Medical Pain Management

How can we control pain? There are a variety of ways to deal with pain which include specialized focused injections, medical treatments to help arthritic joints, nerve blocks for spinal pain...

How can we control pain?

There are a variety of ways to deal with pain which include specialized focused injections, medical treatments to help arthritic joints, nerve blocks for spinal pain, medical procedures to fix damaged tissue, the administration of drugs, or psychological ways to manage coping with pain. Meditation and guided imagery (concentration of the mind on a relaxing image) are methods of relaxation therapy that can help with pain management. Additionally, for those who suffer from chronic pain such as osteoarthritis, there are benefits from injections that return the vital lubricationback into painful joints.

There are a variety of ways to deal with pain which include specialized focused injections, medical treatments to help arthritic joints, nerve blocks for spinal pain, medical procedures to fix damaged tissue, the administration of drugs, or psychological ways to manage coping with pain. Meditation and guided imagery (concentration of the mind on a relaxing image) are methods of relaxation therapy that can help with pain management. Additionally, for those who suffer from chronic pain such as osteoarthritis, there are benefits from injections that return the vital lubricationback into painful joints.

Why are ultrasound-guided injections better and more accurate?

When administering an injection to deliver treatment into painful joints, it is necessary to be exact and precise.

Consider trying to hit a target blindfolded you may know the general direction but would not be certain if you have actually hit your target. With live ultrasound imaging, the targeted areas of pain are viewed in real time while the injection is taking place, guiding the needle with pin-point accuracy.

Ultrasound Guided Injections:

Dr. Norma Bilbool and her team are highly trained in ultrasound-guided injections. These procedures are performed in the office, at the time of your visit. Some of the common structures involved in joint pain may be as little as 2-3mm wide and therefore require a high level of precision to be accurate. In addition, when performing an injection, there are also structures that you want to avoid so you don’t knick or damage them on your way into the joint. The ultrasound machine provides live imaging in real time, to safely place injectable medications or treatments into or around the joint with laser-like precision.


A combination of steroid medication and local anesthetic will provide pain relief and decrease inflammation caused by an intra-articular injury or arthritis. A patient can receive a cortisone injection every 3-4 months as needed to combat pain.

Platelet Rich Plasma Therapy:

Why use PRP?

When there is damage, tissue tears or arthritis, this exciting new procedure (made popular by professional athletes) that heals damaged structures in a joint such as the labrum, tendons, muscle, ligament or cartilage is showing exciting results!

How does PRP work?

When you cut your skin and it bleeds, platelets collect and gather at the wound site. Once there, platelets act like a conductor in an orchestra. They release growth factors that signal the healing activities to begin, resulting in a cascade of events that restore the damaged tissue.

Joints, however, do not have a direct blood supply. Therefore, when a joint structure is damaged or torn, platelets do not gather and orchestrate the necessary events for that damage to be restored. Joint damage either heals slowly or not at all. That is where Platelet Rich Plasma Therapy (PRP) proves valuable!

 Lubrication for Arthritis:

A squeaky gear needs the most oil!  

The joints of the body are normally surrounded by a fluid that acts as a lubricant and shock absorber. This fluid is lacking in patients with osteoarthritis, and leads to pain and inflammation in the joints.

Hyalgan is a naturally derived lubricant that instantly cushions and lubricates painful arthritic joints. By restoring lubrication and cushion, your joints move more freely again with less friction and most importantly, less pain. Hyalgan is injected using continuous live ultrasound guidance ensuring pin-point accuracy exactly where it is needed.

Regenerative Medicine

A Specialist at Optimum Joint says New Treatment Using LIPOGEMS® Could Be the Answer for Arthritis Pain in the shoulder including the rotator cuff, the lower back, hip, knee and other joints.

LIPOGEMS® Could Be the Answer for Pain from Arthritis, Shoulder including Rotator Cuff Tear, Lower Back, Knee including Meniscus and others

JOINT DIAGNOSIS: Diagnostic Ultrasound Imaging to See the Entire Joint

Unlike an X-Ray where all you see are bones, with ultrasound imaging you can view all of the joint structures both internal and external including bone, cartilage, joint capsule, ligaments, tendons and muscle, thus precisely viewing the causes of joint pain. Then, using the streaming ultrasound imaging the needle can be guided with pin-point accuracy ensuring treatment is delivered exactly where it’s needed. Non guided “blind” injections are shown to be 35%-60% accurate while ultrasound guided injections are 100% accurate. This ensures the treatment is placed exactly where it’s needed into every area where the damage is.

LIPOGEMS® is a new treatment option for arthritis pain now offered by Dr. Norma Bilbool, M.D., a double board certified physician specializing in physical medicine and rehabilitation and pain medicine and Dr. Richard Striano, DC., RMSK Certified in Diagnostic Ultrasound and trained in Interventional Ultrasound Guidance..

LIPOGEMS® JOINT REGENERATION: Regeneration with Lipogems Micro-Fragmented Adipose

Optimum Joint, is equipped and has been performing ongoing clinical studies on the shoulder, rotator cuff, lower back, hip and ankle pain where a patient’s own fat is used to alleviate arthritis related conditions. Optimum was among the first practices in the USA trained in the state-of-the-art treatment through LIPOGEMS® technology that is a minimally invasive same day procedure, performed in about an hour and could be the answer for many of those looking to avoid surgery.

There are two sources of regenerative elements in the body, bone marrow and adipose tissue. Adipose has been shown to have more than 100 times as many regenerative cells and bioactive elements and is easy to harvest. Most patient are happy to lose a little fat. Using a local anesthetic with no sedation required, a small amount of fat is taken from the belly area. No cosmetic changes occur. The fat is then processed into Lipogems and using ultrasound imaging to guide the needle every nook and cranny needing treatment is given LIPOGEMS®.

Fat contains over 100 proteins associated with tissue repair and increase blood flow as well as regenerative cellular elements. Our clinical studies using Lipogems have shown excellent results with pain from shoulder, rotator cuff, lumbar spine, hip, knee and ankle conditions. Other joints including the elbow and hands have shown similarly excellent results.

YOUR LIPOGEMS® VISIT: The LIPOGEMS® treatment is done using a small amount of fat taken from the belly area of the patient using a local anesthetic in one office visit. There is no sedation required and no down time. After processing Lipogems, the medical doctor uses ultrasound imaging to guide the adipose during injection with pin-point accuracy exactly where the damage is located. Immediately after the treatment most patients feel significant pain relief. In some patients that relief lasts 5-12 hours and the pain may come back. The next day and over the first 5-7 days there may have ups-and-downs and gradual improvement with peaks of improvement at 5 weeks, 3 months and 6 months according to our clinical studies of all cases treated. The majority of patients treated have shown significant improvement with less pain, improved function and improved quality of life even after other treatments have failed and with joints diagnosed as bone-on-bone osteoarthritis.

NEW STUDY: Adipose tissue contains Adipose Derived Stem Cells “ADSC’s” and more than 600 secreted proteins and included key molecules involved in tissue regeneration. Stem Cell Res Ther. 2015; 6: 221.

NEW STUDY: Lipogems Product Treatment Increases the Proliferation Rate of Human Tendon Stem Cells without Affecting Their Stemness and Differentiation Capability. Results showed that the Lipogems product significantly increases the proliferation rate of hTSCs (human tendon stem cells). Moreover, treated cells increase the expression of VEGF, which is crucial for tissue healing. Stem Cells International Volume 2016 (2016), Article ID 4373410, 11 pages

Dr’s. Bilbool and Striano are among few doctors in the country offering IRB- approved regenerative treatment options using, with a focus on minimally invasive alternatives to surgery. Her work has been recognized and is currently due to be published.

“This is an extraordinary study because of its use of micro-fragmented fat tissue, which makes it more bioavailable to the area we inject, and by using the precision of ultrasound guidance the treatment is visualized being delivered to each area of the joint and tissues in need of repair. “This combination is contributing to the long term impressive results we are seeing”

Patients are monitored to measure improvement for 6 months following Lipogems treatment. We keep a close eye on your case.


What are trigger points?

Also known as trigger sites or muscle knots, trigger points are hyperirritable spots in muscles that are associated with palpable nodules—lump-like knots in tight tender bands of muscle fibers.

Unexplained pain frequently radiates from these points of local tenderness to broader areas, which are sometimes distant from the trigger point itself. There are reliable referred pain patterns which associate pain in one location with trigger points elsewhere. For example a trigger point in the shoulder can radiate pain into the arm.

Compression of a trigger point elicits local tenderness, referred pain, or local twitch response. The local twitch response is not the same as a muscle spasm. This is because a muscle spasm refers to the entire muscle contracting whereas the local twitch response refers a small twitch, no contraction.

Diagnosis of trigger points

Trigger points are diagnosed by examining signs, symptoms, pain patterns and manual palpation. Usually, there is a taut band in muscles containing trigger points, and a hard nodule can be felt. Often a twitch response can be felt in the muscle that activates the “all or nothing” response in a muscle that causes it to contract. Pressing on an affected muscle can often refer pain. Clusters of trigger points are not uncommon in some of the larger muscles, such as the gluteus group (gluteus maximus, medius or minimus in the buttocks). Often there is a heat differential in the local area of a trigger point.


Our Approach:

A successful treatment protocol relies on identifying trigger points, resolving them and if all trigger points have been deactivated, elongating the structures affected along their natural range of motion and length. In the case of muscles, which is where most treatment occurs, this involves stretching the muscle using combinations of passive, active, active isolated AIS, muscle energy techniques MET, and stretching the local area affected. Fascia (soft tissue coverings) surrounding muscles are also treated, with myofascial release to elongate and resolve strain patterns, otherwise muscles will simply be returned to positions where trigger points are likely to re-develop.

Specialized Physical Therapy: Our myofascial trigger point therapists may usemyotherapy (deep pressure), massage, mechanical vibration, pulsed ultrasound and electro stimulation to de-activate the trigger point and relieve pain.

Trigger Point Injections:

Trigger point injections (TPI’s) are a valuable option in treating pain experienced by many patients including,Myofascial Pain Syndrome and Fibromyalgia. The Injections, which include: saline, local anesthetics and cortisonecan provide more immediate relief and prove effective when other methods fail. The injections are performed using continuous ultrasound guidance to ensure pin-point accuracy.

These procedures are effective in treating pain inyour muscles, joints, neck, mid back and lower back.

Most health insurance will cover trigger point injections.

Epidural Pain Management: Using local anesthetics

Patients with known diagnoses of herniated discs or pinched nerves in their neck have complaints that include numbness and tingling, as well as weakness in the arms or hands. Patient may feel weakness in the grip, holding or squeezing objects.

What is an epidural and why is it helpful?

Nerves travel through the epidural space to the neck, shoulder and arms. Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc or from contact with the bony structure of the spine in some way.

An epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, reducing the pain in the neck, shoulders and arms, as well as numbness and tingling into the arms. The epidural injection may help the injury to heal by reducing inflammation. It may provide permanent relief or a period of pain relief for several months while the injury or cause of pain is healing.

What happens during the procedure?

The patient is placed on the injection table with stomach facing downward.The injected area is cleaned and sterilized and a local anesthetic is administered to numb the area of the injection site. After the numbing medicine has been given time to be effective, we direct a small needle, using x-ray guidance called fluoroscopy into the epidural space. A small amount of contrast (dye) is injected to insure the needle is properly positioned in the epidural space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected.

Patients are able to get up and drive home after the procedure, as we do not use any general anesthesia. The procedure is performed in the office and takes approximately 30 minutes.

Facet Joint Pain Management

The small joints in your neck that guide movement back and forth, up and down and around arecalled facet joints. They are small circular joints that are surrounded by a joint capsule. Facet joints are commonly affected by arthritis and inflammation of the capsule called capsulitis. This type of condition results in stiffness and pain with ranges of motion and physical activity, in addition to the constant need to change sleep positions.

When the facet joints and capsules are the primary problem, pain is most often localized to the neck on either side, and usually does not include numbness or tingling into the arms or hands.

What is a Facet Joint Injection?

Facet Joint Injection is an injection of long lasting steroid (“cortisone”) in the facet joints, which are those that guide movement in your neck. These are actual joints with joint capsule that contains lubricating fluids.

What is the purpose of a Facet Joint Injection?

The injected steroid reduces the inflammation and/or swelling of tissue in the joint space. This may in turn reduce pain, and other symptoms caused by inflammation and irritation of the joint and surrounding structures.

Pain management procedures conveniently performed in the office

Because we have all of the necessary equipment in our office for pain managementprocedures, you avoid the extra time and cost associated with having to schedule pain management at the hospital.  We provide the procedures using local anesthetics so there is no recovery time.

Patients are able to get up and drive home after the procedure. The procedures are performed in the office and take approximately 30 minutes!

Our Physical Therapy:  A Different Approach Other Than Routine Painful Exercises

We see many patients who come to us in chronic pain. Many have also had experience with physical therapy where they spent much of their sessions doing exercises and it hasn’t helped. Think of being in pain, having joint stiffness, loss of range of motion or chronic inflammation and then doing exercises to get rid of it. In most cases, you’ll feel worse not better.

Exercise is critical to maintain proper joint strength, but done at the wrong time and your pain often becomes worse. That is why we take an entirely different approach with treatment plans using three phases:

  • Therapeutic Modalities:

Our physical therapy team specializes in using certain modalities like electrical stimulation or ultrasound to reduce swelling and inflammation and increase local circulation to help the healing process. Different modalities can be applied to successfully address spasm, trigger points, inflammation, edema, swelling and damage from tendonitis and tears.

  • Joint Release Techniques:

Techniques are done by hand to gently stretch, massage and release the pressure in each of the muscles, tendons and ligaments surrounding the joint. The result is a soothing improvement in joint pain.

  • The Selective Functional Movement Assessment:

Our physical therapy team is certified in the Selective Functional Movement Assessment (SFMA), which is a series of 7 full body movement tests designed to assess fundamental patterns of movement such as bending and squatting in those with known joint pain. When the clinical assessment is initiated from the perspective of the movement pattern, our therapy team has the opportunity to identify meaningful impairments that may be seemingly unrelated to the main joint pain complaint, but contribute to the pain.

Think of having a painful right knee and favoring that side for an extended period of time. Following a period of uneven gait you may develop pain on the opposite unrelated side. This concept, known as Regional Interdependence, is the hallmark of the SFMA.

The assessment guides our clinical physical therapist to the most dysfunctional non-painful movement pattern, which is then assessed in detail. By addressing the most dysfunctional non-painful pattern, the application of targeted interventions (manual therapy and therapeutic exercise) is not adversely affected by pain.

Our Mission Statement

We want to make a difference. We are dedicated to providing our patients with updated and current treatment alternatives for adults suffering with joint and spine pain. Our staff regularly attends several conferences per year on ultrasound guided interventional medicine with new and innovative, as well as traditional techniques in treating joint pain. This allows us to utilize and implement the practices and techniques of leaders in diagnostic ultrasound imaging and ultrasound guided treatment from Europe, Asia, Canada and the United States at prestigious institutions including the Mayo Clinic. We remain on the cutting edge of treatment objectives to help our patients feel better!



Can an OptimumJoint traditional or regenerative medical procedure help me? To find out if you might be a candidate for an OptimumJoint medical treatment procedure, complete our Optimum Joint Procedure Candidate Form online.