KOCHI: Chronic pain is any pain that lasts more than three months. It may persist for years sometimes, affecting a person’s ability to work or sleep well. This could lead to social isolation and often precipitate financial distress. Chronic pain can badly impact the quality of life of a person.
But chronic pain requires a separate speciality. Acute pain (especially those following trauma) has specific underlying causes 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 and difficult to treat and causes psychological issues like anxiety and depression. Eventually, it metamorphoses into a disease.
The emergence of pain medicine as a speciality was born out of the need to have a holistic approach dedicated to the diagnosis and management of such pain. Chronic pain can have a variety of underlying causes. Identification of the structure that produces pain is the first step, followed by amelioration and prevention of recurrence.
Following are some relevant questions on pain medicine
How can you benefit from consulting a pain management specialist?
Management of chronic pain, irrespective of the cause, can benefit from a multi-disciplinary method. The most common pain-related chronic condition are those that affect the musculoskeletal system — back, neck, knee or shoulder. Other conditions are facial (trigeminal neuralgia), chronic abdominal or pelvic, and cancer pains. A visit to a specialist could give you more insights into all these.
What are the services offered by a pain specialist?
Pain is subjective, and very often healthcare workers or the patient’s caregivers tend to blame the patient’s stress or anxiety for it when everything else (blood investigations, MRI) look normal. Pain generators can produce disabling pain, but may not be visible in any of the investigations.
A pain specialist begins by believing the patient when they say they are in pain. This is very important. The next step is to identify the pain generator. A detailed clinical evaluation is key to identifying the root cause of pain. Blood investigations, X-ray or other imaging modalities may be employed. A specialist will also look for signs of underlying pathology, like tumours, fractures or infections. Such patients are referred to doctors who can take better care of the condition.
Afterwards, an individualised treatment plan depending on the age of the patient, cause and severity of pain, and comorbidities is formulated.
What are the treatments offered by a pain clinic?
We often start by optimising medicines and physiotherapy. Pain killers or analgesics may be employed for a short while but not as a long-term solution.
Chronic pain induces changes in our nervous system. Over time, nerves that transmit pain sensations become hypersensitive. Pain modulators or neuromodulators are used to desensitise these nerves. These drugs are safer for long-term use. We also advise patients to do stretching exercises and physiotherapy.
If a patient does not benefit from medical management and physiotherapy, minimally invasive interventions (injections) are used. 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 with or without steroids, injection of platelet-rich plasma, joint injections, myofascial injections and radiofrequency ablation of nerves.
Are these injections expensive? Do they have side effects?
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 use of an 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. Certain injections, like a transforaminal epidural injection for back pain or sciatica, usually gives pain relief for up to an ear. Radiofrequency ablation of nerves can give pain relief lasting more than a year. However, certain other interventions like joint injections may be more short-lived. Their benefits may last only up to three months. However, interventions often provide immediate and excellent pain relief, which helps the patients do stretching or strengthening exercises more efficiently. This also contributes to the efficacy of the medical management and provide sustained pain relief without recurrence of severe disabling pain.
Will all chronic pain patients benefit from interventions?
No, interventions are helpful when the pain generator can be identified and blocked. In certain chronic pain conditions, interventions may not be possible. In other cases, the patient may not be willing to get an injection. In that scenario, we proceed to modify the procedure.
What are the challenges in dealing with chronic pain patients?
The suffering in chronic pain makes patients extremely anxious, distressed and frustrated. This results in poor treatment compliance. Pain prevents them from doing exercises and with time, muscles, bones and joints become de-conditioned causing more pain. One has to realise that the pain which has been present for months or years, causes sensitization of the nervous system and de-conditioning of the musculoskeletal system. A multi-modal management strategy targeting not just the pain generator, but all these components can provide significant pain relief.
The author is a consultant in the Department of Pain Medicine at KIMSHEALTH