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New Dimensions in Pain Management

Pain is ubiquitous and almost every doctor comes across patients suffering from pain. All through medical education ,we have been taught about the causes of pain pertaining to some systemic disorders.

  • ome Pain Syndromes are frequently seen and have anatomical reasons like muscle spasm, adhesion , neuropathy and entrapment of nerve and plexus while crossing through tough ligamentous In these cases laboratory reports, X-ray, MRI. …and..so on are usually normal and knowledge of these problems can only help in alleviating pain of these patients. Eyes see what your brain knows.
  • here are cases where we can identify some benign pathology but those are harmless and since pain is only disturbance it is widely ignored by doctors in absence of lack of pain relieving procedures which leads to prolonged

It is frustrating that pain can not be measured objectively like Blood pressure , blood sugar. There are reasons where we detect increase in blood pressure without any detectable cause for increase in BP , We call it essential hypertension. We do treat it with medicines , dietary



 

regulation and exercises. In the long run benefits are seen in treated essential hypertensives as compared to those left untreated.

In chronic pain scenarios too if pain is left untreated it leads to an increase in pain distribution ,Chronic Regional pain syndrome , Psychological problems ,depression , social withdrawal…..allodynia, dysesthesias etc. Use of analgesics leads to Acid peptic diseases and Kidney dysfunction. It has also been observed that medicine given in acute pain is not very effective in controlling chronic pain conditions, rather its prolonged use can cause Gastritis, Ulceration and Renal problems. Our growing research on pain pathways and pain generators is opening a new field in modern medicine that is interventional Pain Management

In pain management we have 3 major challenges

Why the pain- How to treat it and What action to be taken

I will explain the above 3 point with citation of real life story,

A lady of 60 years having perineal pain , urinary discomfort for 5 years . All laboratory tests , Scans and Nerve Studies are normal. Pain aggravates after constipation . Her Ultrasound, Cystoscopy and anorectal examination revealed nothing significant.In Fact transvaginal ultrasound increased her discomfort .In winters when people are finding it difficult to get out of bed , she is not able to rest as she has to be constantly going for urination. Life is terrible not only for her but for her family and the people around too. Her problem gets better on its own sometimes and sometimes it is non manageable . Nothing significant has been noted by Gastroenterologist ,Urologists , Gynaecologists and Psychologists . She has tried Pain killers , Tricyclic antidepressant , Sodium channel blockers …… .Either relief was short lived or no relief .

I will evaluate on above 3 points

This is known as Pelvic Pain Syndrome. It is a neuropathic pain. As all the necessary tests have been done and possible etiology to cause pelvic pain is ruled out. Now Some diagnostic tests like Pudendal nerve block, Ganglion impar block, Caudal block, Hypogastric plexus block depending on detailed assessment. Followed by Radiofrequency Ablation of affected nerves can offer a permanent solution to this problem. In my experience some patients got near permanent relief after even a diagnostic block.



 

My purpose of writing in the public domain is to bring awareness and help people fight chronic pain in a more efficient way. As the delay in treatment leads to irreversible neuropathy.

 

I would explain it with an assumption. Suppose A 35 year old sedentary worker comes to me for back pain for a week.

I take detailed history and do thorough examinations and find nothing significant. It is 1-Temporary pain- It will get better after rest and physiotherapy like hot fermentation massage or simple Paracetamol.

I got some clues to investigate further and the scan got signs of tuberculosis. Antitubercular treatment started and he would get better ,This is 2-Pathology Pain.

Now the Above mentioned patient took complete treatment his most of problems got better but pain is not going. This is 3- Neuropathic Pain ,in the process some neural structure got damaged which is sending a painful sensation to the brain though rest of the tissue has healed and disease is under control.

  • - Unexplained Pain- Pain is there , all investigations and scanning is normal. Pain is temporarily getting better after It comes back every time medication is stopped.
  • - Palliative Treatment of pain- Investigation showed some widespread metastasis which can not be cured but to add quality to life , one needs freedom from pain at

 

Hope this brief introduction of pain will help chronic pain sufferers to take appropriate advice .

Writer -Dr Varsha Agarwal