Does being in pain make you feel helpless? Try pain management.
Pain management, a branch of medical science that seeks only to manage (and treat) pain, is still young in India, but it's a start.brunch Updated: Apr 07, 2015 19:14 IST
Aaliya Akbar* is a 29-year-old journalist who has the funniest anecdotes to tell. She’s very animated. She throws her head back when she laughs and waves her arms around when she talks. She breaks into little dances when she’s happy. And like little children – or perhaps like nervous, young brides – she sometimes clenches her fists and presses her hands together. It’s an endearing habit, you’d think.
You wouldn’t notice that she is in fact, clutching at her left ring finger to make it stop hurting. She’s been in pain for 13 years. It comes and goes: sometimes several times a day. There are good days, when she feels no pain. Once, she was pain-free for an entire week.
Everybody feels pain at some time or the other. It can be a simple headache because you didn’t sleep well, a stomach ache because you didn’t eat well. Or it can be more serious. Chronic pain is pain that lasts longer than a few months.
And 1.5 billion humans suffer from chronic pain. (The global population is seven billion.) A recent United Nations report estimates that 5.5 billion people have limited or no access to proper pain-relief treatment. Pain is the number one reason people go to a doctor.
This is how it works: you damage a part of your body, your nerves transmit pain along thousands of nerve fibres through the spinal cord, which first processes it and acts on it – these are your reflexes. So, for example, if you step on a rock, your dorsal hub, a part of your spinal cord, makes you pull your foot away.
Within a fraction of a second, the signal reaches the brain. This is how you make sense of what has happened: the intensity, the sensation and your emotional response. The sensation of pain makes connections with centres associated with anxiety, emotions, sleep, appetite and memory. The brain decides whether you shrug it away, get frustrated or burst into tears. Your mood, beliefs and even gender, all impact the way you feel pain.
And because everybody’s mind perceives pain differently, it is a personal experience. Every pain has its own (painful) story to tell.
Aaliya’s story began when she was 17. She was walking up a staircase in high school, when she felt like a thousand pins were attacking her left hand from within. She ignored it for months. She assumed it would go away. It didn’t.
She was diagnosed with neurofibromatosis – a genetic nervous disorder which caused agonising pain, among other things. The first round of painkillers eliminated the pain for a few months. When it returned, it was contained to the tip of her ring finger. By this time, the meds had stopped working. Nothing has really worked since.
She’s tried physiotherapy and medicines and laser treatment. Right now, acupuncture helps a bit, she says. Almost immediately, her finger begins to tingle.
For centuries, the predominant, and still prevalent, medical view is that pain is a symptom of an underlying problem. That there is a larger reason you’re suffering: a skin injury, a slipped disc, a tumour, a deficiency, and to alleviate the pain the condition must be treated. But in the meantime, the acute sense of helplessness accompanied by the pain makes it important for pain to be considered a problem in itself.
“Substantial evidence suggests that chronic pain is in fact a separate disease altogether,” says Dr Ashok Saxena, a senior professor at the University College of Medical Sciences, Delhi University. We don’t take it seriously enough, despite “considerable breakthrough in scientific knowledge about pain and therapeutic advances”.
How does it work?
Atul Gawande, the celebrated American surgeon and writer, in an essay in the The New Yorker, writes: “a compassionate approach towards chronic pain means investigating its social coordinates, not just the physical ones. For the solution to chronic pain may lie more in what goes on around us than in what is going on inside us.”
This “compassionate approach” is important from the start. You need a doctor who understands your pain.
For five years, Rina Sharma*, a Delhi-based nutritionist, went from doctor to doctor for a debilitating lower back pain. One thought she had a slipped disc, another said depression. Relatives decided she was just being lazy. “Nobody (including doctors) believes you’re in pain because there is no visible proof till they find a source. How can they find it when they don’t understand?”
When she was diagnosed with fibromyalgia, a musculoskeletal disorder that causes pain and mood swings, she was thrilled, “because my problem had a name!” Two years of pain management later, her condition has significantly improved.
The treatments for chronic pain are as diverse as the causes, says Dr GP Dureja, director at the Delhi Pain Management Centre, who also set up the first pain clinic in India in AIIMS in 1985. They range “from over-the-counter and prescription drugs to injections and advanced interventions like radiofrequency lesioning [a procedure that treats spine conditions with electromagnetic waves]... Relief may be found by using a combination of treatment options.” What Causes Pain?
Studies point to loneliness and even job dissatisfaction, writes Gawande. A genetic predisposition is also high. Sometimes, it may be passed down emotionally. So if you watch your mother suffer from constant pain, you will react more sensitively to it too.
One of the first things doctors trained in pain management check for is deficiencies. (Helpful tip: get your vitamin D levels tested.)
If you’re in pain, don’t ignore it and expect it to heal on its own. Treat it with over-the-counter gels, or with hot water bottles and ice packs. If this doesn’t work, get help. “If left untreated, the pain will return,” says Dr Sanjay Nijhara, a Delhi-based orthopaedic surgeon who has now moved to pain management.
“Posture plays an important role,” says Dr Nijhara. “If the left and right of the body are not symmetrical, the front and back, the top and bottom are imbalanced in one way or another, there will be pressure on the muscles. In pain management, we also work on treating postural imbalances.” Yoga, if performed correctly, helps too. But don’t do more than your body allows. Yoga injuries are excruciating.
Sometimes, pain is a symptom of more pain. If you have been suffering from constant pain, your cells at the nerve endings in the spinal cord and in the brain can become over-sensitised. The pain could continue even as there is no longer any damage to the body.
In the 1990s, US-based neuroscientist Vilyanur S Ramachandran devised mirror therapy to relieve pain in amputees suffering from ‘phantom pains’ in their missing limb.
Ramachandran believes that vision can powerfully modulate pain in different contexts. He’d place a mirror in such a way that the reflection of the existing limb would fill in for the missing one to the patient’s eye. And the pain would disappear. This method is now used to treat all kinds of chronic pain, and not just in amputees.
Chronic pain is also associated with serious life-limiting illnesses, like cancer and cardiac diseases. In these cases, patients need to undergo palliative care, a specialised medical treatment to alleviate pain associated with these conditions, and to improve the quality of life.
This year, the WHO adopted a resolution asking countries to integrate palliative care into their health systems.
The case in India
A 2011 Human Rights Watch report revealed that Indian doctors lacked basic knowledge about pain management. Almost as a response, in 2012, the Ministry of Health and Family Affairs approved a national palliative care strategy.
A draconian 1985 Drugs law made doctors liable (by incarceration) for any error in the prescription of morphine, which is essential to palliative care. Most hospitals stopped stocking the drug altogether. This, when India is a leading producer of morphine.
This law was amended last year. And the Medical Council of India introduced a one-year post-graduation specialisation in pain and palliative care, for anaesthesiologists. But, says, Dr Dureja, “Pain management is still a nascent super-speciality, especially in India. People have accepted surgeries, because they are now well-known. But many times, surgery isn’t even required. The pain can be handled through pain management techniques.”
Traditional doctors still advocate surgery, though they admit that pain management is important. “I would use pain management for terminal conditions only,” says Dr Vikas Ahluwalia, director of the Diabesity (Diabetes and Obesity) Centre with Max Super Speciality Hospital, Saket.
“The crux of the problem is the cause,” he says. When it comes to patients of diabetic neuropathy, (nerve damage that can occur if you have diabetes), he prescribes medicines first. And if the pain persists, he refers his patients to pain clinics. Physiotherapy, massage, all help, he agrees. “But it has to be a joint venture between physiotherapists, pain specialists and doctors.”
Many choose to live with pain for years. “Indians like to bear pain,” many doctors told us, amost scornfully. This is dangerous because pain manifests itself in other harmful ways. The first is anxiety and depression, which topples the body’s balance. Your digestion, respiratory cycle or menstrual cycle, or even your heart could be affected. You may develop kinesiophobia, a fear of moving the body part that hurts, worried that it will onset the pain.
The comforting news is that pain is a sign of well-being.
A very rare defect in a gene called SCN9A can cause congenital insensitivity to pain. The few people with this condition feel no pain at all. This sounds like a super power, but it actually means that if they did step on that rock, they wouldn’t realise that it had pierced their skin until they saw the blood. Many years ago, a young boy in Pakistan died of a haemorrhage a day after an accident – all because he felt no pain. He went untreated because he seemed just fine.
Pain is complex. And nobody ever truly understands what you are going through. Your doctor will ask you to rate it on a scale of zero to 10 – and won’t know whether you’re feeling it more or less than other patients.
Either way, you’re a step closer to diagnosis. Pain is frustrating, but ultimately, pain is good.
Treatments in pain management:
Used for slipped disc. Ozone gas is injected into the disc space, which causes the disc to shrink and treat the pain.
Used for conditions like tennis elbow, knee pain, joint pains. Platelets from the patient’s own blood are injected to rebuild a damaged tendon or cartilage.
Synovial fluid replacement:
Used for knee pain and a great alternative to total knee replacement surgery. In this, a preparation of hyaluronic acid, a naturally occurring substance found in the synovial (joint) fluid, is injected into the knee joint. It acts as a lubricant to enable bones to move smoothly and treat knee pain.
Used for long-standing headaches, migraines, trigemenial neuralgia, myofascial spasm, and even spasticity in children. Now also used for cosmetic purposes, Botox is primarily a muscle relaxant. In controlled doses, it can provide safe, effective relief.
Lie on your floor, and tell your body to relax – start with your foot, then your ankle, and go right up to your head, concentrating on each body part. This yoga technique helps in easing pain.
*Names changed on request
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From HT Brunch, April 5
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First Published: Apr 04, 2015 13:23 IST