00:00 – Dr. Fogelson: But you have this pain radiating down the leg even though there’s
00:03 – nothing wrong with the leg. So that’s a referred
00:04 – pain.
00:05 – Melissa: So what’s the difference between this referred type pain that you were talking
00:15 – about and nerve dysfunction? Is that the same thing or something different?
00:22 – Dr. Fogelson: Well, one can cause the other. So nerve dysfunction is a very
00:27 – generalized term. I don’t know what it means per se. It means that something’s
00:34 – not working right within you.
00:40 – But referred pain means that there’s an injury happening in one place but it’s
00:46 – being felt somewhere else. So again, somatic pains. If you have a injury at
00:47 – let’s say your
00:51 – first lumbar nerve root, and it could be you have a ruptured disc and it’s pushing
00:54 – on the first lumbar nerve root, we would expect there to be pain radiating down the
01:01 – front of the leg going down to the knee. So that’s a referred pain. Now, you may have
01:06 – pain in the back itself also, but you have this pain radiating down the leg even
01:10 – though there’s nothing wrong with the leg. So that’s a referred pain. Another classic
01:14 – referred pain in endometriosis is someone that has diaphragmatic pain. They have
01:18 – diaphragmatic endometriosis. They can feel pain in their shoulder, they can feel
01:22 – pain in their neck, and they can feel pain in their ear actually. And the
01:26 – diaphragm is innervated by the phrenic nerve, which is the third, fourth, and fifths
01:32 – cervical nerve roots. And so this is C3, this is C4, and this is C5 on our skin. And so
01:37 – brain just gets confused because it’s getting a signal of the phrenic nerve
01:42 – that’s saying, ow! But the brain doesn’t really expect to feel pain in the diaphragm.
01:47 – We’re not evolved to devote very much of our brain to looking for pain in the
01:52 – diaphragm because that’s not something that we would expect to hurt. And so when
01:57 – the brain gets this signal going up C3, 4, and 5, it says, oh, it must be my
02:02 – shoulder, it must be my neck, it must be my my face. So your brain is perceiving pain
02:07 – here when there’s nothing wrong with these tissues. The problem is in the diaphragm.
02:12 – Facing this, there’s lots of redundant nerves that come together, and where nerves come
02:16 – together and they share common pathways, the brain often is using a best
02:21 – guess at what the signal is. And sometimes it gets it wrong. And when it
02:25 – does that, it tells your brain, it tells your your conscious mind, that you’re feeling
02:30 – pain somewhere that’s not actually where the pain is coming from. And so
02:36 – that’s the concept of referred pain. And it also works in visceral pains. Visceral pains
02:52 – refer differently. So if your right colon hurts, you’ll generally hurt up here. If you have
02:53 – thoracic endometriosis, you’ll probably hurt up in your upper chest. And that actually
02:54 – works at the first
02:55 – nerve plexus. Where the visceral and somatic nerves come together are these
02:55 – nerve plexuses.
03:00 – Where the visceral nerves enter into a nerve plexus, and when there’s about six of
03:01 – them from the bottom to the top, that’s where you’re going to feel the pain. So the
03:08 – right colon, all those nerves come up and they enter the celiac plexus right here, and
03:12 – somewhat superior mesenteric plexus, which is similar location, actually. So that’s
03:16 – where you’re going to feel the pain. And that’s
03:20 – classically – also, I don’t know if you know – but classically when someone has an
03:20 – appendicitis, they start out with having pain in the center of their abdomen.
03:28 – Because the colon is hurting, radiating there through visceral pains, and then once
03:33 – the appendix starts inflaming, the peritoneum, the skin on the inside of the
03:37 – belly… so the peritoneum is somatically innervated so
03:40 – you can feel where you hurt on your peritoneum. So when it’s just the appendix
03:40 – that’s inflamed, you feel the pain in the middle. That’s a visceral referred pain. But
03:48 – then, once it starts inflaming
03:51 – the actual appendix, and that tissue around there is getting inflamed then,

03:57 – now you start feeling it there. So that’s somatic. So that’s just an example of
04:04 – the concept of “nerve dysfunction.” Again, it’s a wastebasket term that means
04:05 – nothing to me. But
04:11 – if you have things that are inflaming nerves, that’s not a lesion, it’s just a
04:17 – state where the nerve is inflamed. Just like, let’s say that you got an infection in
04:18 – your hand,
04:25 – and it’s all red and swollen. It’s not something you could cut out. It just
04:32 – has to heal. And in the same way, nerves can get inflamed. If you were to literally cut
04:32 – the nerve and put it in a slide, you’d find inflammatory cells within the nerve like
04:39 – leukocytes and mast cells, and you’d find steady inflammation. Going in there and
04:45 – trying to
04:51 – operate on that is not going to work. The nerve’s just inflamed. Now, if there’s
04:54 – endometriosis,
04:58 – and we remove the endometriosis, and the nerves around there are inflamed,

05:02 – we’ve removed that source of inflammation. And so now we’ve given the
05:05 – body an opportunity to heal. But that opportunity is happening over a long
05:09 – period of time, and nerves heal very, very slowly.
05:13 – It’s probably the slowest healing tissues in the body.
05:16 – Melissa: How long does it generally take?
05:19 – Dr. Fogelson: Six months to two years. A long time. And the spinal cord doesn’t heal
05:24 – at all. So the central nervous system and the spinal cord doesn’t heal at all. If you cut
05:31 – your spinal cord, it doesn’t doesn’t grow back, whereas your peripheral nerves
05:34 – actually will grow back over a long period of time. And so if you injure the nerve, and
05:38 – you can take away that source of inflammation,
05:41 – you can expect healing. But people have to be really, really patient.
05:46 – That’s one of the most difficult things about it. When you think someone has
05:46 – neurologic pain,
05:51 – it’s hard to tell someone, you will probably be better two or three years from
05:53 – now.
05:57 – Melissa: So there anything that you could do to support that repair process?

06:01 – Dr. Fogelson: Well, not that I know of. You can support

06:07 – making the pain better. So if you take Pregabalin or you take Gabapentin or you
06:08 – take Duloxetine, these things are chemically reducing the signaling of pain through
06:15 – these nerves. And so it doesn’t make the heat nerve heal any faster but it can make
06:22 – pain life more tolerable.
06:26 – And then you can look at sort of pain management strategies too.
06:34 – One of the things I see is that, when someone suggests that a patient go to
06:35 – pain management, they think that they’re being rejected, and they think that they’re
06:41 – being told, I can’t deal with it anymore, go to pain management. Which is not how it
06:46 – should be thought of.
06:48 – You should think, there’s a primary reason the patient’s in pain, and

06:53 – we’re going to try to deal with that, potentially surgically, whatever. But then
06:53 – we’re going to be left over with the nerve inflammation and just the pain, and maybe
06:59 – that’s going to get better over a long period of time. But pain management doesn’t look
07:05 – at pain as, we’re going to fix the primary source. Pain management says that, we’re
07:09 – going to get in between this pain in your brain
07:11 – and we’re going to do something that keeps your brain from experiencing this
07:12 – pain.
07:17 – And that’s also a very valid strategy. It doesn’t fix anything in the long run,

07:21 – but it can make life much more tolerable while that other thing is healing, hopefully.
07:26 – Melissa: Is this when nerve block techniques would come in?
07:29 – Dr. Fogelson: Nerve blocks, neurostimulation. So there’s ways of
07:32 – electrically stimulating the spinal cord or electrically stimulating nerves, certain
07:38 – nerves, and basically interrupting that signal. The most simple version of that is a
07:44 – TENS unit, if you guys know what a TENS unit is. So a TENS unit is a very crude
07:51 – neurostimulation. And basically a nerve is an electrical wire.

07:56 – It’s really a biologic electrical wire. That’s exactly what it is. But rather than carrying

08:05 – electrons through copper, it’s carrying electrons through conductive fluid. And

08:11 – then it has connections on either end that this electricity causes chemical reactions
08:12 – that release neurotransmitters and so forth. But, importantly, it’s electrical. And
08:18 – so
08:22 – you can interfere with that electrical signal, usually with other electricity. So if you can

08:28 – constantly keep the nerve in a depolarized state by constantly stimulating the nerve, it
08:28 – can actually keep pain signals from going through the nerve.
08:35 – Melissa: Is it safe to use the TENS machine for a long period of time or every single
08:35 – day?
08:36 – Dr. Fogelson: I think so, yeah. I don’t think it’s harmful.
08:38 – Melissa: Do you think it would work for people with bladder pain? I know a lot of
08:48 – people use it for period pain and other endometriosis pain.
08:53 – Dr. Fogelson: Oh, great question! It should work but where should you put it? Well, I’ll
08:55 – tell you where to put them, you should put them on your put them on your foot.
09:00 – Can i share my screen with you? Are you seeing my screen? That’s where you should
09:06 – put it. What that’s doing is you’re going to stimulate the posterior tibial nerve, and
09:07 – why are we doing that we’re doing that because that nerve you’re stimulating is S2,
09:16 – which is also creating
09:20 – somatic sensation from the bladder. So bladder somatic sensation is coming
09:26 – through S2, S3, and S4
09:27 – whereas bladder visceral sensation is coming through the inferior hypogastric
09:28 – plexus. So if you’re having a somatic pain of the bladder and you stimulate these
09:35 – nerves, you’re going to block that pain to some extent.
09:39 – Melissa: Would this also explain why some people say they have pain in their foot
09:44 – when they have a UTI?
09:44 – Dr. Fogelson: Exactly why it’s referred pain.
09:47 – Melissa: What other areas in the body are you likely to feel pain if you have a UTI?
09:52 – Because people have described some pretty weird-sounding symptoms but it
09:59 – sounds like there could be many different places.
10:00 – Dr. Fogelson: Well, the visceral pain can radiate into the back, you can get rectal
10:00 – pain, you could get uterine cramps. Those are probably the most common. The other
10:07 – thing I’ll tell you is that visceral pains rise in the body, so it all goes through these
10:14 – Nerves coming from the sides and all these different organs. And then they hit these
10:18 – plexuses, and then the plexus is bridged to other plexuses. What I’ve experienced is
10:22 – that if you have a really, really strong signal, you can get all the way to higher plexuses.
10:27 – And so somebody with a really, really strong visceral pain in the low pelvis may
10:32 – feel pain in up in their chest, they may feel pain in their upper abdomen. And I
10:36 – think what’s happening is that the electrical signal is actually so strong that
10:41 – it’s getting all the way up into the upper plexuses. And I think that’s what’s going
10:46 – on,
10:48 – the other thing I mentioned to you, is in this picture right here.

10:52 – This is how acupuncture works, I believe. I think the whole concept of Chinese
10:52 – meridians and so forth is nonsense, but but that a model that led people to
10:58 – understand. It led people to have a predictable way to map out where, how
11:09 – you put a needle in someone and what impact it may cause in their body. But I
11:15 – think the fundamental model is incorrect. I think the correct model is that we’re
11:20 – dealing with cross-innervation and that you’re stimulating one area that shares an
11:25 – innervation with the area you’re concerned about. And so
11:30 – the better acupuncture model would be a really detailed map of the human nervous
11:32 – system than this concept of you know spleen chi and so forth. I’m not a Chinese
11:40 – medicine doctor, but
11:43 – in my opinion I think those models are probably wrong, but I think that they predict
11:44 – correctly.
11:52 – I had a picture here how in pre-Copernican times, they had a model that

11:59 – predicted where all the planets would be, but it had the earth in the center of the
11:59 – solar system.
12:03 – The models correctly predicted where the planets would be,

12:07 – except that the earth’s not the center of the solar system. So the problem is it doesn’t
12:07 – work.
12:14 – Obviously when you understand that the universe is bigger than our solar system,
12:14 – the whole model falls apart. But within that simple system, it worked. Just like I think
12:15 – that Chinese medicine is a correct model of why acupuncture works in certain areas.
12:25 – And so this particular area is kind of a crossover between sort of Western
12:33 – understanding of neurology and acupuncture.