Managing Chronic Pain – Where to Start
January 04, 2023
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The purpose of pain is to protect you, but for 50 million Americans, the pain is chronic. Pain management specialist, Kutaiba Tabbaa, MD, talks about headaches, back and knee pain, cancer and diabetes-related pain. He explains why a team approach and a motivated patient offer the best opportunity to manage chronic pain.
Pete Kenworthy
We’ve all been physically hurt, before. Right? When you bumped your head on something. You stubbed your toe. You fell and got bruised up pretty badly. Right? Well, probably the worst for me was as a teenager, I went headfirst over the handlebars of a bike and on a street, and I had a few of my teeth knocked out. But even with that terrible accident…it happened when I was 13…I eventually healed. Right? My pain went away. And I went on with my life.
Macie Jepson
I have similar stories, 21 hours of labor. Two children. But I knew that there was an end in sight. I knew that that would stop. But here’s the deal. For 50 million Americans, the pain does not go away. And they aren’t necessarily able to just move on with their lives. Fifty million people. In fact, pain accounts for 20% of all clinic visits. One in every five visits to a doctor is about pain. Now, Pete, the kind that you talked about in your bike story, which by the way made me cringe, that’s temporary, though. In this podcast we’re going to talk about chronic pain, what causes it, and most importantly, how do we deal with it? Hi everybody. I’m Macie Jepson.
Pete Kenworthy
And I’m Pete Kenworthy, and this is The Science of Health. Now, I’m pretty excited about today’s conversation because chronic pain impacts so many people.
Macie Jepson
And we are hoping that we can provide just a little bit of help and a lot of hope for you in this podcast. Joining us today to talk about managing chronic pain is Dr. Kutaiba Tabbaa, Director of University Hospitals Parma Comprehensive Pain Center in Greater Cleveland. Thanks for being here.
Dr. Kutaiba Tabbaa
Thank you for inviting me.
Pete Kenworthy
So, let’s start by talking about the difference between acute pain and chronic pain. Right? In a recent webinar I saw you do, I heard you talk about how pain is essential. Right? But you’re talking about acute pain there. So, what’s the difference between the two?
Dr. Kutaiba Tabbaa
Well, the pain itself is actually, it’s an essential part of the human growth. Your organism, even any animal organism, if we don’t have pain, you’ll destroy yourself. There is, people are born with genetic deformity, and they don’t feel pain. And those kids, they die when they are 15 years old from all the damage of the joint. I have pictures. You can see people putting the pencil in their face and they don’t feel it. And that’s where the extreme happen. And there are some other people in, they are born with genetic disease that they become having neuropathic pain when they are in their 20s and their body become on fire. And all of that is related to the hormones that is in their body. So, the pain is really very important to our growth, to our health. The problem is when the pain become chronic. The purpose of the pain is to protect you. So, that means you broke your arm, you splint it, you don’t move. So, that’s how it heals. So, you have a chest pain, you go to the doctor, see a heart attack. So, that’s how you survive. The problem with the chronic pain, that pain has outlived its usefulness. So, that useful pain that we use to really nourish our body, now it becoming the disease that hurts our body.
Pete Kenworthy
And chronic pain can be anywhere. Right? I mean we’re talking headaches, back, knee, really anywhere in the body. Right?
Dr. Kutaiba Tabbaa
Absolutely. The amazing thing about chronic pain, which is I learned after I was, you know, before surgeon and stuff like that, so many year experience. And it was for me it’s simple. You know, we open the patient chest, we do grafts, we close it. A week later they are out of the hospital doing everything and wonderful. So, when I started, there was only few centers that they had pain management in the country here. And that when we started learning about what the chronic pain, and we started identifying how the connectivity in the body between its organs, hormones, the brain, the site of injury. The site of injury is not becoming important with the chronic pain anymore. It become, it’s like, okay, this is where the back happened, the damage happened, the five surgeries, 10 surgeries. I had a patient, she had 17 surgeries by the same surgeon, 17 surgeries by the same surgeon. I sent her to a psychologist immediately. It’s like, yeah, take a second opinion.
But anyway, it’s really the pain could be coming from the brain itself, like if we have a stroke, there is certain areas in the brain, it feels the pain. That’s becoming stroke related pain. The brain itself doesn’t sense pain. So, I mean, you can cut the brain and all of a sudden, the patient will not feel it. But there is areas in the brain that becoming involved with the pain itself. Spinal cord injuries, that’s centralized pain also. So, you have pain all over the body, and it is horrible pain actually. Unbelievable. So, there is a lot of pain from cancer related pain, from pain that’s related to neuropathies, diabetes, and they have peripheral neuropathies and stuff like that. Women, they have a lot of pelvic pains. And so, it’s a lot of things that associated with the chronic pain. Absolutely. And everyone has it is specific modalities that we can address according to that specific modality of disease and patient.
Macie Jepson
And clearly, chronic pain has massive physiological, as you just described, and psychological consequences. I mean, it’s the leading cause of work loss and disability in this country. And pain impacts families. So, this is why it needs to be treated, I would guess.
Dr. Kutaiba Tabbaa
Well, absolutely. The thing is that really the impact in our profession on a society is huge, not only on the patient themselves. It’s like we don’t really talk about pain for number. I mean, when we talk to a patient about pain, we talk about function, about doing things in their life and stuff. I just had a lady, she’s 67, nurse. She loves working hospice. She had miserable back and surgeries and all that stuff. We got her off all the medication, and she became amazingly with something called IV infusion therapy, and she’s doing great. She went back working full-time for hospice. And she’s so excited. She comes just like the happiest person ever. Now, what I did to the society, I had this patient out from disability into ability, from being consumer, taking taxes and spending social money on them to now producing and contributing to the tax system. So, it is really amazing what you can do with the chronic pain.
Pete Kenworthy
So, let’s move on to how we do that, how we manage chronic pain. Right? Are we talking about a pill, an injection, surgery, therapy? And how many kinds of providers are we going to have to see to manage our chronic pain?
Dr. Kutaiba Tabbaa
You know, it’s really funny what you’re saying there because the problem with the chronic pain that it’s multifaceted. And there is not one thing, not one pill is going to cure it. It’s not like having infection. You have tonsillitis, we give you antibiotics, gone. It’s not that way. It’s not that simple. There is this modification that happened to the brain. The pain itself is principally a sensation like every other sensation in the body. And every experience in pain, which is acute or chronic, it become registered in the brain. The brain has to understand, identify it, and that correlates with events that happening during that event. So, now it is a memory. And it is associated with tissue damage, which is you can see it or you can’t see anything when you have patient has a migraine or they have lower back and you do MRIs, there’s nothing happening.
Macie Jepson
I want to talk about the scenario that you just put out there. You said that sometimes you go into an MRI, you’ve got back pain and there’s nothing there. How often does that happen?
Dr. Kutaiba Tabbaa
That’s really interesting. Few years ago, there was studies done on, I don’t know, hundreds of patients that they had. They took them, put them in the MRI. And they looked to correlate with the MRI finding and what they have in the back pain. And there was really significantly no correlation between the MRI finding and the patient. So, the patient that they have an anomaly in their back, the disc is the degeneration, the facet is degeneration, stuff like that. They did not have a back pain. And the other people, they have an MRI totally normal and they have a back pain problem. So, it is really very common. You see that especially with acute injuries. And now that’s why there is a lot of, actually, I expect in the future we’re going to have a lot more diagnostic studies that works between the brain, the body, the stuff to find out what’s the problem.
Macie Jepson
Looking at the entire body rather than the point of pain.
Dr. Kutaiba Tabbaa
That’s right.
Pete Kenworthy
In a webinar I saw you do recently, you talked about the chronic pain management treatment ladder where the bottom of it was NSAIDs, things like Advil. Right? And then it went up from there. Interventional techniques, corrective surgery, neurostimulation, opioids, intrathecal pain therapy, behavioral modification, and then neural ablation. Right? So, can we start on the bottom of that ladder and talk about how decisions are made, how you decide how to treat certain chronic pain with different treatment modalities?
Dr. Kutaiba Tabbaa
Absolutely. Now, when we see the patient first evaluation, and they have this slower back pain, they have any pain, arthritis pain, et cetera, we need to look at their muscular skeletal system and all that stuff, and we need to look also at their personality and how much that pain affected them. So, in my evaluation, always in my treatment, it’s all that ladder that you mentioned, it’s always, it has a circle around it from behavioral health, chiropractic, massage therapy, acupuncture, all of that are involved with this type of pain treatment including physical therapy. I do a lot of aquatic therapy, water therapy, patient love it because they have back problem, knee problems so they can exercise in the pool. So, that’s why I don’t want to give that conception is that we go from one step to the other without having the other stuff around it, surrounding it.
So, that’s the important part of the treatment. So, we start with the NSAID, it’s from interventional medical management. We start with the NSAID. Now, with NSAID, you could be taking ibuprofen over the counter or more advanced like Celecoxib or high higher dose of Diclofenac, certain type of medication. We associate that usually with the acute injuries, we give them steroids. We don’t give them NSAIDs, actually we give them steroids and that helps a lot. We go to the NSAIDs. I combine always the NSAID with acetaminophen, Tylenol. So, I combine it together because it works really effectively for the patient. We give them muscle relaxant stuff, and we put them into this physical therapy, acupuncture, chiropractic and stuff and see how they’re doing. Whenever a patient is recovered and doing well, we achieved our goals. Now, this patient is not really achieving very well. We want to be now investigate.
Now, if you notice, I’m sure that you had experiences with insurance companies that if you want to have an MRI, you have to have six sessions of physical therapy or certain amount of pain medication that you have to take and stuff like that before you’re allowed the MRI. So, now we are going to have an MRI on the patient, and we are going to see if that patient have a herniated disc, he has facet joint diseases, stuff like that. What kind of procedures we can do now, interventional procedures, try to give the patient window of opportunity so the patient get better, see if they can improve their function and then the muscle gets aligned, the spine gets aligned and that’s when they make the recovery. So, I’m not really doing the recovery for them. They are doing the recoveries through, I’m giving them temporizing things, taking the inflammation, taking the pain away so they can function to the next level.
Now, all right, the patient now did not really get much better here. We’re going to ask the surgeon if we can find pathology there that it is worth it. You have spinal stenosis. You have certain things, maybe you need knee replacement, if you are not 400 pound. So, we can get you to the next step. Now, this is a corrective surgery. To corrective surgery, but it is for the back is really surgery. The problem, whenever you do surgery on the back, there is cascade of things happen. So, it is nearly not a curative; it is you fix some pathology there but you created long-term abnormality in the function of the spine itself. So, that’s what we try to avoid that. But of course, I mean when you have symptoms of weakness, stuff like that, we are going to do that. So, we have corrective surgery. Now, if that corrective surgery is not worked enough for the patient.
So, if the corrective surgery did not work, what we are going to do is we are going to now put the patient on a trial period of maybe pain medication to see if we can get them to the next level. The whole idea of any treatment is to move them from one step to the other so they can preserve their function and improve their life. That’s the whole idea. If that’s failed, well, unfortunately now we are going to go to the intrathecal therapy or spinal cord stimulator. Most of the time I go to the spinal cord stimulator before even any opioid therapy. But the problem is insurance company would not cover for spinal cord stimulator until you get them into this other stuff. But spinal cord stimulator, principally we use wires in the back to fight the electricity, which is going through the nervous system, going to the brain, trying to block or modify the signal and increase the brain capabilities of controlling the pain downward.
So, it is really amazing technology. It is not new. I mean, it started in the 80s, in the late 80s for movement disorder, then pain management, and I start doing those in 1990, I mean 1991. But the technology has improved significantly. The batteries now they can generate a lot of energy, and you have programming and stuff like that. We know about it. So, it’s worked wonderful. So, this is one of the aspects.
The second aspect, intrathecal therapy. Intrathecal therapy is principally instead of giving you medication by mouth and that medication’s going to go through your liver, it’s going to go through until treat small amount to the nervous system where it needs it, we are delivering the medication directly through the spine, to the spine through a catheter. And that gives the patient continuous or intermittent. The patient, the new pumps, now, they can bolus themselves.
So, it’s like a PCA in the hospital. They can bolus themselves for when they have pain and they get good pain relief from it.
And those now we are going to the next step after that. We are going for the neural ablation, what we call it, which is really is not the neural ablation, it’s principally we are like taking the nerve root and cutting them on the level of the spine. So, the surgeons go there and take the posterior nerve root and do rhizotomies on those patients. And many of them they do cordotomies, stuff like that, which really invasive procedure significantly alter the nervous system transmission. It may work in the beginning, and we found out that it really doesn’t work. So, the neurosurgeons stopped doing them. But I put it there as historical fact.
Macie Jepson
Can we go back to opioids for a moment?
Dr. Kutaiba Tabbaa
Sure.
Macie Jepson
If they work, then you don’t have to have the injections and the neural ablation. And by the way, injections kept my husband out of surgery. Thankful for injections. They worked for his degenerative disc disease. But if opioids work, that to me seems problematic, because you can’t live on opioids forever or can you?
Dr. Kutaiba Tabbaa
So, when I started long time ago, from historical perspective, opioid therapy was only for acute and cancer pain. We never allowed to do opioid therapy for chronic pain. Then Oxycontin came in the market, which is long-acting opioid. And they start seeing, because addiction happened because you have a feedback mechanism in the brain itself, the dopamine in the brain that gets high and then gets low and all that stuff. So, this feedback mechanism from a short acting opioid, they said, okay, that doesn’t happen anymore. So, we are giving the patient certain level of opioid, and they are doing really great. And the studies in medicine, how long do you do the studies? Maximum two years. That’s it. We never had 10 year studies. So, at that time, chronic pain became the first vital sign, according to the VA. The VA start prescribing it like crazy. Everybody prescribing medication. And the patient responded for a year and then start developing opioid use disorder.
They start getting hyperalgesic. Honest to God, I had patient, they have more pain the more they take pain medication. They became so sensitive to everything because you are depriving their own hormone to fight the pain. So, they are always soaking their nervous system with this external opioid, and if it drops a little bit, the body scream. So, we discover that happen in the future. So, now the to go back. Alright, now I have patients that they are on maybe 60 pills a month or something. I mean they are doing, they take it only for severe pain. They don’t take it every time I feel, ugh, my back is hurting, I need to pop one or something. You take it only for when you want to go shopping for long period of time; you want to do something. You know what I’m saying? So, you are very vigilant about not letting your body get used to the opioid and become the opioid control you.
Pete Kenworthy
That’s probably easier said than done for some people though. Right?
Dr. Kutaiba Tabbaa
But that’s when you have your pain management doctor watching for that. You don’t go there and just give them the pill and get the fee and walk away. You know what I’m saying? You need really to be careful. And who tells you more about the patient is their family. So, if you talk to the wife or the husband, how he’s doing really. And other things like I measure my patient weight. I mean, I get the patient that they are really, really significantly overweight. I tell them, okay, they have bad knees. Okay, I’m going to give you some pain medication, and I want to see you in the next couple months. Hopefully you will be walking 10 steps a day. They come back with their weight five pound more. It’s like how I’m going to be able to prescribe that for you. That mean you are getting sleepy from my medication. You are not getting positive response from my medication. So, my medication is like my injections, like everything else, has to correlate and has to be part of the program that this patient participating in. So, I’m not going to just give them a pill. They need to participate in that comprehensive program.
Macie Jepson
Thank you for clarifying that, because I know for some people opioids brings up a red flag. Doctor, so thank you for that. Let’s talk about reaction to treatment. It’s different for some people, I would think. You know, what works for one doesn’t work for the other. At what point is psychological treatment a part of the equation for that person who just can’t get relief?
Dr. Kutaiba Tabbaa
Now, I want to ask you guys, I would like to ask you if you have pain day and night and you are not able to perform with your family, you are not able to be with your kids, you are not able to be with your wife, how much that chronic pain is going to affect you. Does that have a psychological aspect or not?
Pete Kenworthy
Sure.
Macie Jepson
Of course it does.
Dr. Kutaiba Tabbaa
Of course.
Macie Jepson
And on your family.
Dr. Kutaiba Tabbaa
Absolutely. Now, psychological pain per se is very rare. It’s less than 10% that people have pain from psychological issues. So, you give them some testing and stuff like that, and that’s called psychological pain. And that’s really completely rare incidents in chronic pain. But every chronic pain has a psychological aspect. The psychological aspect, it doesn’t mean that you are crazy. It means that your pain fighting mechanism are failing. You are letting the pain win. So, what the psychologist will help you is to get back this fighting spirit that you have to fight for your life, for your kids, for your family to fight against that pain. I mean, the idea is really to empower the patients to be able to fight the pain.
Pete Kenworthy
You really have to reprogram how you think in some instances. Right? Because there’s this new pain within you that you didn’t have for the first 40, 50, 60 years of your life, say. Right? And now it’s overwhelming to your brain and your thoughts and your function as you talked about with your family or your kids or your wife or whatever. So, you may need psychological help to kind of help you navigate that and how you think and how you approach things. Is that what you’re saying?
Dr. Kutaiba Tabbaa
Absolutely. Absolutely. It is really very tough for when you have your body and you have your brain develop through hormones that bathing them for long period of time negatively affect your organism. So, your body now is really falling apart and your brain is falling apart. Now, some patients come to me, do you think that my pain is in my brain? It’s like, of course, it’s in your brain. If you don’t have a brain, we’ll give your organ for donations. Everything is in the brain. I mean, one of the techniques in biofeedback is to train the brain to control your uncontrollable instinct, like heart rate, temperature, stuff like that, I mean, and your breathing. I mean it’s amazing how much the psychological aspect of our life. I mean look at the soldiers, okay? They get shot behind the enemy line. His leg is almost amputated. He put that stuff on it, and he keeps running and running and running, hiding and moving until he gets to his safety and suddenly he collapsed. What kept him going? We say adrenaline. No, but this is the fighting mechanism that I’m talking about. They have it in us. We have it in us. We need to just bring it out.
Pete Kenworthy
Wow. That was a great analogy, too.
Macie Jepson
Yeah, it was, wasn’t?
Pete Kenworthy
Let’s think about the future here for a second. You talk about how much things have changed in the time that you’ve been practicing. Right? And you said, I think, quote/unquote a long time. Right? So, what is research showing us on the horizon for pain management? What does the future look like for treatment?
Dr. Kutaiba Tabbaa
You know, after all these years in pain management and practicing pain management, it reminds me so much when I went to cardiac to heart surgery and practice heart surgery. I was amazed with the cardiopulmonary bypass. I was amazed in a few years they used to connect the mother to the baby to be able to do VSD or close a hole in the heart and stuff like that. It was so primitive. And then suddenly the explosion of that happens. You know what I’m saying? And it was really amazing. And I lived the infantile stages of cardiac surgery, and I saw it in the beginning of it. And now, I think still pain management is still in the infantile stages. The newer generation that we teach and they are going to practice, they’re going to enjoy so much more discoveries that’s going to be. Like a lot of now medication that’s concentrating on different mechanism than the opioid mechanism.
So, this medication is going to control your pain through sodium channel. It’s going to control them through acetylcholine, which is not related at all to the opioid. So, that means you’re not going to have an addictive things from it, but you’re going to have wonderful thing. Monoclonal antibodies. This is something that you heard about it in COVID. We have it now for patients with migraines and stuff like that. So, it’s already approved. And then we go to the technologies. Now, the technologies are getting so much, now, there is a special area in the brain. We call it the insula, which is where we think that all the connection for the chronic pain between psychological, physical, all that stuff connect together in that little area. And now they are thinking about putting deep brain stimulation that we use for movement disorder, Parkinson’s disease and stuff like that, we put it next to it and that will control the chronic pain from the brain itself.
So, the advancement, like for example, we have now a snail venom, which is a principally calcium poly peptide, calcium channel blocker that we injected intrathecally spinal in the spinal and that takes care of the pain without having the patient getting any opioid therapy. So, really the advancement in medicine, in pain management, I think, and maybe it’s bad to say, but I think the opioid epidemic actually helped to enhance pain management significantly and made these companies start going to research because there is funding coming from the government. And as you know, if there is no government fund, nothing moves, really. Remember the brain is the Pandora Box. We don’t know much about it. We have the imaging tell us anatomy, but we don’t know the function. So, there is functional MRI that came in the market a few years ago, which is whenever you touch your hand, somebody touch it or burn it or something, it lights in the brain somewhere and we can know which area in the brain is reacting to it and doing it.
Magnetoencephalography is a machine actually, it’s calculate the magnetic field from the electricity that the brain make. So, imagine how much like an EEG, measure the electricity in the brain. So, we can tell us if there is a focus brain and area in the brain and stuff on that. So, this one here, it measure the magnetic field that the electricity in the brain seeing. Imagine how minute is this thing here? And the impact of that really is endless, what’s going to happen. I mean imagine if you can, the way you can diagnose radiculopathy, you can diagnose bipolar disorder or schizoaffective disorder and you know which area in the brain that you can target to treat that disease. You know what I’m saying? I mean it’s really beautiful things what’s going on, you know.
The other thing is gene therapy. Gene therapy actually started in Flint, Michigan. And what they did is they took the virus that causes shingles and modified it, and they injected in the cancer pain patient that they have involvement of their intercostal nerves. So, they injected the nerves in the periphery around it. So, the virus migrated to where they usually the virus migrate and goes to the posterior ganglia. And that’s when the increased the endorphin and the pain relief from that. It was really amazing. So, they started the studies on it and stuff like that. It hasn’t been really available yet, but that’s an example of what we can do to do things differently.
Now, you have regenerative medicine. Regenerative medicine is a field that we do as well, but it is really on a small scale yet. But the research that has been done now, it’s unbelievable. I have my daughter, she is PhD in biomedical engineer, and she does all these research and studies, and I love talking to her because I know what’s right and what’s wrong in regenerative medicine. You know what I’m saying? So, it’s fun.
Macie Jepson
Oh, that apple didn’t fall far from the tree. So, what is the pathway to a pain management doctor?
Dr. Kutaiba Tabbaa
Well, it’s really simple. I mean, you have to find the doctor that you really have a reputation that you like. You don’t want to have, you need the doctor that has a good credentials. And you want to have, most of the insurance companies, they require prior authorization and referrals. So, you may have to go through your insurance company to get those done first before you come. But most of the time the primary, if you tell the primary care your problem, stuff like that, your primary care say, okay, you need to see a pain management man. You know what I’m saying? So, let’s go and send you to a guy that you know and trust and whatever, and you start from that route. So, I really think it is the job of the person himself and the primary care physician to get the patient to the pain doctors early in the process, not late in the process.
To give you an example, a patient who has developed complex regional pain syndrome, which is principally in neuropathic pain happen after trauma to your foot and stuff like that. And I had few of them. And this disease, if you don’t treat it quickly, the leg will atrophy and you lose your leg. I mean, this is how bad it is. While if you send them early, and we start working on them, extensive work between us, occupational therapy, physical therapy, psychology and injections and medication, all that stuff, the patient reverse the cycle and they can go back normal. So, it is really important things to identify. I mean, it’s like the same thing. You know, you don’t want to wait until you have a heart attack and arrest until you go and see your cardiologist. Just go and ask, you know.
Pete Kenworthy
So, the key really, it sounds like, is get to a pain management doctor who can then really be your quarterback. Your pain management doctor can figure out what kind of other therapies you may need, what kind of other physicians or treatments you may need. But talk to your primary care doctor, get to that pain management doctor, and that pain management specialist is going to be able to figure out the best plan for you.
Dr. Kutaiba Tabbaa
That’s what my hope is.
Macie Jepson
Oh, this is so exciting. You’ve given a lot of hope today. Is there any one takeaway that you want to leave with people in this conversation?
Dr. Kutaiba Tabbaa
It’s not too late to change. It’s never too late to change. I, myself, few years ago, I broke my back. I have a couple of vertebrae collapsed. Her name was Jet Ski. She was really fun. But anyway, I didn’t want anything to be done on my back, and I kept doing my life itself and working and working and working. And guess what? I gained more weight. I gained more weight, too. And then I end up having my knees arthritis really bad. I have a family history of knee arthritis. It’s like now I cannot move, my dog who is 17 years old, he can hobble in front of me and I walk half, you know, a quarter of a mile and I’m already dead. So, I decided to change my life. I went immediately on this type of ketogenic diet or this low carb diet and stuff because my body doesn’t like carb for some reason. And I went in the pool. I was doing pool exercises every day, every day, every day. And I lost the weight, and I was able to change my knee. And I never looked back. So, I changed my life to become better. And that’s what I tell my patient. Our job is to take them to the water and they have to drink.
Pete Kenworthy
It’s a great message. Never too late to change.
Dr. Kutaiba Tabbaa
Absolutely.
Pete Kenworthy
Dr. Kutaiba Tabbaa, Director of University Hospitals, Parma Comprehensive Pain Center in Greater Cleveland. Thank you so much for being here today.
Dr. Kutaiba Tabbaa
Thank you very much.
Tags: Pain, Kutaiba Tabbaa, MD