Interview with Dr. John Knab

Spotlight Series Topic: Interventional Pain Management and Rengenerative Therapies

Guest Name: Dr. John Knab

Guest Credentials: MD

Discussion Details: Current treatment options in pain management, regenerative medicine, patient expectations, and the flow of care.

Benefit of Watching: Learn from a leader in the pain management field and a local expert in Wilmington. This conversation also covers who should consider seeing a pain management MD, available treatment options, and what patients can expect.

Address of guest’s business: 1602 Physicians Dr STE 103, Wilmington, NC 28401

Joshua Lyon: Hi everyone, I’m Joshua Lyon, a physical therapist and the owner of AIM Advance In Motion Physical Therapy and host of the provider spotlight series. With us today is Dr. John Knab. He is board certified in both anesthesiology and pain medicine. He’s an interventional pain management specialist specializing in regenerative medicine and non-surgical spine and joint care. He is the founder here in town of the center for pain management and regenerative medicine. He’s also the founder of elite spine and joint which focuses exclusively on the regenerative therapies outside of his very busy professional life. He enjoys time with his family being active in Wilmington here and rumor has it a very strong love for pizza making uh having owned over 10 different pizza ovens. So, I want to dig into that here in a little bit, but uh it’s a little bit on the personal life. Ultimately, and I can resonate with this as a physical therapist. Uh truly rewarding seeing people regain function and get back to activities I love without going down the road of major surgery or long-term medications. So, know you’re going to learn a ton from him and I’m thrilled to have you on the show. Thanks for joining me, Dr. Knab.

Dr. John Knab: Thank you for having me. I appreciate it.

Joshua Lyon: Yeah, absolutely. I know um usually we dive right in and hear a little bit about your background and your story, but I do got to ask about the pizza making. We’re going to kick off with more of a personal note versus a professional because uh that is unique and as a love lover of pizza myself. Tell me a little bit about that personal hobby.

Dr. John Knab: Right. Well, I think it’s it goes back to childhood. It’s always been like my top five favorite foods. And uh yeah, maybe about 20 2010 I started trying to make pizza on my grill and then it just blossomed uh blossomed from there. And so um before you know it, I had uh you know, I’ve got a basically a professional uh woodfired oven in my backyard. Uh but when that’s too big uh you know, to fire up and I’m only cooking for two or three people, of course, I need differentiz pizza ovens. So that’s why I ended up getting getting uh maybe uh probably a total of 10 throughout the years since then, but uh I think I’ve whittleled it down to uh one, two, three, four, probably down to five. And um

Joshua Lyon: you’re scaling you’re scaling back your operations here. Okay.

Dr. John Knab: Scaling back. Yeah. You know, trying to downsize, but uh yeah, it’s cool. So maybe u one day we can uh we can get together and uh you can have some our my pizza.

Joshua Lyon: Absolutely. Let me know when the uh to- go orders are available, too. I’ll I’ll swing by and grab some. But uh I know most people watching this are going to want to know more on the professional side of things. So, um let’s dive in a little bit. I always love hearing your story. What got you into healthcare, uh specifically pain medicine, and uh kind of your overall approach to care. So, what’s your what’s your story there?

Dr. John Knab: Sure. So, you know, rapid fire. My dad was a doc. He was a surgeon. And so, I kind of liked going into the hospital with him and kind of seeing how it worked there. I thought all the, you know, the whole organization of medicine was cool and um so that was my earliest exposure to medicine. I ended up doing premed and um and I was also I was a kind of a Spanish major and premed major at at Middbury up in Vermont and um then uh went to a medical school at the University of Vermont and uh from there went out to Seattle to do an anesthesia residency. So during during medical school, you know, um kind of cycle through all the different specialties. I thought surgery was going to be my my calling, but it turns out that um you know, another love of mine, being on the water and and doing stuff would interfere with um uh with the uh surgical demands. So, I thought, well, okay, I like the procedure-based stuff. I like kind of uh chemistry and and and biology, and I also, you know, kind of like the procedures. So, anesthesia was a good a good fit. And so I went out and did an anesthesia residency in Seattle. And as I was getting towards the end of that, I realized, you know, this wasn’t quite what I had envisioned for the rest of my life. I thought it was challenging. It was great, you know, um, a lot of pharmarmacology, a lot of physiology. Uh, but I was missing the the patient interaction. Obviously, you meet the patient before surgery, but then for the majority of your interaction with that patient, they’re asleep.

Joshua Lyon: Pretty limited conversation at that point.

Dr. John Knab: pretty limited conversation. So like a lot of my favorite times were in the preop clinic. So when I was evaluating patients prior to surgery, I was just getting their histories, you know, finding out why they were going into surgery and just kind of that’s what really intrigued me. And so uh I I came upon this field of interventional pain management uh towards the end of my anesthesia residency. And I ended up doing a fellowship in interventional pain management um in uh San Diego at the University of California. And uh that was kind of it just since then it’s it really kind of found me and um it’s been what I’ve enjoyed doing for the majority of my um my professional career and how it morphed into uh regenerative medicine um was kind of just you know the maturation of me as a physician as a as a you know person kind of looking at what we were doing. Um, you know, I I unfortunately kind of came up through this system right at the peak of the time where everyone was saying we must treat pain with narcotics. We must treat pain with narcotics, which we obviously all know now is a terrible idea, but that was what was being pushed on us by the educational system at the university level, you know, back in uh 19 the 1990s. So, I kind of realized a lot earlier than most that this was something that I didn’t like and uh we got away from that earlier than most. And then it got me thinking about other things that we do. you know, the steroids that we use, um, uh, the burning procedures with radio frequency that we use, which are fine and they all have a role, but what if there’s another way, you know, what if there’s a way that we can kind of slow down the disease process um, with things that come from us, you know, our own cells, our platelets, our stem cells from our bone marrow. Um, what if there were a way that we could use our own bodies to help heal ourselves? So back around 10 years ago now maybe 11 years ago I started looking into this regenerative medicine field and that’s kind of how it started and and again that’s just gone on from there. So you know the way I approach everyone in my practice now is I kind of look at the the problem you know try to you figure out what’s going on um and then for each individual there are different options you know and and I don’t think steroids are all bad. I don’t think radio frequency is all bad and I don’t think PRP and stem cells are always the answer either. So, I like to have as many tools in my toolbox as possible. I’ve really been kind of trying to sort out the, you know, the the real stuff from the false stuff. And we can get into that a little bit if we have time. But um you know I’m trying to help patients understand what their problem is and then give them options so that they can pick and choose how they want to treat it, not just live with the pain or surgery. There’s a lot in between, you know. So, um that’s kind of where I am at my this point in my career. Um and yeah, that’s kind of what I do.

Joshua Lyon: I love that, especially the fact that you’re taking the time to um present the options to the patient, not just slapping a band-aid on and covering up the pain, but actually getting to the root cause and then providing them with options of how they can deal with that and uh you know, ideally live a fuller life. So, that’s wonderful. Um what about people that you know, who do you typically see coming through your clinic? What’s kind of the ideal patient profile or what specifically do you treat? What do you what’s kind of the most common things that you’re seeing in your day-to-day?

Dr. John Knab: So, we’re primarily um spine focused. That’s what you know we uh that was my earliest training was in spine. You know, just doing all sorts of u um injections for people with bad bad discs, uh arthritis in the spine. Um but we also treat peripheral joints, shoulders, knees, hips. So the ideal patient for me is someone who is catching things earlier rather than later. So I think I mentioned in in my note to you that I’ve got my youngest patient is probably was maybe 12 or 13. My oldest current patient is 101. So uh you know uh and surprisingly we see some 101 year olds or you know 90 year old people with decentlook joints and spines.

Joshua Lyon: That’s amazing.

Dr. John Knab: It’s amazing. felt. But, you know, the the healthier the tissue is that we’re trying to treat, the more I enjoy the challenge of trying to to, you know, keep that tissue in the person’s body rather than taking it out and putting in a metallic implant of some sort. So, if I have tissue to work with, I don’t care what your age is. I don’t care whether you’re 80. I don’t care care whether you’re 18. If there’s tissue that we can work with and you’re a candidate for it, I I like working with those patients because, you know, I want to not just improve pain, I want to improve function. I want to improve how these patients are approaching life. And that’s, you know, obviously where, you know, my interaction with all you guys and physical therapists all over the all over the area come into play. It’s like I can help the pain, but it doesn’t help if your muscles are all atrophied and you haven’t used your spine in in in four years and uh you don’t know how to engage your glutes. I mean, treating pain is is worthless if you can’t improve function. So, the more I have someone who’s motivated to do those things to motivated to not just feel better, but do something with their bodies once they feel better, that’s the perfect candidate for me, no matter what the age.

Joshua Lyon: I love that. Yeah. The um having the active participant beyond just, hey, fix the pain, but let me actually get back to doing what I love doing or do new things I didn’t think were possible because pain was limiting me prior. Like that’s got to be super rewarding. Um it is. Yeah. So, what what’s kind of a a common conditions or some of the most common conditions that you’ll see uh coming through the clinic?

Dr. John Knab: Okay. So, back pain, right? You know, everyone everyone, you know, is going to experience back pain. Well, most of us can experience back pain at some point in our life. And and you know, admittedly, even until I was a couple years out after my fellowship, I didn’t really understand the complexity of back pain. You know, you don’t really understand how complex the spine is until you get into it and you start seeing patients and treating patients and realize what what made patients feel better, function better, what didn’t make patients feel and function better. So um I see a lot of patients you know kind of narrowing it down into disc problems. So the discs are the spacers between the bones obviously that uh you know allow us to twist and bend. And most of the time we think about people coming to the doctor when they’ve got a disc that’s kind of blown out. It’s herniated. A herniated nucleus pose is the most common thing that we see. But a lot of times we we we we hear a patient who comes and it’s not really that they’ve got sciatica or they’ve got just an acute episode. It’s these recurring episodes of pain where their back locks up. They get all cockeyed and they can’t they can’t sit. They can’t stand. They can’t bend. They can’t do anything. And then it takes them weeks to get better. And then they finally get better. And during that time they can’t do anything. and they finally get better and then it happens again in 6 months or 12 months or whenever it is. And so those patients are are a little bit more challenging, but we see them so commonly where it’s not just it’s not just a a disc pushing on a nerve. It’s a disc that’s degenerated. It may even be leaking some of the chemicals that are inside the the disc. You know, the center of the disc is like a jelly donut. And once that stuff starts leaking out, it gets into the spine. It might cause irritation of nerves, but just causes that super super tight feeling in your back and you really can’t do anything. And so that’s that’s a patient that I see very very commonly, you know, being a spine centric practice. Um, and we can do a lot of different things for those patients. Uh, figuring out where the pain’s coming from is the, you know, first and most important thing to do so that you can kind of begin to tailor treatments for those patients.

Joshua Lyon: Okay. Yeah. So, someone who’s dealing with that, obviously you start impacting their, you know, timeout, all those times that they’re on the sideline to do the injury, the loss of function, loss of motivation because there’s this constant fear of, well, it’s going to happen in three more months again. Again, the cycle. Um, what do you offer them? You know, kind of maybe talk down the regenerative medicine kind of uh approach. Is that who that would be appropriate for? or when you’re laying out the options for folks, what uh where does that come into play?

Dr. John Knab: So again, coming back to diagnosis, what is it that is causing you to be here? You know, we see things like poor sitting tolerance. That’s pretty common when a person has a disc problem. um if they um if they have uh these recurring episodes probably something that’s at the disc level. And so the first thing is you know what have you done conservatively. We always are going to make sure that they’ve at least tried some strengthening exercises making sure their ilos isn’t too tight making sure their multipetus are not too atrophied. We look at the MRI. We can see multipetus atrophy on MRI and not we can we see it all the time. You know, you look at the MRI and no one just everyone skips over it. And you look at the MRI and you see, you know, stuff up here at L1 L2 looks like uh filet min. And then you get down to the lower lumbar spine and it looks like wagu. It’s like riddled with fat. And so that patient is not engaging their parispinus muscles, you know. So the key has to be well you need to engage that stuff.

Joshua Lyon: We need to get your you moving. Yeah.

Dr. John Knab: And then you run into the problem was like I can’t, you know, I I am in so much pain that I can’t do that. And so that’s where I say steroids aren’t always all bad. I can use a steroid to get you most people I can get out of pain for a brief period of time whether it’s weeks to months.

Joshua Lyon: Yep.

Dr. John Knab: so that they can just start moving again. I send them back to you guys. You now you can work with them. And and so then once things have gotten you’ve kind of unlocked that that locked and frozen state of the spine, then we can start talking about okay, how do we try to arrest this inflammatory process? Maybe not maybe not fix it per se, but fix it with the best band-aid that we know. Uh which are oftentimes the platelets from our own blood, you know. So that patient who, you know, came into me miserable, just they’re not able to do anything, you know, the I see a lot of young people, active runners, they haven’t run in two years, you know, tennis player, pickle ball, all this stuff, they just haven’t been able to do it because it tweaks their back so much. And so I get them to understand that I can this is not in their head. It’s they might have been told like listen your spine looks fine and just cuz the surgeon doesn’t want to operate on you doesn’t mean your spine is fine. You know it’s not a surgical problem but it’s a problem. So once I can show a patient that I can make them feel better. or I get a foot in the door showing them and and showing their brain and nervous system that they actually are fine. They just need to settle down this inflammatory and degenerative process. Uh we can look towards uh things that are less destructive. So not using any steroids anymore. We’re not going to be burning nerves to joints. We can use the platelets to inject them at multiple places in the spine. So a typical a typical PRP procedure for the spine will involve treating all of the facet joints or the facet joints, treating all the muscles, treating the epidural space, treating the SI joint, treating the ligaments that hold our our uh our our bones together and doing that while the patient is really really comfortably sedated in our office. It’s all done in the same day. And those patients surprisingly don’t have a lot of pain afterwards. You know, they might have pain for a couple days and um then they come back about a week later and start using some of our machines like laser, you know, cold laser. So, we’re going to be using that to improve blood flow and and reduce pain. We have shockwave uh both focused and radial shock waves that help to uh heal uh muscle tissue and ligament, tendon tissue. and another one called EMTT which is uh extracorporeal magneto transduction therapy which again helps nerves and and muscles and ligaments to heal faster. So we use those those machines to to kind of speed the process of healing along. And my idea of success for that person is then once they’re over that kind of acute phase of of of pain and inflammation after the procedure, maybe a couple weeks, two, three weeks into it, then again we send them back to uh get physical therapy. We use we work with some of the chiropractors in town who kind of really help to mobilize things and get that patient, you know, functioning normally again. And the success there is when I forget about that patient. I mean, I see them back for a follow-up at about the two-month mark and make sure they’re doing okay. And then some of these patients I I just don’t see again until I hear about something else that’s going on. Uh or maybe 6, 8, nine years later, um I just see them and I see how you doing and they’ve been doing fine, you know, for years. So, and that’s such a different feeling for me than seeing someone every, you know, 2 3 4 5 6 months for steroid injections. It just feels like the right thing to do.

Joshua Lyon: Yeah.

Dr. John Knab: Uh I’m giving these patients their their lives back, their bodies back. I don’t want to see you, you know, I love seeing truly restoring them back to back to health, right? Go and go and thrive. So, that to me is the essence of medicine. If we can use our own bodies to heal ourselves, that’s that’s great. And sure, there may be things coming down the road with, you know, more purified versions of of, you know, actual stem cells that are going to come out from clinical trials that have demonstrated safety and efficacy. You know, that’s probably down the road, but uh, you know, still a little bit off in the distance. So along the way as I’m doing this stuff, I’m also trying to tell patients that you know what you hear uh on the internet, what you you know the ad you get in your mailbox for free dinners saying you can get someone to come to your house and give you stem cells, that’s fake. It’s fraud and it’s bad. And people can get hurt. Yeah. And so, you know, I I always trying to kind of emphasize that to my patients. It’s like if it sounds too good to be true, it it very well maybe, especially in the regenerative medicine field. So, I I’m a little bit old-fashioned and kind of stuck in the mud about things that aren’t well definitely things that are illegal I stay away from. So, that’s things like, you know, umbilical cord stem cells. Those are just plain illegal in in in at the federal level for the entire United States. You can go to places like Florida and Texas where that you have the right to try law where you can, you know, you can do it, but I’m pretty conservative and I’m going to use things that come from you go back into you on the same day. And that’s what the FDA says is okay. So, um I know people are really into kind of uh uh uh you know the the um um what do you call it? Um GLP1 peptides right now. And uh I’m not against it, but I don’t do it.

Joshua Lyon: Okay, fair enough. Fair enough. What about folks who um gosh, I see this all the time where they just delay care because we’re all stubborn, I assume, to a certain point like, “Oh, it’ll get better in time. It’ll get better in time.” and then it actually doesn’t and now it’s somewhat debilitating. So, what would your message be to folks about if you’re on the fence or even if it’s like a more recent injury, don’t wait like get the care you need, get it addressed early uh well before it becomes debilitating. What would your summary message be on on that?

Dr. John Knab: Yeah, I think um you know moving away from the spine and towards other things you know like um peripheral joints um we do see you know a miniscus tear that’s small now we can heal that you know we can we can heal that with PRP we can heal that with shock wave even um but the more uh that you let that go the more of a a negative inflammatory uh destructive environment ment is going on at the source of your injury. And so, you know, some athletes injure their ACL, right? And those patients just if it’s not fixed, there’s such an inflammatory and and kind of biomechanically off problem that um becomes worse and leads to early early onset arthritis in those patients.

Joshua Lyon: Yeah.

Dr. John Knab: that if they had just kind of addressed it right off the bat, they would be neutral. They’d be just like any other patient who had their ACL fixed immediately. So, that’s an extreme example, but I think it carries forward, you know, to to just almost any injury. If you haven’t had a good evaluation and you don’t really know what your diagnosis is, you don’t know if you’re causing more harm by not treating. And so, at the very least, go and get an evaluation. You know, hands-on evaluation. We do point of care ultrasound in our office. So, you can come to me and that same day I can look at your shoulder, which has been bugging you for three years, and I can say, “Well, listen, you’ve got a good looking rotator cuff. you don’t have any arthritis of your AC joint. You don’t have any major arthritis of your glenoumeral joint. I think you’ve got a subchocchromial burcitis and I can tell you that right in the office. I can even put on like a color Doppler and show you that this these blood vessels that are just kind of pulsating in areas where they’re not supposed to be. That’s where your pain’s coming from. I can show you that and treat treat you if without X-ray without MRI you can do a lot of stuff right in the office and very quickly if you if you kind of go to the the right type of person and so that’s the other part of our practice that I really love you know the being able to put hands on examine but also then stick the ultrasound probe on whatever it is your shoulder your knee I can show you you’ve got a 40 cc fluid collection in the top of your knee That’s why it feels stiff. Not just it’s not you’re just just imagining it, you know. I can show you your tears in your meniscus. I can show you the baker’s cyst. It’s it’s a lot of fun.

Joshua Lyon: That’s amazing. So, first visit they go in, they’re going to get and they’ll see that visual as well. So, you’re pointing out to them that makes sense because now it’s like, hey, it’s an arthritic. It’s not torn rotator cuff. Here’s these other things that could be contributing. And you can actually show them right then and there without having to, you know, do anything invasive. That’s incredible.

Dr. John Knab: Yeah. You don’t need an MRI. People are, you know, It’s amazing how many people are are really terrified of MRIs or I just hate them, you know, because of bad experiences. Um, and I mean, I love my MRIs, don’t get me wrong, but um, you know, um, ultrasound is sometimes better than MRI for some of the superficial things that we look at. You know, a lot of thumb arthritis, carpal tunnel, I can do a carpal tunnel exam right in the office. I can tell you whether it’s uh, you know, swollen, inflamed. I can and listen, we’ve got two, so I can compare right to left, right? Hey, this one looks big and fat and this one looks normal. And again, that magic button, I’ve got this color Doppler. It shows this blood flow there, which you don’t have on X-ray, don’t have an MRI. It’s really something unique to ultrasound, which is really, really cool. And um you know, tennis elbow, golfer’s elbow, you see this stuff like it’s so great to be able to see this stuff in real time. Yeah, we can show people very quickly, you know, what’s going on. So, um I would just encourage people to, you know, seek out that type of doc. There’s not a lot of people doing um muscularkeeletal um diagnostic ultrasound around. Um but there’s there’s couple couple people in town, myself included, who who do it. So, that’s the that’s easy because it’s painless, it’s quick, it’s rewarding, it’s it’s, you know, very very inexpensive. Uh usually covered by insurance. So getting getting answers about where the pain’s coming from is is absolutely the first step and ignoring it is a is the wrong direction in my opinion.

Joshua Lyon: Cool. Yeah. The fact that that you’re providing answers, that’s all people want. They want to know what is going on, why is this hurt so bad? Um and then give me a path forward as to, you know, what are my options. So that that leads into our next, you know, topic really is people watching this um for a dozen different reasons probably, but fear being one of them of the unknown like well what is it going to look like? What should I expect when I go in and uh schedule an appointment and just what could you do to either manage that expectation, reassure folks, you know, what can they expect when they come to see you?

Dr. John Knab: So, um there’s a lot of uh misconception about what interventional pain management is. You know, it’s like we’re not drugs. We’re not giving you narcotics. We’re not, you know, trying to get you hooked on drugs. Um we’re using needles and usually some sort of an injection to try to, you know, try to target things specifically. And we’re doing it not just by feel, you know, where’s it hurt and inject it. We’re doing it very specifically guided by either ultrasound or or fluoroscopy. But before we do any of that stuff, we have to get the diagnosis. So the first visit is going to be talking, examining, and maybe an ultrasound. For the most part, first visit, we’re not going to be doing anything painful. You don’t have to anything to be worried about. We just want to get to the bottom of what’s what’s causing the problem. Depending on what happens during that first visit, I might say you need X-ray, you need ultrasound, you need MRI, you need CT scan, you might need something else, okay? Maybe some lab testing. When it comes time to do an actual procedure, some people are like, I don’t care. I don’t have a problem with needles. Other people are like, I’m not having anything done because it involves a needle. So, we prescribe Valium for people who are nervous. We have a nitrous oxide like a laughing gas machine in uh in our office for people who want to use that for some of our bigger procedures like uh where it’s going to take a little bit longer. Uh we have these uh tablets that are called MKO melts which are um uh they were originally um designed for people having cataract surgery. So you know mo mostly older patients goes under the tongue. It’s got mazzlam ketamine and on dancatron. So it basically makes you very very goofy and loopy and you won’t care for about 45 minutes to an hour what’s going on. And then so even bigger procedures we give IV medications. You know I’m an anesthesiologist so we give uh you know very low levels of sedation for patients who need it. Um, and so there’s really no reason to be anxious about anything that we would do because we’re going to make it as comfortable as possible as we’re doing it. And all you need to do is just express those concerns, express your natural fear of needles if you have that. Um, so that really shouldn’t be a barrier for anybody.

Joshua Lyon: I love that. Okay, great options. Um, any final thoughts for anyone watching this that uh you’d like to share about yourself, your practice? um anything that would be helpful for them?

Dr. John Knab: Well, um we my my partner and I both uh just have more enthusiasm for what we’re doing now than when we first came out into practice. And um the the way that most people come to find us is is either word of mouth from their physician or from a friend or family member who’s come uh to to see us. Um we’re slowly but surely um um building our uh library of of uh videos about the conditions that we treat uh along with some testimonials from patients. And that’s on um the Elite Spine Joint uh site on YouTube. So that’s a good place for people to look at, you know, what are we doing? So, it’s um I think it’s just Elite Spine Joint, that’s our regenerative medicine practice or um Elite Spine and Joint on YouTube. And so, there’s a lot of videos that we’ve tried to, you know, help to educate and that’s why I do it. I I’m just trying to kind of demystify things for people. Um and uh so I would encourage patients to go onto that website or onto uh uh our website is uh is uh elitespine jojint.com or port city or portc city.com and both of those websites have a lot of educational material and links to some of the videos on there as well. So, if you’re even thinking that u there’s something that we might be able to help with, I would encourage patients to go to one of those three places, the YouTube or the two websites um for uh further information. And um I’d love to be able to help sort things out and make people feel better. So, come and see me.

Joshua Lyon: Awesome. And on those websites, they can reach out to your office, schedule appointments, all of that good stuff.

Dr. John Knab: Absolutely.

Joshua Lyon: Okay. Awesome. Well, thank you for your time today. I know everyone’s going to love learning more and just uh like you said, demystifying things around pain management, not the narcotics. Um really getting to the root cause of what is going on and then the the myriad of options they have to get that treated and back to a healthy life. So, uh thank you for your time. I know everyone’s going to love seeing this and uh we look forward to talking to you soon.

Dr. John Knab: Thanks, Josh. Have a great weekend.

Joshua Lyon: All right. Thank you. You too. Take care. Bye.