Winning The War On Pain

Interventional pain management procedures and techniques have evolved as a new speciality in India, finds out Shardul Nautiyal

Pain is not just a symptom demanding our compassion, it can be an aggressive disease that damages the nervous system: Gary Bennett

With minimally invasive interventional pain management procedures taking over the conventional techniques, less hospitalisation, less morbidity, better patient outcome along with patient satisfaction have brought about a paradigm shift in pain management techniques. Interventional pain management procedures have evolved as a new speciality in India. Statistics from advanced countries show that 15-20 per cent of population have acute pain (medical and surgical emergencies, postoperative pain, after accidents and injuries) and 25-30 per cent of all population have chronic pain (chronic backache, cancer pain, migraines, arthritis or neuropathic pain). Because it impairs the ability to work and have a productive life, pain has serious economic and social consequences. Mild pain erodes the reserves of capability to work or to relax, altering the quality of life.

Paradigm Shift

"Pain is a more terrible lord of mankind than even death itself," said Nobel laureate Albert Schweitzer in 1931. This forms the opening sentence of the classic textbook Bonica's management of pain in 1953. Today, proper management of pain remains one of the most important and pressing responsibilities of medical institutes. Technology has a major role to play in the development of various interventional modalities of pain management. The WHO theme that 'Pain relief should be a human right' has also helped in developing newer modalities of pain relief from a simple headache to severe pain in a cancer patient. There has been much academic activity, pain conferences and sessions on pain management in conferences of other specialities. For instance, Samvedana Hospital and Indian Society for Pain Research and Therapy are organising an international pain conference on a common medical problem 'chronic pelvic pain' this year.

Interventional pain procedures have long been performed but in a very limited way because of lack of equipment like image intensifier and neglect by authorities.

Interventional Procedures Vs Surgery

According to Dr KJ Choudhary, Senior Consultant, Pain Management, Indraprastha Apollo Hospital, New Delhi, "A young man with intractable low back pain, unresponsive to conservative treatment will end up getting an MRI done, which will show a disc protrusion or prolapse (which may not necessarily be the cause of his pain) and end up in surgery. But if he approaches a specialised pain management physician, he will try to find out the locus of the pain generator, which may be in the muscles (myofacial pain-very common) or disc (confirmed by provocative discography), sacroiliac joint, facet joint, spinal canal stenosis or spinal nerve root compression due to narrowing."

Ninety percent of pain-related surgery can be avoided with the help of interventional pain management procedures. And 95 per cent of cases are of day care. Cost is substantially less in interventional procedure compared with surgery. The procedures can be repeated without major morbidity. Return to work is also almost immediate. "Interventional pain management is a multi-disciplinary approach, orchestrated by a dedicated team of pain management specialists, anaesthetists, nurses and surgeons," explains Dr Kailash Kothari, Pain Management Specialist, Swastik Hospital, Mumbai.

Surgery is a powerful tool in the treatment of disease, be it cancer, infections, orthopaedic or spine problems. However, it has specific indications, and as an invasive treatment has many anticipated problems. "As such surgery is to be performed only where it is specifically indicated. For example, a patient with motor weakness and back pain may need surgery to relieve pressure on his spinal cord rather than a block to relieve pain," says Dr Lakshmi Vas, Pain Management Specialist, Ashirwad Pain Relief Clinic, Mumbai. Similarly, a patient without any motor problems would benefit more from a block than from surgery. "It is binding on both the surgeons and interventional pain specialists to respect these specific indications to work towards the welfare of the patient. In my experience, it is the surgeons who refer patients to me for pain and I refer patients to them if surgery is needed. I simply put myself in the patients' shoes," Dr Vas explains.

A patient with vertebral collapse, either due to osteoporosis or bone metastasis, will be treated with vertebroplasty done through a needle, when bone cement is injected to reconstruct the vertebra, otherwise he would undergo major surgery. It is important to remember that most pain can be relieved by simple pharmacological methods; the WHO 3-step analgesic ladder is the gold standard for pain management. "Judicious and intelligent use of this ladder can relieve 70-80 per cent of all pain," says Dr P Saraswati Devi, Professor and Head, Department of Anaesthetics and Pain Relief, Kidwai Memorial Cancer Hospital, Bangalore.

Centres In Interventional Pain Management

A pain clinic is the place of convergence for all patients suffering from pain, irrespective of the aetiology of pain, medical, surgical, orthopaedic or traumatic oncological. The only criterion is that a patient has to complain of pain for more than three to six months. Interventional pain management techniques are still in their infancy in India and very few dedicated centres exist.

The first department of pain medicine was started in a corporate hospital, Indian Spinal Injuries Centre, New Delhi in 2006, with Prof GP Dureja as head. "Interventions are certainly the mainstay of treatment in chronic pain and there will be more such dedicated centres in future," predicts Prof Dureja. Besides Mumbai and New Delhi, some centres in the South are NIMHANS, Bangalore, Sri Chitrai Tirunal Medical Centre, Thiruvananthapuram and CMC, Vellore.

What Does The Future Hold?

In this fast moving society seeking fast track treatment of illnesses and pain, pain management has a great future ahead, predict experts. Technology helps in locating precisely the cause of pain as well as targeting the drug at the site of origin of pain. Of course, one cannot overemphasise the role of a good clinical examination in diagnosing the cause of pain. Special skills of an anaesthesiologist in blocking nerves and reaching the sites in the spinal cord make him an ideal pain physician. "However, it is now up to him to develop the super speciality of pain medicine so that it is of great help to the millions of people suffering from chronic intractable pain syndromes in improving their quality of life," Dr Dureja maintains.

Pain is a major health hazard, expected to rise with ageing population and lifestyle changes. The future will make greater use of relaxation therapies for managing the psycho-emotional component of pain with non-drug therapies, and with newer and more specific pain medications (many undergoing trials) and equipment to locate pain generators, and modify pain sensation for those pains which are not useful as a warning. "Specific drugs will replace the present crop of painkiller medications. Newer drug delivery systems and regional drug delivery of medication systems will develop, which will be cheaper than the present systems," Dr Choudhary adds.

Pain as a symptom overrides all other symptoms: so much so, that it has been included as the 'fifth vital sign' while evaluating a patient's parameters. Unfortunately, pain is very often under-diagnosed, consequently under-treated. "It is very essential that all doctors are sensitised to this important problem, if they are to make any impact on the patient's quality of life," Dr Devi says.

"The approach should be more patient oriented than disease oriented. This requires significant interaction and seamless co-operation between various specialists and family physicians with the patient's physical and mental well-being the ultimate aim. It requires a team effort involving pain specialists, psychologists, physiotherapists and palliative care personnel," Dr Vas opines.

"Pain management is a vast ocean and there are several explorers out at sea. Newer and more accurate diagnostic techniques mean better chances of identification of the cause and as a consequence, development of more specific therapies in pain management. Right now and more so in the future I think every type of pain can be managed-except probably of broken hearts," Dr Edmund D'Couto, Consultant Physiatrist and Head, Department of Physical Medicine and Rehabilitation, Kovai Medical Centre and Hospital, Coimbatore.

According to Dr D'Couto, "Pain can be of varied aetiology and when we talk about pain management we do not generally talk about the acute pain of trauma, but are generally referring to chronic pain." This can be either from an identifiable and rectifiable condition or an identifiable, but not rectifiable condition or not physically identifiable condition.

Identifiable and rectifiable conditions are ones like chronic low back pain of poor postures, mechanical low back pain, myofacial pain involving the neck and back etc. Identifiable but not rectifiable conditions-conditions like pain of metastatic carcinoma, which is in late stages, intractable pain due to nerve injuries etc. Not physically identifiable condition: like pain of psychogenic origin or pain as a psychosomatic disorder. Here treatment would involve more of psychiatric therapy.

"I prefer a comprehensive therapy using drugs, physical modalities like diathermy, bio-feedback, laser and exercises. The advantage is that it offers a permanent and lasting solution, addressing the basic cause of the pain and not just masking the pain. The disadvantage-not a passive therapy administered by the physician, but involves the active participation of the patient in the treatment process," says Dr D'Couto.

There is a palpable drift away from symptomatic treatment to more comprehensive and aetiology-directed medicine and this trend is likely to increase among patients and practitioners alike. Hence, technologies supporting this trend will gain more importance.

With inputs from Jayata Sharma
ehm@expresshealthcaremgmt.com