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Pain is an unpleasant feeling or discomfort caused by injury, illness or emotional disorder. Acute pain results from a disease, inflammation, or injury. This type of pain starts suddenly and persists for short period, as in pain after an accidental trauma or surgery. Chronic pain is caused by a disease itself and persists for a longer period of time. Pain management involves treatment of the underlying disease with appropriate medications as well as pain relief using medications and alternative techniques such as acupuncture, ice and heat application and massage. The different types of medications used for pain management include:

  • Analgesics: Analgesics are the pain relieving medications which are available as both over the counter and prescription medications. Analgesics may be used to relieve chronic pain in conditions such as osteoarthritis.
  • Nonsteroidal Anti-Inflammatory Drugs: Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in the treatment of back pain and inflammatory conditions such as tendonitis, bursitis and arthritis.
  • Corticosteroids: Corticosteroids are used to treat chronic inflammation of the joints caused by rheumatoid arthritis. They are available in the form of oral medications and injections administered into the joint (cortisone injection).
  • Narcotic Analgesics: Narcotic analgesic medications are used to relieve acute pain, such as pain that is felt immediately following an injury or a surgical procedure. The use of these medications needs monitoring by your physician as they are potentially addictive.
  • Anticonvulsants: Anticonvulsant medications relieve neurogenic (nerve) pain and chronic pain in the soft tissues surrounding the joint caused by fibromyalgia.
  • Local Anesthetics: Local anesthesia is a pain control option used in some types of superficial surgical procedures of the hand and foot. However, it may not provide adequate pain relief in invasive procedures. Local anesthetics are also used for temporary relief of pain. In cases of chronic pain, local anesthetics can be applied as a topical patch over the skin in the painful area.
The other treatment options for chronic pain include:
  • Acupuncture: Acupuncture treatment involves insertion of needles into specific points in the body to stimulate the release of pain relieving substances such as endorphins. It is used in the management of post-operative pain, tennis elbow, carpal tunnel syndrome, sciatica, arthritis and low back pain.
  • Ice and Heat application: Ice packs can be used after acute injuries such as an ankle sprain. Applying ice over the injured area in the first 48 hours will help to reduce swelling and control pain. Ice treatment can also be used in cases of overuse injuries caused by repetitive action during sports. Ice should be applied over these injuries only after the activity to reduce inflammation.
Heat treatment is suitable for chronic conditions such as overuse injuries and should be given prior to any sports activity.




Coordinate with Physical Therapy


Physical therapy is one of the foremost necessary treatment modes of recovery for chronic pain. A physical therapist is a well-trained, skilled health care professional who facilitates improving movement and manages the pain by safe stretching, conditioning, and strengthening exercise techniques. The different modalities of physical therapy include hot or cold packs, ultrasound, transcutaneous electrical nerve stimulation, spinal manipulation, diathermy, massage, and aqua therapy. These treatment options may be indicated depending on the type and severity of pain. The two different forms of physical therapy include:

  • Active physical therapy includes physical exercise or stretching, whereby the patient uses their own force to reduce pain.
  • Passive physical therapy is where the modalities are done to the patient by the therapist.
A physical therapist tailors a particular exercise program per the individual necessities and goals.




Non-Surgical Treatment


Most of the times, pain can be resolved without surgery. The conservative treatment involves use of pain medications and other methods to reduce inflammation and restore normal function. Usually, some self-care methods and medications can help to overcome pain, but if pain and inflammation persists over 72 hours, it is necessary to consult your physician. Self-Care at Home Ice and Heat: is the use of cold and hot compresses over the affected area. This helps to relieve the pain and swelling and also improves the mobility. A cold pack or compress (crushed ice wrapped in a towel) should be applied to the affected area immediately following trauma and kept there for at least 20 minutes. This can be done several times in a day. Heat treatment should be started after 2-3 days of cold compress. Heat is applied with a hot pad or warm bath for a short period of time. This helps to relax muscles and increase the blood flow.

  • Rest: is recommended for 1–2 days and you should resume to normal activities as soon as possible.
  • Exercise: ensures fast recovery and also helps to strengthen the muscles. Your doctor can advise some gentle stretching exercises to relax muscles and relieve pain. If your pain increases and lasts for more than 15 minutes during exercise, you should stop exercising and consult your doctor.
Medications A combination of over-the-counter pain medications and prescription drugs offer effective pain relief. Certain medicines may be unsafe to be taken during pregnancy or may have interaction with some other medicine you are taking, so it is best to consult your doctor before taking any medications.
  • Over-the-counter analgesics: includes nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, naproxen, and ibuprofen .It reduces stiffness, swelling and relieves moderate back pain.
  • Anticonvulsants: are useful in treating neurologic pain and are prescribed with pain medications.
  • Antidepressants: Tricyclic antidepressants such as amitriptyline and desipramine can relieve pain by masking the pain signals from the brain.
  • Opioids: such as codeine, oxycodone, hydrocodone, and morphine are prescribed if the pain is more severe, but only for a short time. Side effects of these medicines include drowsiness, decreased reaction time, impaired judgment, and addiction.
Non-Invasive Therapies There are several options of non-invasive techniques which can be considered when the more conservative methods fail to respond .These include: Acupuncture: Acupuncture is the procedure which involves insertion of fine needles of about the width of your hair into specific points throughout the body in order to relieve pain. This process is said to release some naturally formed painkillers in the body called peptides. It is a method of encouraging the body to promote natural healing and to improve functioning. Acupuncture is performed by a physician or other licensed health care professional. When acupuncture needle is inserted into acupuncture points, stimulates the nervous system to release chemicals in the muscles, brain and spinal cord. These chemicals provide local inhibition to the incoming pain signal. In addition to causing effects in the spinal cord, the nerve impulse is also transmitted to the mid –brain, where brain chemicals are released. These chemicals play a role in suppressing the transmission of the pain impulse. Each acupuncture point area is swabbed with alcohol before tapping the needle into the site. These are stainless steel needles and available in various dimensions. They are very thin, solid, with smooth point and have a finely tapered point. The number of needles used during treatment may vary and they are placed under the skin. After inserting, the needles stay in place for several minutes to an hour. The needles are twirled, energized electrically to intensify the effect of the treatment. Tingling sensation is common when electricity is applied. Biofeedback: Biofeedback can be used to treat most acute pain including back pain. A special electronic machine is used and the patient is trained to be aware of and to follow and gain control over body functions such as muscle tension, heart rate, and skin temperature (done by controlling local blood flow). The patient is also trained to change his or her response to pain by using relaxation techniques. Interventional Therapy: Interventional therapy is used to treat chronic pain by blocking the nerve signals between specific areas of the body and the brain. The treatment approach involves injections of local anesthetics, steroids, or narcotics into the affected soft tissues, joints, or nerve roots. It may also involve complex nerve blocks and spinal cord stimulation. When there is extreme pain, low doses of drugs may be injected directly into the spinal cord through a catheter. Chronic use of steroid injections is avoided as they cause functional impairment.
  • Proliferation Injection: Proliferation injection is also known as sclerotherapy and is a non-surgical treatment for musculoskeletal injuries. It involves injecting the dextrose solution (irritant) into the damaged or injured ligaments and tendons. During an injury the tendons and ligaments get worn out, tears up, stretches, and lead to rupture of the connective tissue causing pain, loss of strength, and instability. For an instance, back pain is caused because of the instability of the vertebrae, which result in the weak or damaged ligaments or tendons or muscles. If the ligaments are damaged, the bones in the vertebrae rub against each other causing inflammation and pain. To reduce the inflammation, anti-inflammatory drugs or even pain relievers are prescribed.
Macrophages are the group of cells that recognizes, attack and dispose the foreign particle out of the body. Macrophages consider the irritant as a foreign body and attack the irritant once it is injected. Meanwhile the body brings in ‘fibroblasts’ which heal the damaged ligaments and produce connective tissue that helps in the reconstruction of ligaments at the weak and injured area. This injection helps in the proliferation of new cells and helps in the repair of connective tissue. The injected solution provides joint stability which decreases pain. This therapy works on all joints and therefore is recommended in various injuries including back fractures, disc herniation, and arthritis. An X-ray is performed to know the exact location of the injury. This treatment is not painful and does not lead to major risks. It is done by injecting a local anesthesia and the PRP solution.
  • Neural Prolotherapy: Neural prolotherapy is a non-surgical treatment of injecting an irritant solution into the painful areas where the ligaments and tendons are injured. It is recommended in the treatment of musculoskeletal pain, arthritis, back or neck pain, sports injuries, torn ligaments, cartilage, and tendons.
The irritant solution irritates the local area causing inflammation. The scavenger cells (macrophages) arrive at this site to dispose the irritant solution. This encourages the repair process where the fibroblasts, the connective tissue builder cells, stimulate the production of connective tissue. Release of growth factors at the site of injury may help in strengthening, reducing the pain, inflammation, and weakness.
Prolotherapy injection is given every 2–6 weeks. This procedure is considered safe and does not have any major risks.
  • Traction: In this therapy, a continuous or intermittent force is applied to the skeletal structure in order to bring it into alignment. Force is applied using some weights. This treatment is not recommended for acute back pain.
  • Transcutaneous Electrical Nerve Stimulation (TENS): TENS is a technique which uses a device to send electric pulses along the nerve fibers so that the pain signals to the brain are blocked. Small electrodes are placed on the skin at or near the site of pain. Mild nerve impulses are produced which block the pain signals coming from the peripheral nerves. TENS may also stimulate the production of endorphins (chemicals produced in the brain having pain-relieving properties).
  • Ultrasound: Ultrasound is a noninvasive technique which uses sound waves that can pass through the skin and injured muscles. It can cause the soft tissues to warm up and thus relax the muscles and ease some amount of pain.




Minimally Invasive Procedures


Minimally Invasive Surgery (MIS) uses the latest advanced technology to treat pain caused by a variety of medical conditions. Special surgical instruments, devices and advanced imaging techniques are used to visualize and perform the surgery through small incisions. The aim of MIS is to minimize damage to the muscles and surrounding structures enabling faster recovery and less pain. Benefits of MIS The benefits of MIS over the traditional open surgery include:

  • Small surgery scars
  • Less risk of infection
  • Minimal blood loss during the surgery
  • Minimal post-operative pain
  • Quicker recovery
  • Shortens the hospital stay
  • Quicker return to work and normal activities
Procedure Minimally invasive surgery is performed through very small incisions. Through these small incisions, segmental tubular retractors and dilators are inserted to retract muscles away from the operative area and provide access to the affected area of the spine. This minimizes the damage to the muscles and soft tissues and lessens blood loss during the surgery. An endoscope, a thin telescope-like instrumentwith a video camera on the end is inserted through one of the tiny incisions to provide images of the operation field on the monitor in the operating room. Special tiny surgical instruments are passed through the working channel of the endoscope to perform the surgery. Sometimes surgical microscopes may also be used to magnify the visual field. Once the surgery is complete, the tissues fall back in place, as the various instruments are removed. The incision is then closed and covered with surgical tape. Risk and Complications As with any surgical procedure, there are risks involved with minimally invasive surgery. The risks and complications of MIS may include infection, bleeding, nerve injury as well as complications due to general anesthesia.




Evidence Based Pain Management


Pain is an unpleasant feeling or discomfort caused by injury, illness or emotional disorder. Pain can be differentiated into two basic types such as:

  • Acute pain – It results from disease, inflammation, or injury. This type of pain starts suddenly, for example, after accidental trauma or surgery
  • Chronic pain – It is caused by a disease itself. Both environmental and psychological factors can worsen it. It persists for a longer period of time. Chronic pain conditions include chronic fatigue syndrome, endometriosis, fibromyalgia, inflammatory bowel disease, interstitial cystitis, temporo-mandibular joint dysfunction, and vulvodynia.
Complete acute and chronic pain conditions evaluation Your doctor will make a diagnosis based on the history of pain you have narrated such as type of pain – whether sharp or dull aching pain, duration and location of pain.
There are various diagnostic techniques used to find the cause of pain and some of them include:
  • Electro diagnostic procedures – Electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies

    • Electromyography (EMG) – help to find out which muscles or nerves are affected by weakness or pain

    • Nerve conduction studies – determine if there is any nerve damage

    • Evoked Potential (EP) – is used to record the speed of nerve signal sent to the brain

  • Imaging, especially Magnetic Resonance Imaging (MRI) is use of magnetic waves to differentiate diseased and healthy tissues
  • A neurological examination involves testing for movement, reflexes, sensation, balance, and coordination
  • X-rays used to see the deformities of bones and joints.
Treatment The ultimate goal of pain management is to improve the function of an individual by enabling him to carry out his day-to- day activities in a normal way. There are many ways by which pain can be treated. Medications Analgesic medications: These are pain relieving medications. Anticonvulsants are used to relieve pain caused by trigeminal neuralgia. Antidepressants are also prescribed. In addition, anti-anxiety drugs are used to relieve muscle pain. Antimigraine drugs are used to relieve migraine headaches. These medications should be taken only on doctor’s advice as they can cause serious adverse effects. Physical therapy Physical therapy involves use of physical techniques and methods, such as heat, cold, exercise, massage, and manipulation, in the treatment of certain chronic pain conditions. These techniques help to increase function, control pain, and rehabilitate the patient. Heat and cold therapy help to relieve pain when applied to the painful areas. Physical exercises include stretching and range-of-motion exercises to maintain strength, flexibility, and mobility. Regular exercises relieve stress and also increase production of endorphins-natural pain relievers. Psychological evaluation and therapy Psychological counseling such as behavioral therapy improves your mental health and manages conditions such as stress and depression which can aggravate chronic pain. It is important to be physically as well as emotionally stable to manage chronic pain.




Interventional Techniques


Interventional therapy can alleviate chronic pain by blocking the transmission of pain signals to the brain. Interventional pain management involves special procedures such as an injection of local anesthetic, steroid, or narcotic around nerves, tendons, joints or muscles, nerve blocks and spinal cord stimulation to treat and manage pain. In some cases of extreme pain, drugs are often given in smaller doses through the catheter directly into the spinal cord. Even though interventional procedures for treating pain seem simple, extreme care should be taken when conducting these procedures. These procedures should be performed by well-trained and experienced specialists. Some of the interventional techniques include the following:

  • Cervical Epidural Steroid Injection: A cervical epidural steroid injection places powerful anti-inflammatory medication directly into the epidural space of the spine in the neck region.
  • Thoracic Epidural Steroid Injection: A thoracic epidural steroid injection places powerful anti-inflammatory medication directly into the epidural space of the spine in the mid back region.
  • Lumbar Epidural Steroid Injection: A lumbar epidural steroid injection places powerful anti-inflammatory medication directly into the epidural space of the spine in the lower back region.
  • Discography: Discography is performed under X-ray guidance, the needle is placed inside the suspected disc and a contrast dye is injected. This test is used to determine whether the disc is the source of pain in patients with neck or back pain.
  • Radiofrequency Lesioning: This technique uses electrical impulses to interrupt nerve conduction and the transfer of pain signals for 6 to 12 months. During the procedure, a special needle is directed into the involved nerve tissue with the guidance of an X-ray. The needle tip is then heated for 90-120 seconds so that the nerve gets cauterized and destroyed thereby reducing the pain.
  • Cervical medial branch block: A cervical medial branch block involves the injection of a local anesthetic with or without a steroid near the medial nerve branches supplying cervical (neck) facet joints.
  • Thoracic medial branch block: A thoracic medial branch block involves the injection of a local anesthetic with or without a steroid near the medial nerve branches supplying thoracic (mid-back) facet joints.
  • Lumbar medial branch block: A lumbar medial branch block involves the injection of a local anesthetic with or without a steroid near the medial nerve branches supplying lumbar (lower back) facet joints.