Conditions leading to chronic pain range from simple age related body changes to much complex conditions such as spinal cord damage after an accident. Do not underestimate the impact of simple knee or back arthritis as they can easily turn simple activities of daily living into big challenges. While it may not always be possible to reverse these changes, there is a lot we can do to control further damage and reduce the impact on our life.

Keep the hope alive:

Pain Medicine as a specialty had turned around the life of many and has given new hope to many others. Advances in the field of regenerative medicine means that we have lot more to offer now. It’s important to stay positive and not loose hope as most comprehensive management options require active patient participation. Whether that be physiotherapy or life style changes or remaining positive / motivated, patients have a significant role to play.

Treatment options:

Pain specialists use a combination of a variety of treatments for the effective management of chronic pain conditions. These start with

• Educating you about your problem and the do’s and don’ts. Do not underestimate the importance of the lifestyle changes and the things you can do to ensure that the problem resolves/ does not aggravate further.
• Medical management may involve a combination of medications, injections, physiotherapy, psychology and alternative medicine options. Often interventions such as injections into the area of problem play an important role in cutting the pain cycle and enabling to engage actively in other therapies such as physiotherapy. Steroids are often used for injections and when given directly close to the site of problem can be very effective. A portion of this does get absorbed into blood stream and reaches other sites but the resultant side effects are much less when compared to taking these orally as tablets.
• Other injection options such as Platelet Rich Plasma (PRP) are considered more natural and create an artificial inflammation promoting the process of healing.
• Nerve blocks involve giving an anesthetic agent+/- steroid close to the nerve carrying the pain sensations to block the sensation from travelling to your brain.
• Options such as Spinal Cord Stimulators (SCS) involve the use of low voltage electrical currents which applied to the spinal cord and they interfere with the transmission of the pain signals to the brain.
• Other than these, there are a variety of alternative therapies options which some individuals find beneficial such as massages, meditation, yoga, acupuncture and chiropractic medicine.

Your treating physician can help you decide on the best treatment for you, by explaining your condition and the evidence base supporting different modalities of treatments.

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Pain, although distressing, has the benefit of bringing medical problems to our attention. It usually abates as healing occurs. Chronic pain is pain that persists beyond the period of healing. Traditionally pain is thought to represent ongoing damage in body. This is now considered incorrect especially in context of longstanding/ chronic pain. To simplify- CHRONIC PAIN DOES NOT ALWAYS SIGNIFY ONGOING DAMAGE.

The newer understanding of chronic pain

In the past patients who usually complained of long standing pain, were often dismissed by healthcare professionals and most patients accepted pain as a part of ageing. In many cases it was not easy to figure out the underlying cause of pain, as chronic pain was not well understood. Over the years, with the amount of research that has gone into the study of chronic pain, doctors now understand more about different facets of pain management – physiological, psychological, pharmacological, interventional etc. There is enhanced understanding of mechanisms which can cause amplification of perceived pain symptoms. These advances and technological developments have enabled pain specialists to offer more to their patients. This stands true for back pain as well. While a significant number of people in a population suffer from back pain, fortunately for most this will resolve with time. However a small proportion does go on to develop chronic pain. The severity can vary from mild discomfort to debilitating illness interfering with activities of daily living and limiting functionality. Pain management specialists use a combination of modalities and specialties known as multimodal multidisciplinary approach to effectively manage the back pain.

What do you understand by pain management?

The complexities of pain and the fact that surgery or pills cannot resolve all pain has been long recognised. Understanding and treating chronic pain is challenging as we all experience and process pain differently. Hence one therapy does not work for all. This has lead to the development of Pain Medicine as a separate speciality. In this speciality the doctors are trained specially to deal chronic pain conditions and develop a better understanding of pain, underlying mechanisms and ways of reducing its impact on life.  A good pain physician focuses on holistic management of patient rather than just treating the disease.

Pain medicine is branch of medicine concerned with evaluation, treatment, and rehabilitation of persons in pain.  It utilises a Multi –disciplinary approach with specialists from different fields working together help in managing your pain, restore functioning and improving quality of life. The team mostly comprises of Pain Specialists, Specialist Nurses, Physiotherapists, Occupational therapists, Acupuncturists, Psychologists and Dieticians.

Role of pain management for chronic back pain

When it comes to chronic back pain, there are a variety of ways in which pain clinic can help.  Most pain clinic interventions have the advantage of being low risk, minimally invasive, non-surgical options without any need for prolonged hospitalisation. The treatment plan is individualised and may include a combination of the following

• Patient Education 
• Medication Management
• Physiotherapy and rehabilitation
• Psychology input including relaxation therapy, coping and self-management skills, cognitive behavioral therapy
• Complementary and alternative therapies including Acupuncture, TENS, acupressure, meditation
• Dietary advice
• Interventions such as injections. These can be especially useful for people where the source of pain is not known despite extensive investigations. Diagnostic injections can help in reliably identifying sources of pain when investigations have been inconclusive. Some of the treatment options are not commonly available elsewhere and these include 

• X-ray/ ultrasound  guided injections like nerve blocks, epidurals, facet joint injections
• CT guided interventions in areas which require precision for accuracy and minimising risks
• Advanced techniques such as Radiofrequency treatment which can provide prolonged pain relief for common conditions arthritis of the joints in the spine

Research and technological developments have opened new avenues in pain management such as 

• Newer technologies – cooled radiofrequency and spinal cord stimulators
• Regenerative medicine options including stem cells and platelet rich plasma(PRP)

As a vast majority of patients with back pain do not require surgery, a combination of above mentioned modalities can help in effective pain relief.  Pain clinic is also an option for patients who have had inadequate results from previous surgery or those who are not keen on surgery or not fit to have surgery.

Consult Best Pain Specialist In Delhi, Dr. Amod Manocha.

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Pain is a common reason for medical consultation. Over the years, studies evaluating the Global Burden of Diseases have found chronic pain conditions amongst the leading causes of disability worldwide. The impact of chronic pain can vary, ranging from an occasional distraction or discomfort to constant severe debilitation. Some examples of common chronic pain conditions include back and neck pain, sciatica, diabetic neuropathy, headache, frozen shoulder, persisting post surgical pain, cancer pain, abdominal pain, pelvic pain and fibromyalgia. Pain in a significant proportion of these conditions is amplified by stressful and sedentary life style with obesity, lack of regular exercise, smoking, poor workplace ergonomics contributing to the increasing incidence and severity.

Chronic or longstanding pain does not always signify ongoing damage. Conditions such as arthritic knee or back pain are often accepted as part of aging process, stopping people from exploring treatment options. It can, however, cause significant distress and compromise the quality of life. With the correct help, you can control your pain better and make your life easier. A pain specialist can help to diagnose the cause of your pain and work towards relieving/ reducing it and minimise the impact on your daily routine. This is how the approach of pain management specialists is different:

Knowledge and experience

When you receive specialist training in a subject and deal with specific conditions on a daily basis (chronic pain in this case) your experience/ learning is bound to reflect your treatments and outcomes. The education and the training received helps in successfully diagnosing and treating pain issues. In India the opportunities for specializing in Pain Medicine are limited with no nationally ascribed curriculum. In the western countries pain medicine is reorganized as a separate specialty with numerous training and super specialization opportunities. Pain clinics form an integral part of most reasonable sized, good hospitals. Pain specialists generally undertake a detailed assessment of every aspect of pain and try to address problems comprehensively.

I have spent a year doing pain research and another year in pursuing advanced training in the field of pain medicine in London, UK. This is addition to the basic and intermediate training in pain medicine during my 7 years of initial anaesthesia training in London, UK. Subsequently I have worked as a Chronic Pain Consultant in UK.

Treating the cause of the pain and not just the symptoms

Pain specialists try to explore why a problem may have occurred as this is important to prevent reoccurrences. Once the underlying problem has been resolved, the pain may automatically ease off giving you lasting relief. This is better approach than just taking medications for temporary relief. Understandably this may not be possible in all cases but this should not become a deterrent to trying.

Treating the body as a whole

Pain management specialists are trained to visualize body as a whole and use a multidisciplinary approach while addressing chronic pain. They don’t concentrate on just controlling the pain, as they understand that pain can affect multiple facets of life from mental health to relationships to jobs to social life etc. Each person is unique and experiences/ processes pain differently and hence the need for individually tailored therapies. They use a combination of modalities including physiotherapy, medications, injections/ interventional therapies, psychological therapies, Complementary and alternative therapies including Acupuncture, TENS, acupressure, and meditation along with patient education to achieve the best possible results.

In certain conditions they are able to offer interventions which are not available elsewhere.

The post Suffering from chronic pain? appeared first on Dr Amod Blog.

I have divided them into different categories-

• Pain Related
• Medication Related
• Interventions Related
• Psychology / physiotherapy Related

Pain Related

I have pain so there must be some ongoing damage in my body

While pain is a protective response and brings to our attention a number of medical issues, longstanding (chronic) pain does not equate to ongoing damage. Longstanding pain can change the way nerves carry sensation to the brain leaving a memory imprint in the nerves. This imprint persists even if the cause of pain is removed and this can explain the persisting pain. There are numerous other mechanisms involved and I can help you understand the ones relevant to your problem. If there are any other concerns like infection then relevant investigations can help to rule these out.

I have had many investigations and treatments and still no one is able to help me

Investigations such as MRI, CT scans are able to tell us what is different from expected/ normal. Unfortunately, they cannot directly confirm the pain source as all of us are unique and every deviation from normal does not cause pain. For example if we do MRI scan of spine of random fit people a significant number of them will show abnormalities, but these individuals may not have any pain. Hence it is important to interpret MRI finding in relation to patient’s history and examination findings.

Sometimes injections are used as an aid in diagnosing the pain source. Let’s assume that you have back pain and we suspect that it is due to arthritis of joints in your back. Now there are many joints in the back and a number of them may have arthritic changes. If I numb the nerve that carries pain from one of these joints and your pain goes away then this will help narrow down the likely source of your pain. These diagnostic injections can help plan the further course of treatment.

Medication Related

I do not want to take any pain killers as they have side effects and may damage my kidneys

Whilst no medicine or intervention is free from possible side effects, the risks are minimised by carefully selecting the right medications at the right dose. A number of factors have a bearing on the medications prescribed and please inform the doctor of

• Your other medical conditions
• Medications you are using
• Medications you have used in the past and the reason for discontinuing
• Any allergies

Each one of us is unique and pain being a personal experience requires nothing less than a tailor-made therapy. If a medicine has caused side effects or not helped someone it does not mean that your response will be the same. A number of sources such as internet, family members, neighbours, books, media etc. play a role in shaping our opinions. It’s important not to generalise from the experiences of others. Even if one experience side effects, majority of them are transient and are resolved with the discontinuation of the medications. If you have any doubts about the medications you have been prescribed you should not hesitate in clarifying with the prescribing doctor.

The issues encountered in the developing countries are unique. On one hand we have patients who are inappropriately concerned about all painkillers causing damage to kidney or other body organs and on the other hand we have patients who misuse medications and are more liable to suffer from such complications. These issues can be addressed by education and good communication.

My pain is better when I take medicines but it comes back when I stop the medicines. What does this signify?

If a pain has persisted for years, getting rid of it completely, can be challenging. Chronic pain is frequently accompanied by weakening of muscles, altered biomechanics, low mood, anxiety, poor sleep and other stresses. It is unlikely that all of these can be addressed by a short course of a magic pill. Most problems in today’s world have a lifestyle component. For example, if you are overweight and have arthritic knee pain then any magic pill or injection is unlikely to provide a long lasting solution. It will require weight management to reduce the load on the knees, exercises to strengthen the muscles along with pain killers and other interventions depending on the severity of arthritis. Life style modifications, self management are an integral component of chronic pain management. While pills no doubt have a role, one cannot rely on them alone.

Chronic pain needs to be treated as a disease and not as a symptom of a disease. Like diabetes and high blood pressure your pain medications will need to be adjusted as your symptoms change. If permanent cure is not possible then I will help you achieve best possible control of symptoms and educate you about the do’s and don’ts.

If I take medicines regularly they will stop working

Tolerance to medicines means the same dose of medicine becoming less effective with repeated use. This is a well know scientific fact and does not mean that medicines will stop working. It can be easily overcome by

• Rotating to a different medicine of the same class (as with opioids) or
• Discontinuing the medicine for some time or
• Using medicines which work by different mechanisms.

Some medicines may need a dose reduction prior to stopping to prevent withdrawal symptoms and this is best done under doctors supervision. This should not become a reason for refusing painkillers.

I will become addicted to pain medicines

Deciding whether or not to use certain medications is dependent on the risk benefit ratio. If the likely benefits outweigh the risks then closely supervised trial of medications while accepting certain side effects or risks is a reasonable option. The risks can be further reduced if you comply with your doctors instructions and attend regular follow up appointments. Addiction is more likely with certain classes of drugs such as sedatives, opioids. In a motivated person, sedatives can be reduced by using relaxation techniques and sleep hygiene practices. Without sounding like I am trying to promote opioid therapy, I feel that carefully supervised opioid therapy, in low doses , can have beneficial effects in certain subgroup of patients. Screening for risk of addiction prior to starting the medicine can help to further reduce the risk .

While the western world may be struggling with opioid abuse epidemic, in the developing nations we see another subgroup of patients who do not want to use painkillers like morphine despite having terminal illness because of the associated taboo. Many believe that it is something for use only in the last days of life. A significant proportion of these patients will however happily agree to use a stronger opioid patch. It’s sad to see patients nearing the end of live refusing to use painkillers and suffering because of the prevalent misconceptions.

Injection Related

Spinal Injections are dangerous

Technology and our understanding of medical issues has advanced significantly in recent times. Using x ray, ultrasound or CT guidance not only helps reduce the risks but also helps to ensure accurate delivery of the medication at the intended site. Risk profile of carefully performed spinal injections by appropriately trained specialists is negligible. Technological advancements such as radiofrequency treatment and in the field of regenerative medicine have opened multiple new avenues.

Steroids used in the injections are dangerous

Every medication has possible side effects and so do steroids. Regularly used oral steroids have a markedly different side effect profile when compared to the one off use as in spinal injections. Majority of side effects seen with oral steroids are rarely seen with one off spinal injections Facial swelling, significant weight gain, thinning of skin, infections etc. Some studies have found that patients on oral steroids are five times more likely to have side effects. To reduce the chances of side effects further I limit the dose and the number of times one can have these injections in a specific time.

I do not want to take injections/ painkillers as I will not know how the disease is progressing if I mask the pain

Pain is a crude indicator of disease and cannot be relied on for monitoring disease progression. Persisting pain apart from prolonging your suffering can have other detrimental effects on your body. If your doctor feels that a close vigil needs to be maintained on your disease then he/she will request for appropriate investigations to monitor the progression. This should not become a reason for suffering.

Physiotherapy and Psychology Related

Physiotherapy is not good for me as I get increased pain with physiotherapy

I will try and answer this with the help of an example- let’s assume I run a marathon tomorrow. I am bound to experience pain and stiffness afterwards because that is not a usual physical activity for me. I will do better if I gradually training myself over a period of time , slowly increasing my running distance before running the marathon. Similarly if you have had limited activity for some time there is a good chance that your muscles have become deconditioned and need to be retrained gradually to undertake the desired level of activity. The goal or the level of activity may vary from person to person (e.g. marathon or just walking to the nearby market ) but what is important is to understand is that most people get more pain if they do more activity than what their body can handle. It does not mean that physiotherapy is not for you. Physiotherapy is essential component of your recovery. The key is to start low and go slow. Which means maintain a certain minimal level of activity irrespective of your pain levels and gradually built up on it giving your body enough time to get accustomed to the new activity levels. A good physiotherapist will gauge your capacity accurately and breakdown bigger goals into smaller achievable steps to keep you motivated.

Psychology input means I do not have genuine pain and it is all in my head

Mind plays a huge role in how we deal and react to ongoing issues and this is where psychology can help. Understandably low mood, anxiety, stress, relationship or work strains are frequent partners of chronic pain. These play a big role in magnifying the perceived pain and correcting these alone can lead to improvement in perceived pain. Besides addressing these factors psychology experts can help you realistically analyse your rational and irrational fears and arm you with coping and pain management strategies to deal with episodes of exacerbation. Sometimes joint sessions with other family members help in dealing with issues more comprehensively.

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Epidural injections are a pain management option for patients with leg or arm pain originating from the spine. This is also known as Radicular pain or Radiculopathy. The pain usually radiates away from the irritated nerves. For Example – the pain could be originating from lower spine and may be felt far away in the legs. Pain specialists offer non-surgical options like this one for pain relief. As the techniques used are minimally invasive, and do not involve surgical incision or prolonged recovery, the risks involved are less.

One of the causes nerve pain is the narrowing (stenosis) of the space for these nerves in the spine or narrowing of the space from which these nerves exit the spine. This may be secondary to a slip disc or rupturing of the discs.

Depending on the problem different techniques /routes may be utilised to perform epidural injection. Nerve root block /transforaminal epidural, caudal epidural, interlaminar epidural are all epidural injections. Different names are used to indicate the technique used and route of entry. The route or the technique used can have an impact on where the maximum amount of drug is deposited.

How the epidural Injection works

Generally a combination of local anaesthetics and steroid are uses in these injections. The resulting pain relief can last for a few months although some people can experience long lasting relief from these injections. Corticosteroids serve dual purpose as an analgesic as well as have anti-inflammatory property. So, they help to control both pain and inflammation.

Immediately after the injection the injection site can feel sore although this is not troublesome for most people. This is mainly because of the mechanical process of inserting needle or at time also due to irritation resulting from the injected medication. But you need not worry about this as it will fade away soon and the pain relief would become apparent as the steroids start to work.

Benefits of Epidural Steroid Injection

There are numerous benefits of epidural pain injection over oral corticosteroids:

• Epidural injection delivers the medication close to the problem as a result more drug reaches the site of action compared to when it is taken orally.
• Side effects of the epidural injection are less compared to oral corticosteroids.
• The duration for which the effect of epidural steroid injection is generally longer. This period can be effectively utilized by the patient to engage in physiotherapy and strengthen the supporting muscles.
• Epidural steroidal injections help in providing quick pain relief in case of severe pain

Epidural injection works very well in case of pain originating from lower back (thoracic spine), neck (cervical spine) and mid back (thoracic spine). You should take expert advice from experienced pain specialists in Delhi as they can give you advice regarding the most appropriate therapy for you. Generally epidural injections are more beneficial in cases where the pain travels (radiates) towards arms or legs. Discuss this option with your specialist to find out if this is the right treatment for you.

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