Chronic Pain Management In Delhi - Removemypain

Pain affects more people than heart disease, diabetes, and cancer combined International Association for the Study of Pain (IASP)

If you do not believe this statement then let me remind you of some common scenes from your daily life. You may have stopped noticing these believing that nothing can be done or accepting them as a part of aging. BUT IS THAT SO?

…remember the grandma who grunts in pain every time she tries to get up

…. the husband who complains of a backache every morning, taking his time to overcome the stiffness before he can start his day

….aunt who finds it difficult to get out of the car because of pain

….your colleague who has to randomly take time off work because of severe headaches

…your work colleague who keeps pressing his neck complaining of neck pain

….your friend who gave up badminton because of shoulder pain

….diabetic uncle who cannot sleep as he feels his feet are on fire

….your close friend who underwent breast surgery a few years back and still complains of pain

#lifewithoutpain#justadream#

Do these sound familiar… I have not even talked about the numerous patients with sciatica, tennis elbow, heel pain, abdominal pain, cancer pain, pelvic pain, testicular pain, chest-wall pain, post-traumatic pain, nerve injury pain, etc. The list is endless. The financial burden of these problems on individuals, families, society, and government is enormous.

Yes, these are all examples of chronic pain

Yes, these are challenging to treat because pain is a very personal experience and one therapy does not work for all.

BUT YES…. there are options that can improve your quality of life significantly. After all, quality of life is important for everyone. For someone, it may all be about being able to play a few rounds of golf and for someone to attend an important meeting at work without being distracted by pain. Your goals are your goals and they are important.

Chronic pain is a frequent condition affecting an estimated 20% of people worldwide. Globally 1 in 10 adults is diagnosed with chronic pain each year. Despite this, not many are aware of the available pain management options. The general perception is that pain management is for cancer pain. Even for the majority of well-informed people, it stops at a few nerve blocks for relieving pain in cancer or trigeminal neuralgia.

In India, there is huge variability in the services offered by the existing pain clinics. The lack of a recognized comprehensive training curriculum in pain medicine with government-approved minimal training standards may be one of the contributing factors. The focus of most specialists is on interventions rather than holistic management. This is contrary to most western countries where Pain Medicine is a separate specialty with a well-defined curriculum and minimum standards that must be fulfilled for one to proclaim himself as a pain specialist. The focus there is on long-term solutions using a multi-disciplinary approach and teamwork. Nevertheless, the awareness of chronic pain options is increasing with an important role being played by the media. I hope that the benefits do not get restricted to a privileged few and that all fellow brothers and sisters are able to benefit.

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Know All About the Treatment Options for neuropathic pain treatment in Delhi

The increasing number of pain management centres in Delhi is a proof of changing times and increasing awareness about pain management options. Neuropathic or nerve pain is one of the common reasons for pain clinic consultation.

Nerves act as the conduction pathways transmitting signals to and from the brain. Sensations including pain are transmitted as chemical and electrical signals to the brain where the pain is actually perceived. When the nerve become damaged or dysfunctional they start generating pain signals themselves. This category of pain is defined as neuropathic pain. Neuropathic pain can be severe, debilitating and you need to choose experienced doctors when it comes to neuropathic pain treatment in Delhi.

Let us first learn what causes neuropathic pain

Neuropathic pain is mainly caused by nervous system damage/dysfunction. Many factors and conditions can predispose to development of neuropathic pain. Some of the common reasons include:

• Diabetes mellitus leading to a condition known as polyneuropathy where multiple nerves of the peripheral nervous system are affected
• Certain Medications
• Nerve compression
• Nutritional deficiencies
• Neoplasms
• Chronic Alcoholism
• Toxin exposure
• Immunological diseases
• Infections
• Idiopathic

Treatment Modalities

It is important to consult the best centres for neuropathic pain treatment in Delhi where the team understands your pain and has extensive experience in diagnosis and management of all linds of neuropathic pain. Neuropathic pain increases the excitability of the neves, receptors and produces changes in the spinal cord such as those in N methyl D aspartate or NMDA receptor. Moreover, there is an imbalance between the excitatory and inhibitory systems further increasing the perceived pain.

If the predisposing factors or the pre-existing damage is unmodifiable then the focus shifts to stopping the condition from worsening, pharmacological management and symptom/ pain control.

• In the reccase of diabetic polyneuropathy, management of blood sugar levels along with exercise and medication is helpful, especially in type 1 diabetes
• In case of vitamin deficiency, vitamin administration and diet changes are recommended.
• In cases of nerve entrapments, local injections can help if providing relief
• Along with the management of the pain, it is equally important to alleviate other associated symptoms such as sleep disturbances and low mood.
• Pharmacological Management: The use of tricyclic antidepressants, anticonvulsants, opioids, topical numbing agents and patches help in managing the symptoms of neuropathic pain. Interventions such as Nerve blocks, sodium channel blocking agents and neuromodulation is often utilised in combination with pharmacotherapy. These may not remove the causative factors but they certainly help in the management of the pain.

It is essential to consult the best pain management centre in Delhi where a multidisciplinary approach is used and the emphasis is on improving quality of life and reducing pain, and discomfort.

Tag = neuropathic pain treatment in Delhi, Pain Specialist in Delhi, Pain Clinic in Gurgaon, Pain Management in Delhi

Cervicogenic Headache Treatment In Delhi | Removemypain

 

What is Cervicogenic Headache?

Cervicogenic headache in simple terms means a headache originating from the neck. Even though the pain you experience is in the head or part of the face, the actual problem in lies in the neck. The possible pain generators in the neck include the joints, discs, surrounding tissues such as the neck muscles, coverings of the spinal cord, and blood vessels.

Headaches afflict people of all ages. The impact is variable from mild discomfort to severe incapacitation, depending on the severity and the frequency of headaches. Often the causative factors are numerous and difficult to pinpoint. Cervicogenic headaches represent one such condition that is easily overlooked and under diagnosed, due to limited awareness about the condition. This is a treatable cause of headaches with possibility of good relief if the diagnosis is correct.

Pain Management in Delhi

Signs & Symptoms of Cervicogenic Headache:

Some of the pointers towards cervicogenic headache include:

• Increase in headache with neck movements such as nodding or rotation of neck
• Increase pain with pressure on certain sensitive points in the neck
• Stiffness and reduced range of neck movements
• Pain is generally one sided and does not change sides. Sometimes both sides are involved
• Generally described as a pressure sensation at the back, side or front of head or in the area around the eye. It may be episodic with varying duration or present constantly. During severe episodes nausea and vomiting and other features similar to migraine can be present making the diagnosis more challenging.

The headaches often start after trauma/ injuries such as whiplash. Conditions such as occipital neuralgia (a problem associated with the nerves at the back of head) are closely linked to cervicogenic headaches.

Pain Specialist in Delhi

Causes of Cervicogenic Headache:

A number of neck conditions have been attributed to cause cervicogenic headaches including:

• Degenerative changes in the joints of the cervical spine such as osteoarthritis
• Discs of the cervical spine
• Whiplash injury to the cervical spine or other sports injuries
• Spasms of the neck muscles
• Bad posture of the neck for long periods of time, such as when working or sleeping

Neck Pain Treatment Gurgaon

Diagnosing Cervicogenic Headaches:

Diagnosing a cervicogenic headache can be tricky, as a number of headaches can present with similar features. Your doctor will obtain a detailed history often taking you back to when it had first started. You will be asked in detail about your pain symptoms, stress levels, work, eating and sleep habits, medication usage etc. This is usually followed up by examination. Diagnostic investigations such as X-ray, MRI, CT scans cannot conform the diagnosis but do provide support to the diagnosis. An injection is often used for confirmation of the diagnosis.

Cervicogenic Headache Management Options:

There are a variety of treatment methods for helping with cervicogenic headaches. These include:

• Lifestyle changes such as regulation of sleep cycle, workplace ergonomics
• Medication may include mild or potent pain killers
• Interventions such as joint, nerve or muscle injections. These generally involve injection of local anaesthetics with or without steroids. Sometimes Botulinum toxin injections are used for muscles
• Radiofrequency treatment can help relieve/ reduce these headaches for a prolonged duration

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Sacroiliac Joint Pain Treatment In Delhi - Removemypain

 

What are sacroiliac joints (SIJ) and where are they located?

The sacroiliac joint is large, strong joints between lower end of the spine and the pelvis. There are two sacroiliac joints, one on each side. These joints play an important role in transmitting the upper body weight to the hips and legs and hence undergo a significant amount of stress in day to day life. They function as shock absorbers and are reinforced by multiple strong ligaments. Sacroiliac joints are supplied by a number of nerves which when irritated can hurt.

What causes sacroiliac joint pain?

Sacroiliac joints do not allow much movement as both too much and too little movement can become a source of pain. Some of the causes of SIJ pain include

• Trauma/ injuries involving the joints or the surrounding ligaments such as following a fall on the buttock or a road traffic accident.
• Mechanical stress due to various reasons such as previous spinal fusion surgery or leg length discrepancy leading to altered weight bearing. As per some studies 75% of patients with previous fusion surgery can develop SIJ degeneration after 5 years.
• Inflammation. Sacroiliitis is a term used inflammation of the sacroiliac joint. Ankylosing spondylitis is a type of inflammatory arthritis which can affect the SIJ and the spine. This is seen more commonly in young men. In severe cases it can cause fusion of the sacroiliac and spinal joints leading to pain with reduced range of motion.
• Normal wear and tear (degenerative changes.) These are more common with advancing age.
• Infections and tumors are fortunately not as common as the other causes of sacroiliac pain.

What are the symptoms of sacroiliac joint pain?

As many as fifteen to twenty percent of all lower back pain cases can be attributed to the issues related to the sacroiliac joint. SIJ pain can mimic pain arising from hip or spine and affects all ages.

Patients with sacroiliac joint pain generally present with buttock or lower back pain and stiffness. Pain is deep aching in character although may be sharp/ stabbing in character. It can involve one or both sides and spread towards the groin, hip, thigh and leg. Activities such as getting up from sitting position, getting in and out of car, climbing stairs, walking and sitting may become painful. Young adults suffering from ankylosing spondylitis generally present with pain and stiffness, worse in the morning and improving with exercises.

Tag = Joint Pain Treatment in Delhi, Pain Management in Delhi, Pain Specialist in Delhi, Joint Pain Specialists in Delhi

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Struggling With Severe Cancer Pain In The Middle Of Night? - Removemypain

 Tag = Cancer Pain treatment in Delhi, Cancer Pain Treatment in Gurgaon, Pain Management in Delhi

Learn More About Breakthrough Pain In Cancer

Medical advancement has transitioned cancer from being a rapidly fatal disease to a chronic disease. Cancer pain, however, still remains a major problem affecting 30–40% at the time of diagnosis, and 75% of those with advanced cancer. Although it may not always be possible to relieve the cancer-related pain completely but fortunately it can be effectively managed in most individuals with appropriate therapy. Effective pain control has been shown to improve the quality of life in all stages of the disease. Breakthrough pain is one pain which troubles even those cancer patients whose pain is otherwise well controlled. Its management requires careful evaluation by specialists with attention to detail. In the subsequent section we discuss more about the breakthrough pain and commonly asked questions.

What is breakthrough pain?

Breakthrough cancer pain (BTcP) is a transient exacerbation of pain superimposed on the background of controlled persistent pain. In simple words it refers to the sudden, relatively short lasting severe pain episodes one experiences from time to time, often catching one unprepared, despite having background pain well controlled.

Here are a few characteristics of breakthrough pain

• Pain is of moderate to severe intensity (between 4-10/10, average score 7/10)
• Onset is rapid (between 3 to 5 minutes) or in some cases more gradual reaching peak intensity within a few minutes. In about two thirds of the patients time to maximum pain intensity is less than 10 minutes
• Duration of an untreated episode can be between 1 min and 4 h (average 30 min)
• Multiple, predictable (in one third of patients) or unpredictable episodes throughout the day

Effective pain management requires assessment of responsible factors and having a management plan rather than trying to reach out for emergency services during unsocial hours in a panic mode. 

How common is breakthrough pain and what causes this pain?

BTcP is a common problem with studies reporting the incidence as approx. 50% to 75%. This is despite using strong painkillers to control the baseline pain. Patients with the severe persisting pain, advanced cancer disease, and aggressive anticancer treatments are more likely to experience breakthrough pain. 

BTcP may result from the cancer itself (70–80% of cases) or the anticancer treatment (10–20% of cases) and is seen more commonly is association with certain cancers like head and neck cancer (70%), gastrointestinal (59%), lung (55%) and breast cancer (52%). Common examples of BTcP include mouth pain on swallowing due to inflammation of mouth lining (mucositis) or bone pain due to movement. 

BTcP can originate from numerous sources (somatic, visceral, or neuropathic) and the cause may be different from the sources of persisting background pain. It may be associated with 

• Voluntary movements like sitting, standing
• Involuntary movements like intestinal distension or
• May occur spontaneously

This distinction is relevant as it may encourage more targeted treatment approaches. Up to half of the patients may experience two or more types of BTcP. Sometimes the term episodic pain is used synonymously with breakthrough pain although some researchers ascribe a different meaning to this term.

Another type of BTcP which one commonly encounters is the increased pain that can occur when the effect of painkillers is wearing off, just before the next dose is due. This is addressed as the “end of dose failure.” Some studies include this as a type of breakthrough pain whereas others do not.

Why do we need to treat breakthrough pain?

Breakthrough cancer pain is a common problem and can be associated with a variety of physical, psychological and social complications. Persisting pain often robs the sufferers of their independence and their ability to perform routine tasks, adversely affecting the quality of life. Besides causing suffering, the severity and unpredictability of breakthrough pain can adversely impact one’s confidence level, emotional health and social interactions. Moreover, it is associated with increased utilisation of healthcare and social care services with obvious financial implications.

How do we address this type of pain?

All cancer pain patients should be specifically assessed for the presence of BTcP. A standard pain management & palliative care practice is to prescribe medications for the constant background pain and a separate on-demand dose of pain relieving measures for breakthrough pain. In BTcP there is no one treatment which works universally and the treatment needs to be individualised. 

Selecting the right option requires a fair amount of expertise and familiarity with all the available options. There are a number of factors which need to be taken in to account when deciding on the treatment and these include

• The underlying cause of pain
• Type of pain (nerve pain, nociceptive, mixed)
• Pain characteristics (onset, duration, severity)
• Predictable or unpredictable
• Previous response to pain relieving medications including opioids (efficacy, tolerability)
• Background analgesic medications (may need to be adjusted) and drug interactions
• Patient-related factors including age, other organ function, stage of the cancer and individual preferences
• Cost, availability and safety aspects

Opioids (morphine-like drugs) are considered the preferred medications for treating BTcP. The profile of the drug selected to treat the BTcP needs to mirror the pain profile one is experiencing. For example, in cases of sudden onset short-lasting pain episodes, drugs like oral morphine may prove to be ineffective as they take 30 to 45 minutes to work. In such a situation rapidly acting drugs are more likely to be useful. A mismatch between pain profile and drug selected is likely to produce poor relief and/or more side effects 

The route of drug administration is important as it controls how quickly the pain relieving effects are apparent. Drugs given directly into the veins have a rapid effect although it requires an intravenous cannula to be present. Alternative routes such as through the nose or by intraoral route (sucking on tablets) of the rightly chosen drugs work within 5 -15 min. The dose of ‘rescue medication’ is determined by individual titration to ensure maximum relief with minimal side effects and may be subject to change over time.

A predictable episode of BTcP triggered by known factors for example, eating can be managed by a planned administration of medicine prior to the activity taking into account the time taken for the medication to work. Some patients choose to restrict activity to reduce the number of  BTcP episodes.

Once the trial medication has been started, dose titration and regular reassessments are essential. All patients with new BTcP medications should be reevaluated within 48–72 h. Patient education regarding the correct and appropriate use of medications is essential as research evidence demonstrates incorrect usage, misuse/abuse, and underuse in a significant proportion. 

Other non-opioid drugs are also useful in the management of BCP. Examples include anti-inflammatories, benzodiazepines, paracetamol, etc. Preventing and treating BTcP is not just about medications as interventional techniques and non-pharmacological methods are other options that can be helpful.

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Struggling With Pain After Breast Cancer Surgery? Learn More About Post Mastectomy Pain

Breast cancer is a common cancer among women worldwide. A variety of problems can occur during treatment, and persisting pain after surgery is one such issue. It can affect 20% to 50% of women after mastectomy (operation involving removal of breast) and is defined as pain in the chest, armpit, upper arm, and shoulder persisting for more than 3 months post-surgery. Treating this pain is important as persisting pain besides causing suffering, can negatively impact on mood, sleep, activities of daily living, social interactions, and overall quality of life. Reduced working ability and financial implications are obvious consequences as shown in one study where 54% of individuals reported reducing their workload to part-time as a direct result of pain. As survivorship is increasing, enabled by the technological advancements in medicine, the focus needs to be equally on quality of life and reducing suffering. Phantom breast sensation (where one feels that the removed breast is still present) has an even higher incidence (60-80% of patients). The actual problem and pain may be underreported due to reasons such as worries about cancer reoccurrence, barriers in discussing personal issues, fear of being misconstrued, etc.

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 strong family history. Advances in surgical treatment like breast-conserving approaches have enabled patients to really 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 a 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 tumor with a 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 makes 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 

• The medial cutaneous nerve of the arm (provides sensation to the lower medial skin of the upper arm (damaged during a 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 the risk for lymphedema which is another reason for persisting pain. The 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 the 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 a greater likelihood of persistent pain. Although the exact reason is not known, some postulated factors include the 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. 

Tag = Cancer Pain Treatment in Gurgaon, Cancer Pain Treatment in Delhi, Pain specialist in Gurgaon, Pain specialist in Delhi, Pain Management in Delhi

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Cooled Radiofrequency Treatment In Delhi for Chronic Knee and Sacroiliac Joint Pain

Cooled Radiofrequency treatment has recently become available in New Delhi, India. It is an alternative for those suffering from chronic knee pain secondary to various reasons such as osteoarthritis, degenerative joint disease and persisting pain after knee replacement. It offers a safe, effective non surgical, minimally invasive alternative to knee replacement for patients who are either

• Not keen on surgery or
• Not fit for surgery due to other medical problems or
• Have persisting pain after knee replacement.

This procedure can also be used for sacroiliac joint pain as in patients with ankylosing spondylitis and for low back pain secondary to facet joint arthritis. It is a day care procedure performed under local anaesthesia with no requirement for hospital stay or prolonged rehabilitation. Normal activities can generally be resumed soon after the procedure with little or no recovery time. Less pain can lead to improved functionality and reduced medication requirements.

Knee joint is supplied by branches from many nerves and these are collectively addressed as genicular nerves. The initial diagnostic procedure involves local anaesthetic injections close to the nerves supplying the knee joint. If the diagnostic procedure produces good pain relief then it is beneficial to proceed with radiofrequency treatment from pain specialist. Radiofrequency treatment aims to reduce the pain signals being transmitted by the nerves to the brain. This is achieved by heating up a small area of the nerve using the electric current produced by radio waves. The procedure involves placing needles close to these nerves under x ray or ultrasound guidance followed by heating of nerves. Cooled differs from conventional Radiofrequency as it has water circulating through the device, needle tip and can create a larger treatment area increasing the chances of success. It can provide lasting pain relief for up to a period of 18- 24 months and has a low complication rate. I trained in this procedure in Germany a few years back and I use a combination of ultrasound and x rays to improve the chances of having a successful outcome.

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

Tags >> Chronic Knee Pain, Cooled Radiofrequency Treatment, Cooled Radiofrequency Treatment In Delhi, Sacroiliac Joint Pain