Tackling Pain – The MPM Approach
Pain, a distress signal sent to the brain, provides immediate and simple information, when it’s new. When it’s old or recurrent, pain signals differently.
When patients come to us, they have often been dealing with pain for many years, and this pain has developed layers and complexities. Often secondary and compensatory pains develop, and these may be more painful than the primary pain.
As a multi-specialty practice, we work collaboratively across each specialist’s zones of expertise. Our specialists assess the body holistically to understand its functions broadly, and from this, they reverse-engineer what causes the pain and why. What is generating it? How did it come to do so? What keeps it from healing? The answers to these questions reveal what needs to be fixed, how to fix it, and how to maintain the fix moving forward.
The Journey
Our journey takes 3 phases. It begins with Discovery, where we identify any and all factors involved. This is the diagnostic process. Once we have a reasonable understanding of the “what?, how?, and why?” of pain, we begin Treatment. After we achieve optimal treatment, we enter the Maintenance phase, where the patient understands what happened and how to manage their body going forward.
The most important part of this journey is that it is a journey. Sometimes we can identify and unwind everything on the first visit, but more often, it takes several visits with an iterative process of discovery, treatment, and maintenance. We learn as we go along, from each test, from each treatment, what is going on with the body, how it relates to everything else, why it’s happening, and what we need to do to permanently correct it. Like untying a knot, we see which threads to pull on first, and then know which to pull next.
Discovery
We work to understand the pain. What is generating pain? Why? How did it come to do so? What keeps it from healing? The answer to these questions tells what needs to be fixed. We assess holistically to understand broadly how the body functions, and from this, reverse engineer what causes pain and why.
Initially, we assess for systemic sensitization. Sensitization means that the body over-reacts to a stimulus. The nervous system can be sensitized, as can the immune system, and our emotional processing. Each of these domains affects what pain signals the brain receives, and how it processes them for our interpretation.
Neurologic Sensitization: When the nervous system holds a grudge.
Neurologic Sensitization means that the nervous system both responds to lower level stimuli and reacts with hyperactive reflexes. Examples include light sensitivity during a migraine, or light touch and cold intolerance with complex regional pain syndrome.
With chronic pain, the nervous system has received multiple repetitive pain signals, and has re-programmed how it processes signals from a region (or the whole body) with a heightened awareness of any sensory stimulation in that area. This means that any pain, when sensitized, becomes amplified before it reaches the brain.
It’s very much like the nervous system holds a grudge, and any new insult triggers a disproportionate response. Neurologic sensitization can occur in the peripheral nerve (at the DRG), within the sympathetic nervous system (the ‘fight or flight’ response), within the spinal cord, or the brain.
Psychological Sensitization: When the brain no longer wants to engage.
Psychological Sensitization means that the conscious brain’s ability to engage with and respond to chronic repetitive pain signals is either disengaged or beyond its ability to cope. Disengagement means that the brain has dissociated from the part of the body with pain, almost like it’s not part of the same person. It’s a learned disregard that saves the conscious mind from experiencing constant discomfort. Both patients and doctors often miss this quiet process.
The emotional exhaustion and desperation of lost coping ability calls out for help. Patients in this situation live in fear, anger, distrust, frustration, and sadness to an extent that limits their ability to think granularly about the pain, engage with treatment decisions, and tolerate any possible fluctuation in pain (which is always part of the pain journey). They often want an immediate singular fix, and struggle to consider patience for the pain treatment journey.
Pain Psychologists specialize in the pain journey, and help ground patients through this process. To identify areas of control, choice, and develop contingency plans. Strategy for care, understanding rationale for treatment choices, tracking responses and measuring results grounds the patient. Sometimes ketamine helps too.
Why we address sensitization first
We spend much time during the initial visit determining which systems participate in the pain experience, how to best identify, confirm and treat them. Sensitization, in any domain, clouds the diagnostic process and must be addressed before focal anatomic issues can be reliably identified or treated. It’s like a fire where the flames are so big that you can’t see what’s on fire. Knocking the flames down doesn’t put out the fire, but it helps us identify the source which must be treated.
After we identify and manage sensitization, or when there is no obvious sensitization, we proceed to identify focal anatomic structures involved in pain generation. This may be a joint, a disc herniation, a hernia, or any other structural process. Sometimes this is straightforward and easy, other times, it’s the tail end of a cascade of suboptimal biomechanics. We identify and clarify chicken-or-egg scenarios, like neck vs. shoulder, or back vs. hip vs. hernia vs. endometriosis. Often there are a few chickens and a few eggs.
We use physical examination, imaging, and diagnostic injections to clarify the role of specific structures in the pain cascade. At the end, we have an initial understanding of which structures are involved and how they are related. This allows us to proceed with reasonable treatment decisions. Treatment responses further inform our understanding and each step adds another data point.
Treatment
Treatment of sensitization ultimately requires treatment of the reason for sensitization, but initially, we can reduce the sensitization to better understand what is going on behind it. The process of treatment generally takes two paths simultaneously: 1) getting the patient comfortable, and 2) confirming our understanding of the “what?, how?, and why?” of pain generation.
If we suspect neurologic sensitization, we will often trial medications to reduce this, such as intravenous lidocaine (if the whole body is affected), or focal sympathetic blocks, like a stellate ganglion block or lumbar sympathetic block. If migraine is a driver, we will treat the migraine. Once it’s out of the way, it’s easier to see what else is in play that’s not migraine.
For immune sensitization, we may trial a course of oral steroids or an anti-inflammatory for 2 weeks as an autoimmune test. Or cromolyn for mast cell activation syndrome (MCAS). There is often crossover between inflammatory and neurologic sensitization, and we will often test both separately if suspected.
Psychological sensitization treatment begins with conscious awareness. Pain psychologists, pain support groups, supportive companions are helpful. Understanding the process of diagnosing and treating pain (this message) is helpful. Contextualizing and choosing control is helpful. Hope is not necessary. Slow, steady gains show proof that improvement is possible. Then the patient has to consider what they will do if the pain is gone, and that can be frightening. There is often a reassuring co-dependence with the anger and frustration of lost hope.
Treatment of focal anatomic structures depends completely on the how and why of their pain generation. A cervical disc herniation may feel better with an epidural, but without understanding the reason for its existence, it will likely reoccur. If we can treat the reason, such as hypermobility at that spinal level, the disc may heal without the epidural.
Sometimes the structure where pain is felt isn’t the problem. Pain may be referred – meaning it’s coming from somewhere else, but felt in that location (Shoulder joint pain is often felt in the middle of the back; Adenomyosis is often felt in the sacroiliac joints, as is an L5 nerve root). OR, pain may be a mechanical trickle-down effect (pelvic floor dysfunction is often due to a hypermobile hip, where the hip doesn’t itself have any pain; Thoracic outlet syndrome is often due to muscle guarding of the neck or shoulders). There are known constellations that lead us in the right direction. We confirm with treatment.
Maintenance
Once the reasons for pain are understood – we know which structures are malfunctioning and why – and we have a tested and proven treatment plan, then we begin the maintenance phase.
This is the first time the patient truly sees the light at the end of the tunnel. For some this is relief, for others, this is when panic hits. The question of what they’ve been through, what it all means, and what if it returns (although now they know what it is and how to treat it) are all very real.
The patient may not need us again, or there may be a condition that requires ongoing treatment, such as a biologic for psoriatic arthritis or a toxin for migraine. If anything new pops up, we’re available, otherwise the patient knows what to do.
Collaboration Across Zones of Expertise.Each provider at MPM brings deep experience in one or more zones of expertise
Chronic Pain
Hypermobility
Autoimmune Disorders
Autonomic Dysfuntion
Pain Psychology
Pelvic Pain & Dysfunction
Headache & Facial Pain
Spine
Joints
Mission, Vision & Values
Mission
At Manhattan Pain Medicine, we seek to transform the practice of pain medicine through
the process of root cause discovery, education, and empowerment.
Vision
We help people regain control of their lives and learn to ward off future pain by guiding them through a journey of diagnosis, education, treatment, and maintenance.
Values
Specificity
We believe that life can be better and that all problems have an answer if you look in the right places. Because pain is complex and individual, we focus on delivering personalized, holistic care tailored to each patient’s specific needs, addressing not only the symptoms but also the root cause(s) of pain. Patients in our practice expect more extended visits than at other clinics, as consultations are handled with more consideration and care.
Curiosity
We are driven by the belief that every pain has a source that can be identified and treated. We start with a detailed evaluation to uncover the reason(s) for the pain(s), confirm our findings with further workup and tearing, and ensure that every patient understands the process(es) taking place in their body. We remain curious until we are confident that we have the knowledge and tools to help each patient.
Collaboration
We are a pain-centered multi-specialty practice with experts from a wide range of medical disciplines for holistic, comprehensive treatment plans. We collaborate to find solutions where “the system” may have failed. Our work with each patient is iterative, as pain often has multiple layers of cause and effect, and we work with you to unravel them all.
Empowerment
We give patients knowledge, tools, and treatment options to empower them to make decisions about their care.
Our Logo: The Rainbow Crow
Our offices are situated on the ancestral territory of the Lenape people, who named the island of Manhattan. The Lenape also gave us the story of Rainbow Crow, who saved other animals through tenacity and kindness:
Long ago, it is said, that crows were beautiful birds with rainbow feathers and trilling songs that brought joy to the forest. But a winter – so bitter that no animal could survive its cold – came to grip the world. Chosen for his beauty and strength, the Rainbow Crow flew into the heavens, fetching fire to warm the freezing earth. The crow flew with a flaming torch in his beak for three days and nights, braving wind and hail to save the other animals. But in doing so, the fire lit up his feathers, and smoke singed his voice. The crow’s brilliant colors turned black, and his melodic song became a raspy caw. The world forgot his beauty, but animals who knew his story remembered his courage, his sacrifice, and the warmth he carried through the dark.
That is why the Rainbow Crow is the symbol of Manhattan Pain Medicine.
We honor the belief that those who hurt deserve to be seen with compassion and understanding – in full color. We treat the whole person, not just the symptom. We listen deeply, examine carefully, and move with compassion.
Because true expertise doesn’t just come from clinical processes — it’s in the care, time, and respect we give to every patient’s full story.