Traditional Medical Services

Traditional medical services at IFSMED are defined by the scopes of rheumatology, musculoskeletal, and internal medicine practices.

What distinguishes us from other rheumatology clinics?

• Highly individualized approach to the problem
• Nonstandard thinking process in decision making
• Freedom from the pharma “brain wash”
• True interdisciplinary approach
• Utilization of world class, state-of-the art diagnostic and therapeutic modalities
• All-inclusive service

Dietary modifications represent a part of complex therapy for various autoimmune and chronic inflammatory conditions.

The gastrointestinal tract is the main entry for foreign materials (foods) into the human body and the main transitory route for an enormous mass of microorganisms and products of their activity in the form of feces. Food and microbial products are the main stimulants of the immune system and the main external regulator of various metabolic pathways. Accordingly, composition of the consumed food can influence immune responses and inflammatory processes leading to the development of distinct forms of arthritis and autoimmune diseases. Reversely, various types of arthritis and autoimmune diseases are associated with frequent pathological changes in the intestine and colon.

The role of specific diet in therapy of such forms of arthritis as gout, pseudogot, psoriatic arthritis, ankylosing spondylitis and gluten-associated arthritis is a well-accepted fact. Dietary interventions in some other forms of arthritis or autoimmune diseases such as lupus, rheumatoid arthritis, Sjogren’s syndrome and osteoarthritis are still poorly defined. There are no universal recommendations regarding diet for arthritis.

The position of the Institute for Specialized Medicine is that dietary interventions in arthritis treatment and autoimmune diseases should be highly individualized. There are different approaches in the selection of the customized diet. Some of them are based on the known facts regarding the contribution of particular foods or food components to the development of specific forms of arthritis (e.g., high purine foods contribute to gouty attacks). Other ones are relied on highly individualized immunological responses of a particular person to specific foods and utilize complex immunological tests focused on determining food intolerances. In addition, we utilize comprehensive stool and saliva testing for the optimization of dietary recommendations and food supplements.

Our nutrition consultations analyze generated test results, patient’s medical history, current eating habits and lifestyle and formulate instruction on how to eat nutritiously within specific dietary restrictions. In addition, we help our patients with meal and menu ideas, recipe modification, plans for eating out and during travel.

IFSMED is recognized as a premier medical facility for conservative treatment of lower back pain. One of the most efficient methods for low back pain treatment by practitioners in the San Diego and La Jolla areas including IFSMED is a lumbar epidural steroid injection.

This type of treatment has been in use since 1952 and has produced a significant body of results – more than 50% of patients find measurable pain relief using these injections, and injections are far more likely to target the source of lower back and lumbar pain than oral steroids or painkillers.

As epidural injections can be administered directly to or very near the source of pain, there is a far higher chance that they will be able to not only effectively manage it, but flush out proinflammatory molecules which cause a severe back pain flare up. Although the epidural steroid injections do not correct the abnormal spinal anatomy, their pain-relieving effects may last for months and years. This type of steroid injection can have significant and fast-acting results for those who are experiencing a serious and intense episode of back pain.

At IFSMED, we perform epidural corticosteroid injections under strict aseptic technique and under direct sonographic guidance. During the initial course, the injections will be performed 3 times over a 6–week period with subsequent injections every 3 months on as needed basis. To maximize the injection’s efficacy, we recommend at least 18-24 hours of rest after each injection.

In addition to the epidural injections, our comprehensive program for low back pain incorporates various modalities such as physical therapy, chiropractic manipulations, acupuncture and prolotherapy in San Diego.

To find more information about IFSMED approach to the low back pain therapy, call us at (858) 794-9192 or send us an e-mail at

Infusion therapy is an effective way of delivering fluids, nutrients, medications or blood product medications directly into the blood stream. Institute for Specialized Medicine utilizes intravenous infusions as a part of integrative therapy for conditions varying from rheumatoid arthritis, psoriasis, multiple sclerosis, and lupus to osteoporosis, gluten intolerance and fibromyalgia. Your infusion therapy experience will vary based on your medical condition and tolerance to a prescribed medication schedule. During an intravenous infusion, an experienced registered nurse administers your treatment in a physician-supervised environment.

The institute welcomes referrals from outside physicians and will obtain prior authorizations and bill for all services rendered. Patients will be notified of any co-pays, out-of-pocket expenses and deductibles prior to treatment.

Intravenous Medications administered include but are not limited to:

• Infliximab (Remicade)
• Abatecept (Orencia)
• Rituximab (Rituxan)
• Etanercept (Enbrel)
• Adalimumab (Humira)
• Natalizumab (Tysabri)
• Intravenous immunoglobulin (various brands)
• Zoledronic acid (Reclast)
• Ibandronate (Boniva)
• Alefacept (Amevive)
• Efalizumab (Raptiva)
• Cyclophosphamide
• Methotrexate
• Intravenous corticosteroids
• Intravenous antibiotics


As a key component in treatment of chronic infections, malabsorption, and autoimmune diseases we also provide various infusions of micronutrients, antioxidants, and vitamins.

Direct intravenous administration allows us to reach therapeutic concentrations in the blood.

Some of these include:
• Iron
• Multivitamins
• Glutathione
• L-Carnitine
• Vitamin B12
• Vitamin C
• Branched-chain amino acids
• Glutamine
• N-Acetylglucosamine

IFSMED has set policies and procedures that are followed based on standards. Our primary concern is patient safety. Safety procedures are in place and followed. Our institute utilizes aseptic techniques in a relaxed, clean, safe, and friendly environment.

To find more information about infusion therapy at IFSMED, call us at (858) 794-9192 or send us an e-mail at

Soft tissue and joint injections are the part of everyday therapeutic protocols utilized in our clinic for pain and inflammation control.

Corticosteroids combined with anesthetics/pain killers are the most common drugs used for soft tissue and joint injections. By delivering an anti-inflammatory drug directly to the site of inflammation, the therapy has a significantly greater chance of success.

Typical conditions treated with injections include but are not limited to:
• joint inflammation and swelling due to rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis
• osteoarthritis
• rotator cuff syndrome
• trigger finger
• tennis elbow
• carpal tunnel syndrome
• neck and low back pain

To optimize the efficacy of the injections, IFSMED performs them under strict ultrasound guidance.

A typical procedure incorporates several steps including:
• ultrasound examination of the area(s) to be injected (to avoid puncture of the blood vessels and nerves)
• cleaning of the skin with bactericidal agents (soap, betadine, alcohol)
• topical anesthesia
• local anesthesia or nerve block with lidocaine to minimize the discomfort from the procedure
• ultrasound guided injection (or aspiration if needed)

To achieve maximal benefits, we recommend immobilization of the injected area if possible for 12-18 hours.

In general, soft tissue and joint injections are very safe. Rare side effects include postinjection transient pain, hypopigmentation of the injection area, mild atrophy of the subcutaneous fat, and infections.

IFSMED is one of the premier locations to receive joint injections in San Diego and the surrounding areas.

To find more information about soft tissue and joint injections at IFSMED, call us at (858) 794-9192 or send us an e-mail at

Ultrasound is a powerful diagnostic tool for the imaging evaluation of various musculoskeletal and rheumatic disorders and a guidance tool for performance of joint injections and aspirations. Current ultrasound technique allows not only to visualize the anatomy of joints, tendons, and ligaments but also to assess the activity of inflammation at its early stages when other approaches fail.

Dr. Shikhman is one of the first rheumatologists in the United States to use various ultrasound techniques in everyday rheumatology practice.

Currently, musculoskeletal ultrasound is used in our clinic for the following indications:
• assessment of gross joint anatomy (synovial lining, tendons, ligaments, muscles, nerves, menisci, etc.)
• assessment of joint inflammation
• detection of joint fluid
• assessment of rheumatoid arthritis activity
• assessment of ankylosing spondylitis / reactive arthritis / psoriatic arthritis activity
• assessment of nerve entrapment syndromes (carpal tunnel syndrome, tarsal tunnel syndrome, etc)
• assessment of therapeutic responses
• needle guidance of joint aspirations and injections
• needle guidance for soft tissue injections and nerve blocks
• needle guidance for epidural injections
• needle guidance for prolotherapy

Our clinic is equipped with high resolution ultrasound allowing us to generate 2D and 3D gray scale images as well as images of the joint and soft tissues blood flow (Doppler technique).

To find more information about our use of ultrasound, call us at (858) 794-9192 or send us an e-mail at

Salivary glands are common targets for various autoimmune and chronic inflammatory diseases (e.g., Sjogren’s syndrome, lupus, sarcoidosis, etc.) Therefore, sonographic analysis of salivary glands can be a valuable diagnostic tool in the hands of an experienced physician. A salivary gland ultrasound typically involves analysis of large parotid and submandibular salivary glands. It assesses salivary gland size, architecture, blood supply and inflammation, as well as size, texture and specific appearance of intraglandular lymphatic nodules. To find more information about salivary gland ultrasound at IFSMED, call us at (858) 794-9192 or send us an e-mail at

IFSMED Physical Therapy provides services that identify and maximize quality of life and movement potential. We diagnose, treat, manage disorders, diseases, and injuries affecting muscles, bones, joints, ligaments or tendons. We specialize in treatment for the following disorders: arthritis, neck pain, low back pain, hip pain, knee pain, ankle/foot pain, shoulder pain, elbow pain, wrist/hand pain, sprains/strains, osteoporosis, and fibromyalgia.

How IFSMED Physical Therapy Can Help

Complete musculoskeletal evaluation to determine the cause of pain, limitation of motion and/or strength.

Implement a treatment plan to reduce pain, increase mobility, and/or strength for the found problems in the spine, extremities, and post surgical areas.

Onsite innovative technologies to expedite your recovery, such as the class IV laser therapy, pulsed electromagnetic field therapy, shockwave therapy, mechanical decompression therapy, electrical stimulation, ultrasound, and iontophoresis.

Direct hands-on manual therapy (joint mobilizations, soft tissue mobilizations, muscle energy techniques, scar mobilizations, friction massage, myofascial trigger point) treatment for rapid results.

Assist with a focused routine that addresses posture, range of motion, flexibility, muscle imbalances/asymmetries, spine stabilization, muscular strength/endurance, balance, and gait with state of art equipment, such as the pilates reformer, pilates classic trapeze, power plate, shuttle balance system, functional shoulder pulley system, and complete stretching system.

Offer pilates-based rehabilitation and fitness, using the body as the means of resistance in exercises blending core and extremity strength, flexibility, balance, breathing, and coordination. Pilates may be used to promote weight bearing or non-weight bearing exercise for joint protection and correction of muscle imbalances and asymmetries for proper spine and joint alignment.

Physical Therapy Staff:

Nicole Blacher, Director of Physical Therapy

Graduate from the University of Cape Town, South Africa
10 years at the Scripps Clinic Sports Center
25 years of international experience