for Back Pain: A Case Report of Successful Emergency Department Management of Radicular Low Back Pain Symptoms, The Journal of Emergency Medicine,Volume 61, Issue 3,2021,Pages 293-297,ISSN 0736-4679 Ruiz‐Lopez, Ricardo, and Yu‐Chuan Tsai. "A randomized double‐blind controlled pilot study comparing leucocyte‐rich platelet‐rich plasma and corticosteroid in caudal epidural injection for complex chronic degenerative spinal pain." Pain Practice 20.6 (2020): 639-646. #prppain #paincme #sciatia #ultrasoundmsk #ultrasoundprp #epidural #nypaindoctor #prppainwindsor

Supplements for Pain: Does the Evidence Support it?

Episode Overview In this episode, Dr. David Rosenblum discusses the role of supplements and complementary strategies in the management of chronic pain. Drawing from clinical practice at AABP Integrative Pain Care, as well as his teaching and training programs, Dr. Rosenblum reviews how nutraceuticals, regenerative therapies, ultrasound-guided procedures, and neuromodulation can work together to improve patient outcomes and reduce opioid reliance. This episode also highlights educational opportunities and exam-prep resources for pain fellows, residents, anesthesiologists, physiatrists, and APPs looking to expand their interventional pain, ultrasound, and regenerative medicine skill sets. Key Topics Discussed * Evidence and clinical rationale for select supplements in chronic pain management * The role of ultrasound guidance in improving accuracy and safety in interventional pain procedures * How regenerative medicine techniques such as PRP and BMAC are shaping personalized pain care * Practical considerations when combining supplements with neuromodulation, RFA, or injections * Patient case applications and real-world treatment planning Educational Offerings & Learning Opportunities PainExam / NRAP Academy Training & Programs: * Neuromodulation & Regional Anesthesia Workshops * Ultrasound-Guided Pain Procedures * Regenerative Pain Medicine Training * Virtual Pain Fellowship * Pain Management Board Review & Question Banks Learn More / Register: www.AABPpain.com 🔹 https://PainExam.com [https://painexam.com/] 🔹 https://NRAPpain.org [https://nrappain.org/] Board Prep & Certification Support Prepare for: * ABA Pain Boards * ABPM * ABIPP * Pain Management Board Certification Exams * (No reference to FIPP included, per request) Access Board Prep Courses & Q-Banks: ➡️ https://PainExam.com [https://painexam.com/] ➡️ https://NRAPpain.org [https://nrappain.org/] Clinical Practice AABP Integrative Pain Care (Brooklyn & Great Neck, NY) To schedule a consultation or referral: 🌐 https://AABPpain.com [https://aabppain.com/] 📞 Brooklyn: 718-436-7246 About the Host – David Rosenblum, MD Dr. Rosenblum serves as Director of Pain Management at Maimonides Medical Center and Managing Partner at AABP Integrative Pain Care in Brooklyn, NY. He is recognized as an early adopter and leading educator in ultrasound-guided pain procedures, neuromodulation, and regenerative medicine. He has: * Developed regional anesthesia training programs * Published widely in pain medicine literature * Lectured nationally and internationally through ASIPP, ASPN, NANS, IASP, and more * Helped over 3000 physicians pass pain board exams * Hosted the PainExam, AnesthesiaExam, and PMRExam podcasts Awards (Selected): * New York Magazine Top Doctors: 2016–2025 * Top Doctors NY Metro Area: 2016–2025 * Schneps Media Honors: Multiple Years Connect with Dr. Rosenblum * LinkedIn: https://www.linkedin.com/in/davidrosenblummd/ [https://www.linkedin.com/in/davidrosenblummd/] * Instagram: https://www.instagram.com/painexam/ [https://www.instagram.com/painexam/] * X (Twitter): https://x.com/AlgoSonic [https://x.com/AlgoSonic] Practical Takeaways * Evidence strength varies widely; preclinical support is more robust than human RCT data for most supplements. * Potentially reasonable adjuncts in select contexts * Vitamin D: plausible benefit in deficiency states, including diabetic neuropathy and chronic pain-related quality-of-life factors; confirm deficiency and monitor. * Magnesium: consider IV regimens for refractory neuropathic components (e.g., cancer pain, PHN); oral efficacy uncertain. * Curcumin: consider as adjunct, especially formulated phytosome combinations; monitor for additive effects and tolerability. * B vitamins: consider B12 in deficiency or neuropathy with suspected demyelination; overall human evidence limited. * Zinc: mechanistic rationale with preclinical support; limited human data—consider deficiency correction rather than supraphysiologic dosing. * Cautions and contraindications * St. John's wort: significant drug–drug interaction potential via CYP/P-gp induction. * Alpha lipoic acid: may cause hypoglycemia; monitor glucose, especially in diabetes. * Agent-specific toxicity thresholds should guide safe upper limits; prioritize lab-confirmed deficiencies. Risks, Limitations, and Research Gaps * Heterogeneity in study designs, small samples, lack of controls, and multi-ingredient formulations limit causal inference. * Need for large, well-designed RCTs stratified by neuropathic pain etiology (e.g., CIPN vs. DPN vs. PHN) with standardized outcomes. * Translational gap between animal models and human clinical efficacy remains significant. References Frediani, Jennifer K., et al. "The role of diet and non‐pharmacologic supplements in the treatment of chronic neuropathic pain: A systematic review." Pain Practice 24.1 (2024): 186-210. Huang, Wei MD, PhD*,†; Shah, Shivani DO†; Long, Qi PhD‡; Crankshaw, Alicia K. MD†; Tangpricha, Vin MD, PhD§,∥. Improvement of Pain, Sleep, and Quality of Life in Chronic Pain Patients With Vitamin D Supplementation. The Clinical Journal of Pain 29(4):p 341-347, April 2013. | DOI: 10.1097/AJP.0b013e318255655d Haddad, H.W., Mallepalli, N.R., Scheinuk, J.E. et al. The Role of Nutrient Supplementation in the Management of Chronic Pain in Fibromyalgia: A Narrative Review. Pain Ther 10, 827–848 (2021). https://doi.org/10.1007/s40122-021-00266-9 [https://doi.org/10.1007/s40122-021-00266-9] Abdelrahman, K.M.; Hackshaw, K.V. Nutritional Supplements for the Treatment of Neuropathic Pain. Biomedicines 2021, 9, 674. https://doi.org/10.3390/biomedicines9060674

BMAC and PRP for ACL Tears- Journal Club

Pain Exam Podcast Recent Conference Activities * London Conference Weekend: Successfully attended and spoke at ISPN and SOMOS care conferences * Somos Care Conference: Delivered presentation on pain management for primary care physicians * Presentation consisted of 50+ slides with only one slide dedicated to opiates * Emphasized shift away from opiate-based treatments in interventional pain management * Recommended primary care physicians refer patients to pain specialists for comprehensive treatment options * ISPN Conference: Participated in international pain management conference * Met with doctors from London, Iraq, and various other countries * Observed different international approaches to pain treatment including increased phenol use and varying regenerative medicine restrictions Upcoming Events and Workshops * New York-New Jersey Pain Conference: November (NRAP Academy booth presence) * IV Ultrasound Placement Workshops: Monthly sessions in New York * Regional Anesthesia and Ultrasound-Guided Interventional Pain Medicine Workshops: * New York: December 13th, January 10th * Florida (Fort Lauderdale/Hollywood): November 8th * Detroit: January 18th, February 15th * Alternative Options: Online ultrasound courses and shadowing opportunities available * Board Prep and NRAP Community at PainExam.com [https://www.painexam.com/] or NRAPpain.org [https://www.nrappain.org/] * ABA ABPM ABIPP FIPP Pain Management Board prep, Question Banks, and Virtual Pain Fellowship https://www.painexam.com Educational Offerings and Events * Training and Courses: https://www.nrappain.org/pages/ultrasound-training Research Review: ACL Treatment Study * Study Focus: Non-surgical treatment of ACL tears using bone marrow concentrate (BMAC) and platelet products versus exercise therapy * Key Findings: * BMAC group showed significantly greater improvement in Lower Extremity Function Scale (LEFS) and Single Assessment Numeric Evaluation (SANE) scores at three months * Sustained improvement in function and decreased pain maintained through two-year follow-up * Patients reported median subjective improvement of 90% at final follow-up * No significant improvements observed in exercise-only group during initial three months * Treatment Protocol: * Bone marrow harvest from posterior superior iliac crest (60-90ml from 6-8 sites) * PRP preparation from 60ml whole blood * Fluoroscopy-guided injection directly into ACL ligament * Comprehensive 52-week rehabilitation protocol with activity restrictions Clinical Practice Implications * Current ACL Treatment Landscape: Over 400,000 ACL reconstruction surgeries performed annually in the US * Surgical Limitations: Risk of graft failure, persistent instability, cartilage injury, and increased arthritis risk * Return to Sport Statistics: Post-surgical rates vary significantly (33-92% return to sport, 65% return to pre-injury level) * Practice Integration Considerations: Potential incorporation of BMAC/PRP protocols for ACL tears, though insurance coverage remains limited David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures. Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023 Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology. He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more! Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques. Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office. For an appointment go to AABPpain.com or call Brooklyn 718 436 7246 References Centeno CJ, Berger DR, Pitts J, Markle J, Pelle AJ, Murphy M, Dodson E. Non-surgical treatment of anterior cruciate ligament tears with percutaneous bone marrow concentrate and platelet products versus exercise therapy: a randomized-controlled, crossover trial with 2-year follow-up. BMC Musculoskelet Disord. 2025 Sep 30;26(1):882. doi: 10.1186/s12891-025-09153-2. PMID: 41029301; PMCID: PMC12486544. [https://link.springer.com/content/pdf/10.1186/s12891-025-09153-2.pdf] #pccwindsor #paincareclinicswindsor #painwindsorontario #paindocwindsorontarior #paincareclinics #prpwindsorontario #prp #aabppain

Chronic Pain and the TENS Unit

Project Sync / Status Update Summary Podcast Episode Overview * The host discussed Transcutaneous Electrical Nerve Stimulation (TENS) as a recurring pain board topic and reviewed mechanisms, efficacy, and clinical considerations. * Emphasis that TENS appears on pain boards annually and is a foundational topic from early podcast episodes. * Board Prep and NRAP Community at PainExam.com [https://www.painexam.com] or NRAPpain.org [https://www.NRAPpain.org] * ABA ABPM ABIPP FIPP Pain Management Board prep, Question Banks, and Virtual Pain Fellowship Educational Offerings and Events * Training and Courses:https://www.eventbrite.com/cc/ultrasound-guided-regional-anesthesia-pain-med-351559?utm-campaign=social&utm-content=creatorshare&utm-medium=discovery&utm-term=odclsxcollection&utm-source=cp&aff=escb * Monthly ultrasound courses in New York and upcoming courses in Detroit covering ultrasound-guided regional anesthesia and chronic pain. * Ultrasound Guided Acute and Chronic Pain course in November near Hollywood/Fort Lauderdale with venue pending confirmation. * Multiple instructors to offer diverse perspectives; registration via the CME calendar at nrappain.org. * Conferences and Teaching: * New York–New Jersey Pain Conference in November (hosted by Soudir Duwan). * ISPN conference in London next week, with ultrasound teaching participation by the host. * Community and Coaching: * Private coaching and shadowing opportunities available; contact via newsletter replies. * Access to the NRAP community forum upon signup at nrappain.org for discussions on neuromodulation, regional anesthesia, and pain. TENS: Mechanisms and Parameters * Device and Parameters: * TENS delivers adjustable pulse frequency and intensity; configurations include low (50–100+ Hz), and mixed frequencies. * Mechanisms of Analgesia: * Activation of large-diameter, non-noxious A-beta afferent fibers in the periphery, driving descending inhibitory pathways and reducing hyperalgesia. * Board-relevant point: selective activation of A-beta fibers is frequently tested. * Central effects: * Reduces central excitability and nociceptive dorsal horn neuron activity in uninjured and injured models. * Frequency-dependent opioid receptor mediation: * High-frequency analgesia blocked by delta receptor antagonists. * Low-frequency analgesia blocked by mu receptor antagonists (spinal cord and rostral ventral medulla). * Additional receptor involvement: muscarinic M1/M3, GABA-A, and cannabinoid (CB1) receptors; blockade reduces or prevents TENS analgesia depending on frequency. * Peripheral effects: * High-frequency TENS reduces injury-related increases in substance P in DRG neurons. * Blockade of peripheral opioid and CB1 receptors can prevent analgesia from both low- and high-frequency TENS. * Clinical dosing considerations: * Adequate dosing (timing, frequency of use, intensity achieving strong but non-painful paresthesia) influences efficacy. * Analgesia has rapid onset/offset and may require repeated administration throughout the day for sustained relief. Evidence and Efficacy Summary * Clinical experience suggests potential adjunctive benefit for acute pain, but systematic reviews are conflicting; more rigorous studies are needed. * For board preparation, the critical takeaway is A-beta fiber activation. Key Takeaways for Board Prep * TENS targets large-diameter non-noxious A-beta afferents to reduce nociceptive signaling. * High-frequency TENS: analgesia mediated via delta opioid receptors; blocked by delta antagonists. * Low-frequency TENS: analgesia mediated via mu opioid receptors; blocked by mu antagonists in spinal cord and RVM. * Additional receptor systems influencing TENS efficacy include muscarinic (M1/M3), GABA-A, and CB1. Action Items Review TENS mechanisms with emphasis on A-beta fiber activation for board prep. Verify and publish final venue details for the November Florida ultrasound course. Share registration links and schedules for Detroit and New York ultrasound and chronic pain courses via CME calendar. Prepare teaching materials for ISPN London ultrasound sessions next week. Update board prep resources on painexam.com and nrappain.org with current TENS evidence and dosing guidance. Promote NRAP community forum access and private coaching/shadowing opportunities through the newsletter. David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures. Patients can go to www.AABPpain.com [https://www.AABPpain.com] or call 718 436 7246 Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023 References Johnson M. Transcutaneous Electrical Nerve Stimulation: Mechanisms, Clinical Application and Evidence. Rev Pain. 2007 Aug;1(1):7-11. doi: 10.1177/204946370700100103. PMID: 26526976; PMCID: PMC4589923. Vance, C.G.T.; Dailey, D.L.; Chimenti, R.L.; Van Gorp, B.J.; Crofford, L.J.; Sluka, K.A. Using TENS for Pain Control: Update on the State of the Evidence. Medicina 2022, 58, 1332. https://doi.org/10.3390/medicina58101332 [https://doi.org/10.3390/medicina58101332] #painnyc #painbrooklyn #prpbrooklyn #prpspine #regionalanesthsia #pccwindsor #paincareclinicswindsor #painwindsorontario #paindocwindsorontarior #paincareclinics #prpwindsorontario #prp