Seeing The Big Picture

A patient-centered approach to establishing neurological health.

AtMcGreevy NeuroHealth, the practice of board-certified neurologist and interventional pain management specialist Kai McGreevy, MD, DABPN, RPVI, RMSK, they have created an approach to establishing its patients’ neurohealth that begins with listening to the patient.

Photo of Dr. Kai McGreevy in office

Dr. Kai McGreevy

“Over the years, I have treated many patients with neurological, pain and musculoskeletal disorders, and often those were chronic and complex conditions,” Dr. McGreevy observes. “The prevailing theme was that these patients visited multiple physicians and other health care providers and still did not have their questions answered and did not feel better.

“Neurological disorders are among the leading causes of death in the US. In my experience, the field of neurology has made great strides with stroke, epilepsy and multiple sclerosis but has not focused nearly enough on pain, even though it is a neurological symptom.”

Dr. McGreevy says this may be true because most neurologists are objective-minded, and pain is largely a subjective experience that cannot be detected through an examination, blood test or MRI. Yet, pain affects more Americans than diabetes, heart disease and cancer combined.

Pain is the most common reason Americans access the health care system. It is a leading cause of disability and a major contributor to health care costs. Chronic pain is the most common cause of long-term disability. The negative impact of chronic pain on quality of life is more severe than that of heart failure, kidney failure or major depression and is comparable to terminal cancer.

The field of pain medicine has made mild advancements with neurostimulation but has otherwise been stagnant. And it has primarily treated symptoms and not causes. Pain medicine has been led by anesthesiology, largely a procedural specialty without a firm foundation in the nervous and musculoskeletal systems.

“Traditional pain management practices tend to have a limited scope of possible causes for pain, often attributing pain to the spine,” Dr. McGreevy notes. “What may be confusing is that sometimes an MRI reveals problems in the spine that often produce no symptoms, and the history and examination do not agree with MRI findings. Intervening with injections or surgery for the wrong diagnosis will result in poor outcomes.

“At McGreevy NeuroHealth, we implement musculoskeletal ultrasound at the point of care to seek out mimickers of spine and extremity pain, including injuries to joints, muscles, tendons, ligaments and peripheral nerves. Many times, pain is referred from these structures or may compound spinal pain problems. In my experience, these factors are often the causes of pain after years of failed spine injections from previous providers.”

Vascular medicine must be emphasized in pain medicine as well because proper blood flow is essential to the health of the nervous system. Since patients with multiple medical problems are more likely to suffer from chronic pain, one of Dr. McGreevy’s goals is to eliminate or prevent these problems to reduce risk of chronic pain.

“Identification of vascular diseases is critical because they often present acutely and may lead to serious life-threatening or limb-threatening problems,” he educates. “Pain is often the presenting symptom. Therefore, pain physicians should be equipped to identify vascular conditions early and manage aggressively.

“In our clinic, we implement vascular ultrasound to seek out causes for leg pain such as peripheral artery disease (PAD), blood clots or venous insufficiency that can mimic spine and nerve problems. Sometimes, we employ leading-edge laser and radiofrequency vein ablation treatments to ameliorate leg pain, swelling, heaviness, fatigue and cramping.”

Filling Holes

“There are holes in the specialties of neurology and pain medicine, and I know this because I face it when I see patients,” Dr. McGreevy reports. “Using feedback obtained from patients over many years, I morphed a hybrid of specialties that I term neurohealth.”
In neurohealth, Dr. McGreevy brings together the best of the specialties of neurology, pain management, musculoskeletal medicine, vascular medicine and mental health. Anything that directly or indirectly affects or has the potential to affect the nervous system is under its purview.

“I have found that diagnostic persistence, diagnostic precision, vascular disease assessment, health and wellness assessment, and mental health assessment are areas that are profoundly lacking in our current management of patients and current delivery of health care,” Dr. McGreevy asserts.

“When I see patients, I spend extra time with them simply listening to them describe what is irritating them so I can get a better understanding of how their conditions are affecting their lives. If a patient comes to me with low back pain, for example, I must determine how that pain impacts that person as a whole.”

The information-gathering process at McGreevy NeuroHealth begins with completion of the new patient paperwork.

“We start learning about the patient the moment they complete the paperwork so that we are prepared to identify potential issues and tackle them by the time the patient is seen,” Dr. McGreevy offers. “The value patients receive at McGreevy NeuroHealth far surpasses a neurology or pain clinic because we have the perspective and the overall patient in mind.

“I’ve learned through years of practice that the more information I glean from the patient, the more I am able to help them and the more they trust me as a physician to do the right thing. That’s the neurohealth philosophy.”

There is a secondary benefit to Dr. McGreevy’s methods. Though he specializes in neurology and subspecializes in interventional pain management, he also evaluates the patient’s general health. That helps him diagnose conditions related to overall neurohealth.

“Patients with chronic diseases such as diabetes, high blood pressure, high cholesterol and vascular disease, including histories of stroke or heart attacks, have a higher incidence of chronic pain, memory disorders and other neurological syndromes.

“Our approach is to strip down the list of risk factors that play into the big picture and address those risk factors with the patient. This may require testing to better understand what those risk factors are and how they are related.”

Detective Tools

McGreevy NeuroHealth uses interventional pain management, musculoskeletal medicine and vascular medicine to direct successful treatments. Testing is tailored to each patient based on symptoms.

Dr. McGreevy uses ultrasound to diagnose disorders of the muscles, tendons, ligaments and nerves.

Musculoskeletal ultrasound is used to dig deeper into the causes of pain from neurological entities as well as issues with joints, ligaments and tendons. It enables Dr. McGreevy to see how these body parts work in a dynamic fashion.

Ultrasound is unique to MRI and CT for this purpose because MRI and CT are static images. With ultrasound, however, physicians can take high-resolution, moving images while the patient is performing a physical maneuver such as flexing the joint. This allows them to visualize mechanical problems with the joint or soft tissue.

“The beauty of musculoskeletal ultrasound is that I can actually see the potential problem in real time,” Dr. McGreevy says. “The problem may be a nerve entrapment or adherence of a nerve to a specific structure, as in carpal tunnel syndrome. Another example is identification of a degenerated rotator cuff or meniscus in the knee causing chronic pain.

“The problem may be an underlying rheumatological disorder such as rheumatoid arthritis or lupus creating joint swelling or inflammatory fluid not due to wear and tear. Having the overall neurohealth concept allows us to catch systemic conditions and sometimes leads us to identification of downstream pain or neurological problems.

“We employ electromyography (EMG) and nerve conduction studies to evaluate large fiber nerve problems and spinal nerve root issues, and localize the source of pain, numbness, tingling and weakness,” Dr. McGreevy describes. “We also utilize autonomic nervous system testing (ANSAR) for detecting disease involving small nerve fibers and vessels, which can be seen with autonomic disorders not readily assessed by EMG or ultrasound.

“ANSAR will sometimes prompt investigation into prediabetes as painful neuropathies may be the presenting symptom of uncontrolled blood glucose. ANSAR also enables us to identify autonomic causes for light-headedness, pre-syncope or syncope when the nerves to the heart and blood vessels are diseased.

Many patients with neurological and pain conditions are susceptible to balance disorders dizziness, vertigo and falls, which are a major cause for morbidity and mortality.

Dr. McGreevy reports: “In our Fall Risk Program, we utilize neurological examination, imaging and video and electrical testing known as VNG to identify where balance issues originate.

“We treat patients with headaches and vision problems in our Headache Center using fundus photography, which detects pathology much better than a standard bedside fundoscopic exam. This test is particularly beneficial for ruling out increased, potentially life-threatening intracranial pressure.

“Electroencephalography, or EEG, allows us to evaluate brain function in addition to understanding the brain’s susceptibility to epilepsy and other seizure disorders presenting as spells involving memory lapses, blank staring, speech arrest, vertigo and confusional states. Sometimes these symptoms are subtle, and an interruption of signals is the underlying cause.

“Within our Spells and Epilepsy Program, we employ video EEG monitoring to synchronize the EEG recording to the time the patient is experiencing symptoms. This way we can identify the exact seizure subtype and treat specifically.

“Our Memory Disorders Program uses eVox, a neuropsychological assessment for cognitive problems such as memory loss, brain fog, brain fatigue, confusion, attention and concentration deficits, and difficulty with multitasking. Dr. McGreevy uses the eVox to see electrical activity in the brain and measure responses to stimuli, essentially testing certain brain regions for adequate firing.

“The eVox is particularly useful in patients with cognitive complaints in association with headache, traumatic brain injury (TBI), mild cognitive impairment, memory disorders, attention deficit disorder, depression, anxiety, and stress and pain conditions,” Dr. McGreevy states. “We know that cognitive problems occur in neurological and psychiatric conditions such as stroke, multiple sclerosis, Parkinson’s disease and epilepsy.

“We also know there are specific pain pathways taking messages to specialized brain centers for processing and producing behavioral responses to pain. Patients are often overwhelmed with what starts out as pain but develops into a pain, stress, anxiety complex, which amplifies the pain experience when the patient may not recognize it is happening.

Easing stress and anxiety profoundly reduces the experience of pain. Addressing these components of stress and pain are crucial for overall management of the problem. Identification of regions of interest that are firing abnormally may be targeted for correction through a non-invasive treatment such as EEG neurofeedback, which is available at McGreevy NeuroHealth.

“With EEG neurofeedback, the patient can be taught brain-training approaches, akin to physical therapy for the brain,” Dr. McGreevy describes. “I don’t believe this technology is utilized enough in other practices for the benefit of patient care.

Beyond Standard

Dr. McGreevy uses all treatments available within the practice of interventional pain management, including ultrasound-guided trigger point injections, facet blocks, radiofrequency ablation, spinal cord stimulation, and epidural and steroid injections.

“In addition to these standard interventions, we also have regenerative treatments specific to failing joints, tendons, ligaments and soft tissues,” Dr. McGreevy notes. “Often, patients do not need surgery to fix shoulder, knee, foot or ankle problems, or conditions such as carpal tunnel syndrome. Sometimes, I can perform minimally invasive injection treatments under ultrasound guidance instead.

“Using ultrasound, I can direct the needle to within a millimeter of the structure I am approaching. That cannot be done with MRI or CT. Not only is that not feasible with those modalities, those tests are also much more expensive to use.”

According to the doctor, McGreevy NeuroHealth is doing more than other pain management and neurology centers in the country. They have combined the benefits of neurology and pain management as well as musculoskeletal medicine, vascular medicine and mental health to optimize patient care.

“The patients in previous Florida Health Care News articles are pleased with their outcomes, but perhaps even more importantly, they attest to our process and our approach to care,” Dr. McGreevy reports. “Our internal outcome measures at McGreevy NeuroHealth further support this.

“The nervous system has such a broad scope from head to toe. Pain has an even broader scope because it involves physical problems and also impacts the mental well-being of the patient.

“By virtue of these specialties, the job of a neurologist, in my opinion, is to become a better pain management specialist. In turn, a pain management specialist must become a better neurologist.”

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