What is sciatica?

Sciatica pain is felt along the sciatic nerve, which is the body’s longest nerve. Sciatica pain usually occurs when a bone spur or herniated disc compresses a spinal nerve root in your lower back, causing intense pain in your back, leg, and buttock.

Sciatica is more common in the elderly due to the normal wear and tear on the spine that occurs with age.However, younger people can have sciatic pain as a result of a fall, or an injury.

When you have sciatica, knowing what to do is as important as knowing what not to do, and by following these tips, you will reduce your chances of experiencing sciatica symptoms.

If you have sciatica, you may have tried everything to stop your pain, including physical therapy, and other drugs, but did you realize that every day there are several things that can aggravate your condition?

The do’s for recovering from sciatica

• Remain active and mobile: Severe pain may make bed rest essential for some time but retaining mobility as much as easily possible is essential as bedrest alone can be counterproductive. This is supported by research evidence and old days of absolute bed rest are only reserved for some specific conditions such as spinal fractures.
• Regular stretching: Stretching on a daily basis can be beneficial as can be yoga. However extreme stretches are best avoided when experiencing a flare up episode (increased pain).
• Strengthening exercises: Gentle strengthening activities are essential for future prevention and can work wonders in long term.
• Use heat or cold packs: While many people suffering with sciatica want to grab for an over-the-counter pain reliever, using either heating or cooling packs is an alternative option for pain relief. Heating pads might help relieve aching muscles that are tense. Cooling packs, on the other hand, can help reduce swelling/inflammation.

The don’ts for recovering from sciatica

• Stay away from complete bed rest: You can stay in bed for as long as you need to if you are in severe discomfort but try to maintain as much mobility as possible.
• Avoid Lifting heavy objects: You must follow your doctor’s advice, but in general, avoid lifting anything heavy especially during the acute phases of sciatica.Avoid bending and lifting objects from the ground as this places extra stress on the spine which our muscles and ligaments bear. When this is paired with the weight of the object you’re lifting, your ligaments, bones, and discs may get overloaded, causing injury. Combining twisting motions with other movements like forward or side bending should especially be avoided.
• Warming up before exercises is essential: Certain workouts with a lot of resistance can worsen your sciatica if you don’t warm up your muscles first.
• Sitting for long periods should be avoided: While many of us have professions that require us to sit for lengthy periods of time, sitting down can worsen or increase the frequency of pain. Standing desks/ variable height desksare an alternative to consider.
• Avoid taking long car trips: Of course, this isn’t always possible, but if you’re on a long trip, take frequent rests with regular change of position and stretching.
• Be mindful of your posture and ergonomics: prolonged unhealthy postures can cause increased strain of back and worsen the pain in long term.

The final word about sciatica. . . .

The majority of sciatica patients do not necessitate surgery. Usually, time and self-care therapy are all that are required. However, if basic self-care methods do not reduce your pain, interventions such as injections (nerve root blocks, epidural) can be considered. Feel free to get in touch with us for further information. 

How a pain management specialist can help with your sciatica pain

If you are suffering with sciatica pain and not getting relief, make an appointment right away with Dr. Amod Manocha, the best pain management specialist in Delhi and Gurgaon, to receive the best of his expertise and world-class treatment options.

The post Know The Do’s And Don’ts To Recover From Sciatica appeared first on Dr Amod Blog.

Another subgroup of patients undergoing mastectomy are those who want to reduce their risk of developing breast cancer such as those with gene mutations (e.g., BRCA1, BRCA2) and a strong family history. Advances in surgical treatment like breast-conserving approaches have enabled patients to realistically consider this option.

Who are at risk of developing persisting pain ?

Some factors associated with increased risk of persisting pain include:

Type of surgery: Nerve preservation approaches are associated with reduced incidence of sensory deficits (53 % vs. 84 %) but may not be possible in all cases.

Different breast cancer surgery options include

• Radical mastectomy – involves removing the breast, skin, fat, chest muscles (pectoralis major and minor), and all the lymph nodes of the affected side.
• Modified radical mastectomy spares the chest (pectoral) muscles when compared to the surgery mentioned previously.
• Lumpectomy with axillary node dissection involves removal of the tumour with surrounding margin of normal tissue and the axillary (armpit) lymph nodes.
• Breast-conserving surgery (lumpectomy) also known as breast preservation, conservative breast surgery, wide local excision, partial mastectomy is generally used in early breast cancer  and involves removal of the tumour and a margin of normal tissue.
• Lumpectomy with sentinel lymph node biopsy involves removal and examination of the first axillary node (sentinel node) receiving drainage from the breast. The node is identified by injection of a special dye/ radiolabeled substance prior to the operation. If this node is free of disease, axillary dissection is not required.

Axillary nodes dissection leads to increased chances of lymphedema (arm swelling due to inadequate drainage) and poses risks to one of the nerves (intercostobrachial nerve) which is responsible for the sensation of the inner aspect of the upper arm. Both of these factors can become a source of persisting pain. The wide variation in the size, location, and branching patterns of the nerve make it more vulnerable to injury. Damage may occur as a result of stretching during surgery or direct nerve injury, presenting with numbness and pain in the area supplied by the nerve. As per one study women with axillary node dissection are 3.1 times more likely to experience moderate-to-severe pain at rest.

Other nerves in the area are also at risk of injury and can become a source of persisting pain. These include 

• Medial cutaneous nerve of the arm (provides sensation to the lower medial skin of the upper arm (damaged during section of the tributaries of the axillary vein)
• Medial and lateral pectoral nerves (control the chest wall or pectoral muscles)
• Long thoracic nerve (controls the serratus anterior muscle present along the side of chest wall close to armpit)
• Thoracodorsal nerve (controls the latissimus dorsi muscle)

Other treatments like radiation therapy administered in conjunction with surgery increase risk of persisting pain. This may be due to increased tissue fibrosis, neural entrapment, and impaired shoulder movement. Moreover, radiotherapy also increases risk for lymphedema which is another reason for persisting pain. Later-stage disease also is likely to require more aggressive treatment (i.e., chemotherapy) and may be associated with higher rates of pain. Regardless these are necessary treatments and when indicated should be pursued. 

Pre-existing pain prior to surgery is one of the most consistent factors related to increased risk of persisting pain after surgery. Even those patients with unrelated pain conditions such as headaches or low back pain are more likely to develop chronic pain after surgery. 

Severe pain after the operation requiring high doses of painkillers increases the likelihood of persisting pain.

Age: In several studies, younger age was seen to be associated with greater likelihood of persistent pain. Although the exact reason is not known, some postulated factors include presence of more aggressive cancers requiring more aggressive treatment, higher preoperative anxiety, and the need for adjuvant chemotherapy in this group.

Psychosocial distress can be both a risk factor for and a consequence of chronic pain. Preoperative anxiety has been found to be related with immediate postoperative pain levels. Numerous studies have found correlations between persisting pain after surgery and depression, stress, and psychological vulnerability. 

What are the symptoms of postmastectomy pain syndrome?

Postmastectomy pain syndrome may cause persistent or intermittent burning, shooting, stabbing, pulling, tightness, heaviness sensation or aching pain in

• Chest
• Axilla (armpit)
• Arm
• Shoulder

Other symptoms in addition to pain may include

• Numbness
• Tingling or prickling pain 
• Increased sensitivity in the area
• Spasms
• Severe itching 
• Phantom breast sensation & pain

What are the causes and different types of pains found after breast surgery?

Pain may persist after surgery due to numerous reasons such as surgical injury- nerve or muscle damage, nerve entrapment, lymphedema, mechanical causes, radiotherapy and chemotherapy, post-surgical scarring, recurrence of tumour, etc. Nerve injury pain has been further divided into the following types

Phantom Breast Pain

Phantom pain is seen after amputations where the absent body part (phantom) hurts. The patient may experience sensation as if the removed breast is still present and is painful. Often patients are confused and reluctant in sharing this with others as they feel unsure if this is actually real and possible, but phantom pain is real and not just in one’s head. Controlling this can be challenging and requires a multi-modality (using many treatment options in combination) approach.

Nerve Injury & Neuroma pain

Nerve injuries can lead to the formation of neuromas which in simple language can be explained as swelling at the end of the injured nerve. These neuromas can generate spontaneous or provoked tingling, electric shock like sensation with increased sensitivity in the area. Neuroma pain may be more common following lumpectomy than mastectomy. I have come across a few cases where the patient experienced pain as if she was having a heart attack requiring multiple visits to hospital emergency whilst the actual problem was injured pectoral nerves and the pain responded to nerve blocks. 

Post-Mastectomy Pain Syndrome (PMPS)

These patients present with persisting pain and sensory abnormalities following surgery. It is more common after operations involving the upper outer portion of the breast or the underarm area. Pain may be felt in axilla, inner side of upper arm, chest wall, shoulder or the surgical scar. Intercostobrachial nerve damage which can occur with axillary node dissection is considered as a common cause. 

Mastectomy patients are also at increased risk for pain in the shoulder and/or scapulothoracic area (upper back and back of shoulder area). In one study approximately 27% of patients reported such problems even after 6 months of surgery and the possible causes can include 

• Axillary web syndrome
• Adhesive capsulitis
• Myofascial dysfunction
• Brachial plexopathy 
• Rotator cuff injury

Reduced movements and guarding can lead to further decline in function, reduced lymphatic drainage and increase in pain.

What is the prognosis of post breast cancer surgery pain and what are the treatment options?

There is paucity of good quality evidence regarding the long-term outcomes in post mastectomy pain with some studies suggesting reduction in chronic pain /sensation abnormalities whereas others reporting long term persisting pain in a significant proportion of patients. Persisting pain after surgery can be multifactorial and hence besides pain management, addressing psychosocial and functional disruption, using a multimodal approach, is equally important. Some of the options used in the treatment include

Medications: These may include different classes of medications such as special types of painkillers used for nerve pain called anti neuropathic medications. These include the anticonvulsants and antidepressants which are well known painkillers.

Before starting painkillers, an assessment to identify the likely pain generators is carried out and the therapy is tailored accordingly. Sometimes even the side effects of medications are utilised to our advantage like the sedative side effect to improve sleep. There are numerous other painkillers which can be utilised like opioids, anti-inflammatory agents, topical agents (e.g. capsaicin), numbing patches, painkiller patches, oral tablets, pain relieving nasal sprays and lollipops etc. 

Physical therapy. Early initiation of physical therapy with gradual increase from range of motion exercises to active stretching, followed by strengthening is recommended. The aim is to preserve glenohumeral and scapulothoracic movement, strength, and to minimise arm dysfunction. Early initiation of physical therapy is supported by research evidence demonstrating  better range of motion at 2 years post axillary node dissection surgery.

Another subgroup that can benefit from early therapy is those experiencing pain secondary to lymphedema. Apart from physical therapy other interventions such as occupational therapy, compression garments, manual lymph drainage, lymph-reducing exercises, skin care and weight loss may also be required. 

Psychological treatments these may include options such as cognitive behavioural therapy (CBT), hypnosis, mindfulness-based therapies, meditation, self-management programs (individual vs. group) etc. Self-management programs focus on education, cognitive restructuring  to modify thought processes and reduce distress, coping skills training (e.g., pacing, communication) and relaxation training (e.g., hypnosis, mindfulness).

Interventions/ Injections– these are discussed in the next section

What other interventions can be performed for postmastectomy pain?

The most appropriate intervention is decided keeping in mind the likely pain generator. Some of the options include

Trigger point injections Muscles ability to contract and relax plays an important role in body functioning. When muscles fail to relax, they form knots or tight bands known as trigger points. Common causes include inflammation, injury of the muscle or the neighbouring structures. Injection of local anaesthetic and steroid at the points of maximal tenderness can relieve chronic post mastectomy pain. The local anaesthetic blocks the pain sensations and the steroids help in reducing the inflammation, swelling. I prefer to perform these injections under ultrasound guidance as it improves the accuracy and reduces the chances of complications. Post injection physiotherapy is essential to prevent recurrence and maximise the benefits. 

Nerve Blocks & Pulsed Radiofrequency – Intercostal, Pectoral Nerves 
Intercostal nerves run in between two ribs to supply the chest wall. They carry messages from the chest wall to the brain and vice versa. Indications for intercostal block can be diagnostic or therapeutic. The procedure involves injecting a mixture of local anaesthetic and a small amount of steroid under ultrasound guidance. Using ultrasound helps to visualise the spread of drugs and reduce the chances of complications as the needle can be kept away from important structures such as lungs. Pulsed radiofrequency treatment can be performed to prolong the effects of the injections.

Cryoablation of Nerves The primary aim in cryoablation is deactivation of the nerves transmitting the pain signals and this is achieved by freezing the nerves in a controlled fashion to temperatures as low as minus 80 degrees. The procedure is performed using a special probe called cryoprobe, which is guided to the correct location using ultrasound, x-rays and nerve stimulators. The extremely low temperatures achieved at the tip of the cryoprobe results in formation of an ice ball which freezes the nearby nerves thereby reducing pain. This technology is a minimally invasive pain-relieving alternative that does not require any cuts or incisions. It is a safe, day care procedure with the potential of providing quick and lasting relief.

Plane Blocks – Ultrasound guided Serratus Plane Block (SPB) & PECS Block
These injections are commonly used during anaesthesia for breast surgery and can sometimes be useful in chronic pain situations. They involve injection of local anaesthetics and steroids, using ultrasound guidance, in specific planes between the muscles ensuring blockage of multiple nerves with a single injection. Serratus plane block can also block the intercostobrachial nerve, which is implicated in chronic post-mastectomy pain. In chronic pain conditions they are often used to break the pain cycle enabling patients to start physiotherapy.

Botox injections
Botox injections can help in situations where muscles are the source of pain and their spasm is an issue. They can also be useful when muscle pain is produced by the temporary expander as a part of the breast reconstruction. They work by temporarily paralysing the muscles thereby producing relief. Injections are best performed under ultrasound guidance to ensure accuracy and may need to be repeated after a few months if the problem persists. 

Pulsed radiofrequency (PRF) of dorsal root ganglion (DRG)
DRG can be looked at as the modulator of the pain signals being transmitted from the periphery to the brain. By performing a block and pulsed radiofrequency procedure the pain impulses reaching the brain can be modulated/ reduced and this can produce pain relief. PRF of the DRG is considered for patients with inadequate response to other treatments discussed previously. 

Stellate Ganglion Block this can be helpful in some cases in reducing pain and improving range of shoulder movements. These injections target special nerves called the sympathetic nerves, that can get involved in transmitting the pain signals to the brain.  Sometimes a series of injections may be required to produce lasting relief. 

The post Struggling With Pain After Breast Cancer Surgery? Learn More About Post Mastectomy Pain appeared first on Dr Amod Blog.

Frozen shoulder is a condition in which there is significant loss of motion of shoulder joint accompanied by pain and stiffness. The movement involving reaching straight up and rotation of joint such as while reaching behind the back may be affected first although with time all movements may get affected. Pain may be deep seated, poorly localised and constant or only at night when lying on the affected side.

To understand the condition better it is helpful to know about the basic anatomy of shoulder joint. The shoulder joint is formed by three bones – the arm bone (humerus), shoulder blade (scapula), and the collar bone (clavicle). The rounded head of the arm bone (humerus) is relatively large compared to the socket of the shoulder blade and this size discrepancy allows for the large range of motion of the shoulder. The shoulder joint is surrounded by the strong joint capsule and further supported by a group of muscles called the rotator cuff.

In frozen shoulder the capsule surrounding the shoulder joint becomes thickened and tight thereby limiting the movements of the joint. The joint may loose some of its lubricating fluid reducing the space for the arm bone ot move. Movement of shoulder causes pain, hence one tries to avoid this which leads to further contraction of the capsule. As the condition advances scarring or adhesions may develop between the capsule and the head of arm bone further limitating the movement. With time there may be relative weakening of the muscles with loss of muscle mass (atrophy).

What causes frozen shoulder?

The cause behind the condition is not well understood. This condition is estimated to affect 2-3 % of individuals although this may be an overestimation as previously many more conditions were labelled as frozen shoulder – with it becoming more like a waste bin diagnosis. The actual incidence may be around 0.75%.

It is seen more commonly in

• Women as compared to men
• People over the age of 40 years, most commonly between the age of 40-60 years
• Diabetics have approximately five times more chances of developing this condition compared to non – diabetics. (10 – 20 percent of individuals with diabetes may develop frozen shoulder and about 30% of people with a frozen shoulder also have diabetes).
• Periods of shoulder immobilization like after a fracture or stroke (more like an under use injury)
• Patients with overactive or underactive thyroid
• Parkinson’s disease

How is frozen shoulder diagnosed?

Frozen shoulder is diagnosed clinically, however investigations are required to rule out other conditions which may present similar symptoms.

To diagnose frozen shoulder, your doctor will:

• Take detailed history of your condition and look for any predisposing factors
• Conduct a physical examination of your shoulders, arms and neck:
• The doctor will evaluate the range of shoulder movement. In frozen shoulder both the active movements (when you move your shoulder/ arm) and passive movements (when the doctor moves your shoulder /arm) are reduced. Examination may reveal tenderness in the front of shoulder at a specific spot called the coracoid process.
• The doctor may carry out other special tests to rule out other conditions which may present with similar symptoms
• He may conduct examination of your neck as neck problem manifests with shoulder pain frequently
• Investigations- X-rays of the shoulder may be requested to rule out arthritis, MRI scan and ultrasound may be requested to rule out other problems such as a rotator cuff tear. Ultrasound scan can show thickening of coracohumeral ligament or the capsule
• Blood tests may be requested to check for diabetes / thyroid problems

Can a frozen shoulder recover on its own?

A significant number of cases improve with simple exercises and pain control, however, it can take a long time too and sometimes as long as 3 years. The limitaion of daily activities can have significant impact on the quality of life. It is often self-limited, however, some patients never regain full function of their shoulder.

Typically the condition is described to pass through three stages

Freezing stage

This is the initial stage where the pain and restriction of movement develops. Intitially pain may be only on movement or at night when lying on the affected side. Slowly, it can increase in severity, affecting the shoulder joint diffusely and often spreading towards the upper arm. This stage can last from 6 to 9 months.

Frozen stage

In this stage the pain may become better although the restriction of movement persists and may become worse. This stage can last 4-12 months.

Thawing stage

During this phase, the movements start to return slowly and it can last 6 months to 2 years.

What is the treatment for frozen shoulder?

The treatment for a frozen shoulder is focused on relieving pain and restoring the shoulder’s normal range of motion. Timely interventions can help control pain and restore function sooner. A pain clinic can play a significant role by prescribing medications, using timely interventions such as injections and providing supervised physiotherapy. This Multi discliplinary approach has the best chances of improving outcomes and reducing disability.

Treatment options are explained below and it is important to understand that they are to be used in tandem and not seen as alternatives to each other.

• MEDICATIONS– anti-inflammatory drugs can help reduce the pain and inflammation, although these should not be used without the advice from your doctor. Your pain specialist may consider other stronger medications depending on your pain severity and other medical comorbidities.
• INTERVENTIONS– This may include a shoulder joint steroid injection or hydrodistension of the shoulder joint. These injections can help reduce pain and improve range of movement, reducing disability.

Shoulder joint steroid injections- Steroid injections injected directly into the joint are preferred over the oral steroid as they are associated with fewer side effects. Some studies have found that oral steroids are as much as 5 times more likely to give you the typical steroid side effects when compared to the one with off joint injections. Also the lack of long-term benefits makes oral steroids a less attractive option in this condition. Some studies comparing physiotherapy with steroid injections have found no significant difference in pain relief or shoulder function whereas others have found improved shoulder function with steroid injections.

Hydrodistension of the joint involves injecting sterile water or local anaesthetic into the shoulder joint with the intention of stretching the joint capsule to improve range of motion. There is evidence supporting the use of a combination of hydrodilatation and corticosteroid injection, as it may expedite recovery of pain free range of motion compared to corticosteroid injection alone.

Both these procedures can be performed in OPD settings under ultrasound guidance. Ultrasound helps to improve accuracy, maximising the changes of getting benefit from injections.

• Physical therapy. This forms an essential component of frozen shoulder treatment and requires regular active participation of the affected individual. The aim of physical therapy is to maintain, improve range of motion and help in strengthening of the joint, Physiotherapy and corticosteroid injections combined may provide greater improvement than physiotherapy alone.
• Surgery. This is rarely necessary to treat frozen shoulder. It is considered when there is minimal improvement after 6 to 12 weeks of nonsurgical treatment. Options include manipulation under anaesthesia and arthroscopic capsule release. Shoulder manipulation  involves forcefully moving the shoulder under general anesthesia to loosen up your shoulder tissue and disrupt the adhesions. This needs to be supported by physiotherapy after the procedure. Arthroscopic capsular release is considered in some cases when other treatments have failed to provide relief.

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Headaches can hinder day to day activities and severely affect the quality of life especially in individuals who experience frequent severe headaches or long lasting / constant headaches . Recurrent headaches can be quite difficult to handle since they tend to develop suddenly, not giving you an opportunity to prepare for it and plan your day. There a variety of measures that you can take in order to reduce the impact and frequency of these headaches. Some of these are quite simple, but most people doubt the effectiveness and hence are hesitant to implement. These can work synergistically with the other management options suggested by your pain specialist. These include

General lifestyle modifications

• Regulating your sleep cycle: Having a regular sleep cycle goes a long way in helping to reduce these headaches. Good sleep environment plays an important role and includes a darkened bedroom, a quiet place where you are comfortable and it helps to unwind. Some find a relaxing hot bath helpful in unwinding prior to heading off to bed. It is advised to avoid watching TV, using laptops or mobiles before you go to bed.
• Hydration: Keep yourself well hydrated, because dehydration is a known trigger of headaches, and can worsen pre-existing headaches.
• Regular meals: Have you meals on time. This another important factor that plays a role in the development of headaches. Low blood sugar/ hypoglycemia can trigger headaches. If you are in the habit of skipping meals or eating late and heavy meals, then you should consider changing this.
• Avoiding triggers: Other trigger/ precipitating factors may vary from individual to individual. From particular foods to the brightness of TV screens to loud noises, certain smells etc there are numerous factors. You are the best person to identify these and avoid them as much as possible.
• Tea and coffee: Minimize your intake of coffee and tea, because they are known to precipitate headaches. Avoid taking them late in the evenings and just before going to bed.
• Quit smoking
• Stress management and relaxation: Learn how to manage your stress in a productive manner and practice relaxation techniques.

These general measures, when used in combination with advice from your pain specialist can help you control your headaches better. Some of the common medical interventions used in management of headaches include:

Medications:

Medications for headache can be used to terminate the headache at the time you are experiencing it or can be taken as a preventive measure to reduce your chances of developing a headache. Preventive medications are usually taken when people experience frequent or continuous headaches, and they should be taken as prescribed by your doctor. Too much of any medication can also end up being the cause of your headache as well, and is given the name Medication Overuse Headache. The different medicines used for recurrent headaches are:

• Antidepressants: These medications, besides the pain relieving effects can also have other beneficial effects like reducing anxiety and sleep disturbances. The drug selected will depend on your individual situation.
• Beta blockers: Beta blockers, commonly used in management of high blood pressure and heart problems. They are helpful in the management of migraine related headaches
• Anti-seizure medicines: Several anti-seizure medicines help in the prevention different types of recurrent/ chronic headaches including migraine.
• NSAIDs: Nonsteroidal anti-inflammatory drugs are commonly used over the counter medications for mild to moderate pain, and they are effective in various different types of headaches. On frequent usage they can have harmful side effects such as gastritis and peptic ulcer disease; therefore they must be used with caution and under medical supervision.

Other interventional methods:

When simple measures such as lifestyle modifications and oral medications are not successful in resolving the headaches, then it may be worth considering other interventional methods. The intervention used will depend on the diagnosis. The common interventions include:

• Nerve blocks
• Injections of the cervical spine
• Radiofrequency treatment
• Botulinum toxin injections

Complementary & Alternative therapies

These include:

• Acupuncture – which involves the insertion of thin needles at definitive points in your body, with the intention of providing pain relief
• Massage therapy – this can help to reduce the stress and tension. It helps to relax the tightened muscles and thereby provides relief.
• Meditation and relaxation therapy
• Herbs and nutrients – Several organic herbs help in preventing migraine headaches and reduce the intensity of headaches. In deficiency states vitamin and mineral supplements can be taken to reduce headaches and prevent them from reoccurring.

It is best to seek medical advice before you starting with any of the above methods.

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Chronic knee pain troubles a significant number of people worldwide. It is a common problem amongst the aging population, and can indeed be very painful and debilitating, sometime even confining individuals to the bed. The most common cause of knee pain in elderly is osteoarthritis (OA), a condition where the cartilages of the knee joint have worn out due to wear and tear. This results in friction between the bones of the joint during movement which results in pain. The impact is more in overweight and obese because of the extra load on the knees. The risk of knee OA in overweight women is nearly 4 times and in overweight men is 5 times greater. It is not just the mechanical factors which promote OA in obesity but also the co-existence of disordered glucose and lipid metabolism and the highly metabolic and inflammatory environments have a significant role.

What can be done for chronic knee pain?

Initial management involves lifestyle modification, supplements, simple pain killers and physiotherapy. It is estimated that an extra Kg of weight exerts a force of nearly three to six times across the knee while walking. Thus, weight loss is an important modifiable factor in the treatment of knee OA which the affected individual can drive. Various studies have demonstrated that weight loss improves both pain and function in obese subjects with knee OA.

Local injections are considered depending on the severity of problem and other factors such as age, functional status etc. When the pain and discomfort is severe your doctor may offer you the option of undergoing a knee replacement surgery. This involves removal of the worn out part of joint, shaping the ends of the bone and placing a metal implant. This reconstruction of the knee joint allows for smooth, pain free movement for most individuals. However some, even following the rehabilitation process, continue to experience pain.

For those who are

• Not keen on the replacement surgery or
• Not fit to have one or
• Continue to have pain after knee replacement surgery

Cooled Radiofrequency is an alternative treatment. Details about this treatment can be found in the Knee pain section of the website and in old blogs.

What causes continued pain following surgery?

The causes of knee pain following replacement surgery can be located inside the joint (intra articular causes) or outside the joint (extra articular causes).

The intra articular causes include:

• Knee joint instability
• Loosening of the implant
• Infection of the bone or the joint space
• Problems related to the kneecap (patella)
• Osteolysis (loss of bone)
• Issues related to size or type of implant

It is important to rule out the extra articular causes when a patient complains of persistent knee joint pain following surgery, because they can have serious consequences if they are missed.

The extra articular causes include:

• Localized knee problems such as tendinitis and bursitis
• Pain radiating from the nearby joints/body parts such as spine, hip and ankles
• People who have ongoing psychological illnesses will also tend to experience longer postoperative pain
• Nerve injuries/ problems

The focus of a recent research in Oxford, UK has been weather the knee replacement should be done earlier and not as a last resort. The authors suspected that long term persisting knee pain can lead to changes in the nervous system (nerves, spinal cord and brain) which can be responsible for persisting pain even if the original cause is corrected.

Diagnosing the problem:

You doctor will go through multiple steps in order to evaluate the pain you are experiencing. This process includes, taking a detailed history of the pain, such as when what type of pain you are experiencing and when you experience it the most. Then your doctor will go on to examine the knee, which will help him/her to further narrow down on probable causes & identify problems such as stiffness, swelling, and issues with alignment of the joint.

You will be asked to undergo investigations such as, X-ray, MRI, blood tests including inflammatory markers such as CRP and ESR etc.

How to manage this condition?

Depending on the cause of your pain, you doctor may suggest a variety of treatment plans. On some occasions pain relief medication may help to control the pain, and even get rid of it completely. Physiotherapy is another option which has proven to be effective in managing pain following knee replacement surgery. Nerve blocks are sometimes offered if nerves are suspected to be the pain generator. Cooled Radiofrequency of the nerve supplying the knee can help in reducing or resolving your pain issues. Sometimes repeat surgery such as revision knee replacement is required If.

The post Why do you continue to experience pain after knee replacement? appeared first on Dr Amod Blog.

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.

The post Effective Chronic Pain Management appeared first on Dr Amod Blog.

With age you do become more prone to developing conditions such as arthritis but for most people pain control can be optimised to reduce the impact on quality of life. This requires willing to invest time and effort on part of the affected individual.

Choosing your Pain Specialist

In the field of medicine learning continues for life and keeping up to date with the latest evidence, technological developments are essential. Understandably, around the world, there is a huge variability in the pain treatments offered based on local expertise, risks involved, ethical and social considerations, lifestyles, patient expectations and believes. Treatment cost has a huge bearing on the offered/ accepted treatment modalities.

When it comes down to choosing your doctor everyone wants the best. Not the second to best but the best. So how do you decide who is best? Or is there something like the best doctor?

• For most individuals if a doctor in the media/limelight and treats renowned people then he must be good
• For others if the doctors name comes high up on internet search engines then he/she is assumed to be good
• Some rely on the feedback/ experiences of previous patients
• Word of mouth or recommendation is important for some
• Perhaps a foreign degree/ experience is a clincher for others

If I had to choose, who treats my pain, I would not be looking at just the doctor, but also for the setup he works in. For me the key question is – will he/she be able to offer me the comprehensive services required for a long lasting solution to my pain issues.

The most important component of treatment plan is diagnosing the source on problem (if possible) and deciding on what can be done for sustained, long-lasting benefits. This requires contribution from the individual in the form of life style modifications, weight management, regular physiotherapy etc. The process starts with education patient about his condition, advice on do’s and don’ts …is your best doctor willing to spend time on these???

Equally important is to be reasonable assured that your doctor has received the necessary training and experience to safely deliver the proposed treatments

For me I need a specialist

• Who understands pain
• Who looks at pain not just as a symptom, but as a disease and
• Tries to reduce the impact on life
• Someone who is willing to make a difference, to work with me and help me move towards my goals
• Someone who may not have all the answers but is willing to search for them

Someone for whom every pain is a mystery…. waiting to be solved…. One consultation with the Doctor should be more than enough for you to gauge whether you are with your best doctor or do you still need to carry on searching….. Good Luck

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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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Acute pain is the pain that is present after an injury until healing occurs. Pain in this situation is a protective response bringing our attention to the affected area and helping us protect, rest the affected tissue providing an opportunity for healing. As the tissue heals, the pain gradually abates.

Chronic or persisting pain is pain that persists even after the usual time required for healing. It is important to understand that chronic pain does not always signify on-going damage. Nerves have a memory (plasticity in medical terms) whereby they develop changes which remain even after the original inciting problem is corrected. A simple example to explain this is persisting leg pain even after amputation of the affected part. There are numerous mechanisms to explain this and your doctor can help you understand these better.

Impact of chronic pain is not limited to the involved person but also affects their loved ones and family members. The longer it persists the more chances that it will have an impact on multiple aspect of your life including your ability to work, sleeping pattern, mood, social life, relationship with family and friends etc. Hence it is important to take corrective measures to reverse or control the condition as soon as possible.

The management varies depending on the actual pathology, severity, co morbidities, patient preferences, available resources/ expertise and many other factors. At your first consultation with me you can expect a detailed assessment including history, examination and review of investigations. This is aimed at identifying the underlying reason for pain, so that an appropriate personalised management plan can be made. Some more tests may be requested as necessary. Close liaison with specialists in other fields such as neurology and surgery is maintained to formulate the best plan tailored to your condition and requirements. Some of the common pain treatment modalities include:

Medical management

I normally review your current medications and any existing medical problems prior to suggesting new medications or changes to current medications. Therefore it is a good idea to carry a detailed list of your medications and make of list of the ones you may have tried previously. Doses of medications tried previously are equally important as some medications if not used in right doses for the required duration are unlikely to be effective.

Different types of pain may need treatment with different medications, for example pain of inflammatory origin maybe be effectively managed with anti-inflammatory medication and pain due to irritation of nerve may need medication which help to desensitize the nerves. Hence the importance of identifying the likely pain generators prior to prescribing medications.

Interventional procedures

In certain situations I suggest procedures such as

• Injections/ radiofrequency procedures that help to reduce the pain signals being transmitted by the nerves to your brain
• Injections directly into a joint space/ around the area of problem such as a tendon or bursa which can help reduce the inflammation more effectively than medications taken orally. These procedures along with being therapeutic may also help the consultant confirm diagnosis

Regenerative medicine has opened new avenues where cells from your body are used to promote healing and reduce pain. Awareness of options such as Platelet-Rich Plasma (PRP) and stem cells is increasing and new research in this area is improving our understanding day by day.

Some interventional procedures can be done in the outpatient setting, whereas others will require a day case admission. This depends on the procedure being performed and your general health, other medical problems. We aim to reduce your pain as much as possible by offering you most appropriate interventions keeping your goals and preferences in mind and with an integrated multi speciality team approach based on biopsychosocial model of pain you have best chances of managing your pain.

Role of Physiotherapy

There are few common elements in management of most chronic pain situations like weakness accompanied by disuse of affected part for long time will require gradual mobilization and strengthening. A good chronic pain physiotherapist offers more than physiotherapy. They play an important role in

• Patient education regarding their condition, do’s and don’ts specific to their condition,
• Setting realistic goals-dividing exercises into smaller achievable steps
• Help patients understand and implement pacing of activities
• Promoting compliance, increasing confidence and making you self reliant
• Challenging your unhelpful thoughts, mitigating any false believes and minimising catastrophisation

Role of Psychology

Chronic pain can generate significant distress, anxiety and depression and all these, in turn, can magnify perceived pain. This is a normal human reaction which is often more visible to friends and family. Addressing these factors can help in reducing perceived pain and in improving quality of life. Psychologists can help you by challenging maladaptive beliefs, attitudes and emotions. They can help by

• Teaching coping and self-help strategies
• Relaxation techniques- these can be a useful tool especially in dealing with sleep disturbances and periods of increased pain
• Cognitive Behavioural Therapy (CBT)

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

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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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