Pain

Pain that persists for months or years, affects a person’s ability to work, disturbs their sleep, leads to social isolation and often precipitates financial distress

Pain Medicine is a relatively new medical specialty that deals with the comprehensive management of chronic pain. Chronic pain refers to any pain condition that lasts more than 3 months. Pain that persists for months or years, affects a person’s ability to work, disturbs their sleep, leads to social isolation and often precipitates financial distress. On the whole,  it imposes a huge negative impact on a person’s quality of life.

Does chronic pain need a separate speciality?

The answer is of course ‘Yes’. Acute pain (e.g. pain following trauma) has a specific underlying cause that can be easily identified and treated. Chronic pain, on the other hand, irrespective of the underlying cause, induces many changes in our nervous system, over time, the pain becomes even more complex, difficult to treat and causes psychological issues like anxiety, depression. Eventually it metamorphoses into disease in itself.

The emergence of pain medicine as a specialty has resulted from the necessity of a holistic approach dedicated to diagnosis and management of pain. Chronic pain can have a variety of underlying causes. The foremost challenge lies in identification of the structure that produces pain (‘Pain Generator’).  This is followed by steps for amelioration of pain as well as preventing the recurrence of pain.

Chronic pain irrespective of the cause, can get benefited from the multi-disciplinary management employed in our speciality. The most common chronic pain related condition treated are those that affect the musculoskeletal system, e.g. back pain, neck pain, knee pain shoulder pain etc. Another common condition is facial pain (trigeminal neuralgia). Other conditions that benefit from a reference to a pain specialist include chronic abdominal or pelvic pain, cancer pain etc.

Services offered by a pain specialist

Pain is subjective, andvery often healthcare workers or the patient’s caregivers tend to blame patient’s stress or anxiety as the cause for pain, when everything else (blood investigations, MRI) looks normal. Pain generators, can produce disabling pain, but  may not be visible in any of the investigations performed.

 First of all, we believe the patient when they say that they are having pain. This is very important. Then next step is to identify the pain generator. A detailed clinical evaluation is the key to identifying the root cause of pain. If needed certain blood investigations, Xray or other imaging modalities may be employed. One very important aspect is to look for signs of a serious underlying pathology -aka- ‘RED FLAGS’ – like tumours, fractures, infections etc. If such a red flag is identified or if the patient’s condition demands surgery, he will be referred to the concerned specialist for further care.

 Once the red flags have been ruled out, an individualized treatment plan depending on the age of the patient, cause of pain, severity of pain, coexisting diseases like diabetes/ hypertension etc is formulated.

Is it all about prescribing different kinds of pain killers?

Treatment often starts by optimizing the medical management (medicines) and physiotherapy. For medical management, pain killers or analgesics may be employed for a short while but never given on a long-term basis and an attempt is always made to gradually scale down medication.

Chronic pain induces changes in our nervous system, over time nerves that transmit pain sensations become hypersensitive. In that scenario, we use pain modulators or neuro modulators to desensitize these nerves. These drugs are safe and can be given for a longer period. We also advise the patient to do stretching exercises and physiotherapy.

If a patient does not get benefit from medical management and physiotherapy, the treatment is escalated to minimally invasive interventions (injections). X ray or Ultrasound guided injections targeting the pain generator, have an important role in establishing the  correct diagnosis as well as in the management of pain. Commonly performed injections include nerve blocks, injection of local anaesthetics +/- steroids, injection of platelet rich plasma, joint injections, myofascial injections, radiofrequency ablation of nerves etc.

Are injections expensive?

All interventions are done with the help of image guidance- either X ray or Ultrasound. This improves the accuracy of the procedure and makes them very safe. Serious adverse effects are exceedingly rare. The cost of the procedure depends on the type of injection- simple nerve blocks, myofascial or joint injections are not expensive. Newer treatment modalities like radiofrequency ablation involve the the use of a RF device and are therefore slightly more expensive.

How long will the patient be pain free after the interventions?

This depends on the cause of pain and the type of injection utilised. Certain injections like transforaminal epidural injection for back pain or sciatica usually gives pain relief for 6 months to 1 year. Radio frequency ablation of nerves can result in pain relief lasting more than a year. However, certain other interventions like joint injections may be more short lived and the benefit may last for around 1-3 months.

However, interventions often result in immediate and excellent pain relief which helps the patients to do stretching or strengthening exercises more efficiently. This also contributes to the efficacy of the medical management, may help to provide sustained pain relief without recurrence of severe disabling pain.

pain

Will all chronic pain patients get benefit from interventions?

No, interventions are helpful when the pain generator can be identified and injected to block the pain sensations. In certain chronic pain conditions, interventions may not be possible. In other cases, the patient may not be willing for an injection, in that scenario, we proceed to modify the medical management and physiotherapy so that patient gets the best possible pain relief.

Challenges in dealing with chronic pain patients

The suffering in chronic pain makes patients extremely anxious, distressed and frustrated. This in turn results in poor treatment compliance. Pain prevents them from doing exercises and with time, muscles, bones and joints become deconditioned resulting in further aggravation of pain. Patients see many doctors and still do not have any significant benefit.

One has to realise that the pain which has been present for months or years, causes sensitization of nervous system and deconditioning of musculoskeletal system. A  multi modal management strategy targeting not just the pain generator but all these components can result in significant pain relief. This may take time but with enthusiastic patient participation, the wait is worthwhile.

Dr.Vineetha Gopal, the author, is a Consultant at the Department of Pain Medicine, KIMSHealth

By Ram

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