PainExam Podcast

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 pain 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 Physicians & APPs - Continue Your Education: PainExam Board Review & Refresher Course - question bank and lectures; over 3,500 physicians have passed the pain boards. Virtual Pain Fellowship - comprehensive fellowship material for board prep, recertification and day-to-day practice, with CME. 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 All Pain Management CME Courses: https://www.nrappain.org/pages/pain-management-cme-courses Pain for Advanced Practice Providers (NPs & PAs): https://www.nrappain.org/courses/Pain-for-the-Advanced-Practice-Providers 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. This episode is brought to you by NRAP Academy and PainExam - 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, 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 with higher efficacy but more side effects at higher doses - Key trials, including Corriger et al.'s 1-year follow-up (256 patients) and Orhurhu et al.'s systematic review and meta-analysis - Common side effects (nausea, psychomimetic symptoms) versus rare but serious adverse events, and how premedication with clonidine/midazolam affects risk - Why blinding failure may be inflating reported effect sizes - The absence of standardized protocols, guidelines, or a clear "exit strategy" for long-term SDKI therapy 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   This episode is brought to you by NRAP Academy and PainExam - visit www.NRAPpain.org for CME in neuromodulation, regional anesthesia, and pain medicine.    

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.