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Category Archives for General

Identifying Fibromyalgia – A common pain problem in females

Fibromyalgia is a chronic pain condition that causes widespread diffuse body pains. It is the most common cause of generalised musculoskeletal pain in women between 20 and 55 years. Many patients also experience fatigue, sleep disturbances, headaches and mood disturbances such as depression and anxiety. Although some degree of muscle pain is always present, it varies in intensity and is aggravated by conditions such as anxiety or stress, poor sleep, exertion or exposure to cold or dampness. Muscle stiffness is typically present upon awakening and tends to improve as day progresses.

Persistent fatigue occurs in more than ninety percent people along with complains of unusually light non-refreshing or non-restorative sleep. Patients may also feel numbness, tingling or unusual crawling sensations in arms and legs. Other pain syndromes such as migraines or muscular headaches, irritable bowel syndrome or urinary complaints such as bladder pain and urinary urgency and frequency are commonly seen.

Fibromyalgia is thought to be the result of change in pain perception, a phenomenon termed ‘Central sensitisation’, which might be due to genetic predisposition, stressors including physical or emotional trauma, sleep disturbances or other medical conditions. There is no specific laboratory or imaging test used to diagnose fibromyalgia as no abnormalities are detected in underlying muscles or other tissues.

The objectives of FMS treatment are to reduce pain, improve sleep, restore physical function, maintain social interaction and re-establish emotional balance. To achieve these goals patient will need a combination of social support, education, physical modalities and medication. ADEPT is a six step outline of strategy which stands for attitude, diagnosis, education, physical modalities, treatment with medication and living.

While a positive attitude change is needed in patients, the attitude of family members, employers, policy makers all have an impact on patient’s condition. Clinicians must be prepared to accept fibromyalgia syndrome as a real condition that exerts a tremendous impact on the patient’s life and must approach with empathy. Patients need to be educated and understanding is power when it comes to maintaining a proper attitude, adapting to limitations and taking active role in therapeutic program. Aerobic exercises not only helps to maintain function in everyday activities but also to reduce pain, improve sleep, balance mood, restore cognition and facilitate a sense of well- being. The application of heat in the form of hot bath, hot water bottle, electric heat pad or sauna can relax muscles, facilitate exercise and improve a sense of well-being. There have been new medications that have been developed and tested for this condition which include analgesics, antidepressants in low doses and a few anticonvulsant medications which are useful in managing this condition.

Fibromyalgia is thus not a diagnosis of exclusion. A correct diagnosis along with a multidimensional approach to management and with patient and family education and participation can help these patients’ lead better lives.

Managing low backache and other spinal pains – perspective of a Pain Physician

Low backache and Neck pain are among the commonest debilitating conditions in modern society. Such pains while commonly responsible for absence from work can cause disability, impaired gait, loss of sleep and appetite, anxiety, depression and other sufferings.

Most acute episodes of back pain (strains, sprains and muscle spasms) are self-limited with progressive symptomatic improvement and complete resolution in a couple of weeks. The present guidelines to manage acute low back pain stress on staying active and discourage bed rest, analgesics like paracetamol or other NSAIDS if necessary and spinal manipulation for pain relief. However one in three sufferers have continuous, moderate pain three months after the acute episode when it is called chronic or persistent back or neck pain. Some patients experience recurrent episodes of back or neck pain, which is similar to exacerbation of a chronic problem.

Chronic back pain presents a diagnostic challenge. Due to the small region in sensory cortex of the brain dedicated to the back, precise localization of the pain is difficult. This explains why the complaint of back pain suggests a potentially large number of problems, musculoskeletal and otherwise. Pain may originate from spinal structures such as facet joints, vertebral periosteum, intervertebral discs etc as well as from paravertebral muscles, abdominal or pelvic organs. Also scientific evidence suggests that psychological illnesses can contribute to the cause of chronic back pain problems.

Pain Medicine is a discipline of medicine concerned with the study of pain as well as prevention, evaluation, treatment and rehabilitation of persons in pain. The role of Pain Physician lies in the proper assessment of the chronic pain condition in order to pinpoint its cause and its management by interventional pain procedures if not responding to conservative management. The interventional pain procedures are minimally invasive procedures (injections), mostly done on day care basis which are meant to either deposit a drug (local anaesthetic / steroid) near the pain generator, ablation of nerves or implantation of intrathecal pumps or spinal cord stimulators. Interventional pain procedures are used for not only for therapeutic pain relief but also to confirm the diagnosis.

The management of chronic low back and neck pain is multidisciplinary. Apart from a Pain Physician, a multidisciplinary chronic pain management team comprises of Physical medicine professional for physical therapy and a Psychologist for managing the psychological comorbidity. As the causes of low back pain and neck pain are diverse, such patients will need extensive evaluation and at times diagnostic blocks might be needed to confirm the origin of pain from particular structures in the back.

A plan for pain management is made which is individualized for each patient addressing the various factors responsible for the origin of pain, be it physical, functional restoration, social or psychological. The goal of the pain management includes reconditioning, reducing pain, improving function, sleep and mood. Throughout the focus is more on self management of pain and enable patients to become active participants in the management of their illness. The Radiofrequency ablation of nerves and Neuromodulation techniques such as implantable pumps and spinal cord stimulators have made it possible to provide long term pain relief by modulating the pain signals travelling to the brain thereby reducing pain perception.

The chronic back and neck pain management should therefore be seen as a process rather than a quick fix measure involving a multidisciplinary approach, utilizing education, medications and interventions, physical, occupational and behavioural therapy for alleviating pain and other related sufferings.

Managing tailbone pain or Coccydynia

Coccydynia or coccygodynia is the pain in the region of coccyx or the terminal segment of spine. Coccyx not only serves as the insertion site for various muscles, ligaments etc but is one of the leg of tripod along with the ischial tuberosities that provides weight bearing support to a person during sitting position. Trauma, female patients, obesity are the risk factors associated with coccydynia.

The conservative options for management of coccydynia pain include proper sitting posture, application of heat or cold, modified wedge-shaped cushions (coccygeal cushions) which can relieve the pressure on the coccyx while sitting along with NSAID use for short period.

Among pain interventions ganglion impar block is used in resistant cases where pain persists despite conservative measures. The ganglion impar is a sympathetic ganglion which marks the end of two sympathetic chain and is situated anterior to the sacrococcygeal junction. A fluoroscopic guided ganglion impar block is usually successful in managing coccydynia pain. In recurrent cases, a radiofrequency ablation of ganglion impar may be undertaken for long term pain relief.

Surgical intervention (coccygectomy) is the last resort as it is associated with complications and at times failure to relieve pain.

The coccydynia or tailbone pain therefore should not be ignored and appropriate interventions should be undertaken in cases of persistent pain not responding to conservative measures.

Is fibromyalgia pain real?

Fibromyalgia syndrome (FMS) is a widely misunderstood and sometimes misdiagnosed chronic condition, commonly characterized by widespread muscle pain, fatigue, concentration issues, and sleep problems. It is a common medical condition with prevalence ranging from 2% to 12% in the general population. Middle aged women are four to seven times more likely to be affected than men of similar age. The risk factors for the development of fibromyalgia may include physical trauma, febrile illness or a family history of fibromyalgia.

Patients complain of widespread body pain present for more than three months but the clinical manifestations are usually more complex than body pain alone. Patients often describe disordered sleep, fatigue, cognitive dysfunction, dizziness, stiffness, headaches, depression, dysesthesias or burning sensations in the hands, irritable bowel/bladder syndrome.

The sensations that a fibromyalgia patient experiences as pain are as real as any other pain. The current consensus is that fibromyalgia is not a problem with the muscles, joints, or tendons, but rather a problem with the central nervous system. It is most likely a result of Central sensitization, or unusual responses in the nervous system with regard to pain perception. There seems to be an increased release of substance P after painful stimulus or even in the absence of stimulus. In addition, the brain’s regulatory effect, which sends “down signals” to turn off pain, also appears to be abnormal in patients with fibromyalgia – so when a painful stimulus does occur, it gets amplified rather than dampened.

The management of fibromyalgia is multidisciplinary. The objective is to reduce pain, improve sleep, restore physical function, maintain social interaction and re-establish emotional balance. A six step outline of therapy called ADEPT (attitude, diagnosis, education, physical modalities, treatment with medication and living) is mostly used to manage fibromyalgia. The medications which include analgesics, antidepressants and anticonvulsants are used along with various lifestyle changes to control various symptoms.

Fibromyalgia is thus not a diagnosis of exclusion and the suffering is real. Patients should be recognized early and guided for appropriate management so as to help them lead better quality of life.

Why should Chronic Pain Management be multidisciplinary?

Pain is one of the commonest symptoms in patients attending OPDs. While pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”, chronic pain is any pain that has persisted beyond the expected illness or injury, arbitrarily defined as lasting beyond the expected time course, or “3 months”. Low back pain (LBP) & osteoarthritis (OA) are ranked 2nd only to cancer as leading cause of disease burden in the world. While LBP with point prevalence ranging from 12% to 33% is highest contributor to disability, knee OA with prevalence of 6% & 13.7% in urban and rural community is fourth common cause of disability in the world. Neuropathic pain is a common contributor in many pains and exact incidence is not known. Pain is also one of the dominant symptoms in cancer patients especially advanced cancer.

Chronic pain is better explained by a biopsychosocial model rather than a biological model (more useful in acute pain), which suggests that chronic pain is end result of biological (underlying pathology), psychological and social problems. The answer to the question as to why any pain becomes chronic lies in various micro mechanisms happening simultaneously in peripheral and central nervous system after any injury. Central sensitization or wind up is an important phenomenon responsible for signal amplification occurring at the level of dorsal horn and higher centers involved in the pain pathway in the CNS. Various receptors like NMDA, NK1, AMPA are involved and lead to increased spontaneous activity of dorsal horn neurons, expansion of receptive field size and reduction in the threshold for neural activation.

‘‘Pain management continues to be the most difficult problem facing medicine today.’’ These words by Jason R. Bauer and Charles E. Ray, Jr puts chronic pain management in right perspective as of date because despite the technological advances in medical science for the diagnosis and treatment of various diseases, managing chronic pain, its suffering and disability still remains inadequate. The reason for this is explained by the biopsychosocial model for the origin of chronic pain, according to which for managing chronic pain we need to have a strategy in place which looks into and addresses all the factors responsible for giving rise to chronic pain, whether these are biological due to the underlying pathology, psychological or social. Therefore a multidisciplinary approach is a prerequisite for the efficient management of chronic pain.

A multidisciplinary chronic pain management team comprises of medical doctor (a Pain Physician/ Surgeon), a Psychiatrist and Psychologist for managing the psychological comorbidity and a Physical medicine professional for physical therapy. While dealing with a patient in chronic pain apart from the physical basis or underlying pathology giving rise to chronic pain, factors which suggest psychological comorbidity or physical disability should be specifically sought and should be addressed while making the overall treatment plan.

The role of Pain Physician lies in the proper assessment of the chronic pain condition in order to pinpoint its cause and its management by interventional pain procedures if not responding to conservative management. The interventional pain procedures are minimally invasive procedures (injections), mostly done on day care basis which are meant to either deposit a drug (local anaesthetic/ steroid) near the pain generator, ablation of nerves or implantation of intrathecal pumps or spinal cord stimulators. Interventional pain procedures are used for therapeutic pain relief as well as to confirm the diagnosis.

There is ample evidence that the psychological factors play a significant role in the experience, maintenance and exacerbation, if not the cause of pain. Since there are no cures for chronic pain and some level of pain will persist in most pain sufferers regardless of treatment, psychological approaches are useful complements to more traditional medical and surgical approaches.

A comprehensive pain management program should include the services of a Physiatrist, who can offer various physical modalities such as therapeutic heat and cold, hydrotherapy, ultrasound, electricity, TENS, manual techniques in addition to active exercises. Physical techniques benefit the patients by causing functional restoration, maximizing and maintaining pain relief for long and a feeling of control of one’s own pain.

A multidisciplinary approach is certainly of benefit in chronic pain patients to help them relieve their pain and bring them back to functionally active life.

References

  • Multidisciplinary rehabilitation for chronic low back pain: systematic review. Jamie Guzman, Rosmin Esmail, Kaija Karjalainen, Antti Malmivaara, Emma Irwin, Claire Bombardier BMJ. Jun 23, 2001; 322(7301): 1511–1516.