September is observed as the pain awareness month, chronic pain becoming one of the country’s greatest hidden health crises. How do you know if you have chronic pain? If it lasts for three months or more and persists beyond the normal time of healing, you need medical attention. Due to changing lifestyles as well as the ageing population, the number of people suffering from chronic pain is increasing. The commonest cases are those related to the lower back, neck, knees, shoulders, head, orofacial region, herpes and cancer.
What is chronic pain? How would you define it?
Chronic pain is often described as a long-standing pain that persists past the normal time of healing or occurs along with a chronic health condition. It has various causes and needs multidimensional assessment and treatment. Broadly, chronic pain is defined as any pain lasting beyond three months after tissue healing. Though acute pain (<6 weeks) is considered a warning sign and symptom, chronic pain is a condition in itself.
Can our lifestyle and diet influence chronic pain?
Yes. A sedentary lifestyle with bad posture, lack of exercise and bad eating habits are the major reasons for various chronic pains. In the past, chronic pain was usually thought to be associated with ageing and a degenerative condition of the human body but now we see many young adults, even adolescents and children complaining of extreme discomfort. It may soon assume epidemic proportions among the younger population.
Has the number of people visiting your pain clinics increased?
When we started in 2009, we had nearly 20-25 patients per clinic and nearly 1,500-2000 patients per annum. Over the last few years, this has increased to nearly 70-80 patients per clinic with around 4,000-5,000 patients per annum.
Chronic pain, according to you, is one of the greatest hidden health crises in our country. Do you have data to that effect?
Chronic pain is one of the greatest hidden health crises not just in our country but across the globe. If we talk about evidence-based data, a survey conducted by the World Health Organisation (WHO) in 15 centres across Asia, Africa, Europe and the US demonstrated the prevalence of chronic pain among 33 per cent of the population. The surveys from our country across eight cities have shown chronic pain prevalence in 13 per cent of our population, which is huge. Our recently published community-based population study from Tricity revealed that nearly 50 per cent suffered from chronic low back pain. Chronic pain is a hidden crisis because the condition hugely impacts all aspects of life, be it physical, mental, social or financial. It accounts for long sick leaves and job losses among sufferers. Chronic pain patients are reported to be more anxious and depressed.
What are the most common conditions associated with chronic pain at your clinic? Which age group is affected the most?
We get complaints of low back pain in about 70 per cent patients. We also see neck, knee, shoulder, trigeminal neuralgia, postherpetic neuralgia, fibromyalgia, pelvic, cancer and myofascial-related pain in our clinic. Previously we had the middle-aged and elderly population coming in but over the last few years, we have started seeing all age groups, from 13 to 90 coming in.
What are the warning signs and symptoms of chronic pain? Is there a way that people can seek early intervention before the pain turns chronic?
Pain is a subjective symptom and sadly it cannot be tracked in objective lab tests. People should understand that chronic pain is a disease in itself and early intervention is required to avoid its huge impact on the functional ability and mental health of patients. We see patients suffering for years.
Why is chronic pain usually under-treated and under-managed?
Chronic pain is usually neglected, inadequately assessed and under-treated globally but more so in developing countries, including India. One of the main reasons is inadequate pain education and awareness both at the professional and public level. Chronic pain management needs to be taught at both the undergraduate and postgraduate levels. Chronic pain is a speciality in itself and there are not many specialised pain education courses in India. However, since 2020, pain education is now part of the MBBS and MD curriculum. Now for any college to get recognition for MD Anaesthesia, there is a mandatory requirement that it has a well-established chronic pain clinic. Still its implementation at the national level is yet to happen. I do not know how many are aware that there is a pain clinic run in the PGIMER OPD on a regular basis.
How does chronic pain impact all domains of our life?
Chronic pain affects all aspects of our life. The significant impact of lower back pain on sleep, depression/psychological problems and social life are observed in nearly 24-50 per cent of chronic pain patients. Nearly 60-80 per cent of our first-time attendees clinic cry as they are abandoned by their family members and caregivers who convince them that the pain is in their head. When we empathise with them, nearly 30-40 per cent of their management is done then and there.
What are the treatment options/strategies for chronic pain? You say a well-planned bio-psycho-social model and inter-professional treatment strategy is an option. Please explain.
Chronic pain is complex as it impacts all domains of life and requires a bio-psycho-social-spiritual model for its management. It requires interdisciplinary management, where the involvement of many healthcare professionals such as a pain physician, physiotherapist, psychologist, dietician and yoga trainer are required. All health professionals work together to reach a common goal of overall improvement of Chronic Pain Patients (CPPs). A well-trained pain physician is well aware that just biomedical management with medicines and minimally invasive injections are not sufficient for the adequate management of CPPs. The aim of management is not just pain reduction but managing all domains associated with chronic pain. I would also like to emphasise here that patients’ self-management is also very important and plays a huge role.
What are the minimally invasive techniques used to treat people who do not respond to conservative management?
There are a variety of minimally invasive injection therapies available for patients who do not respond well to conservative therapies. These are usually known as MIPSI (Minimally Invasive Pain and Spine Innervations). These interventions depend on the chronic pain conditions. For example, we offer epidural injections, facet joint injections, median nerve block, selective nerve root block, dorsal root ganglion block and sacroiliac joint injections for lower back pain, individual nerves like maxillary, mandibular, supra/ infraorbital nerve RFA or trigeminal ganglion block for trigeminal neuralgia. The procedure lasts 15-30 minutes and is done under local anaesthesia. The patient can go home the same day.
What are new technologically advanced treatments available today?
Spinal cord stimulator for most refractory neuropathic low back pain, intrathecal drug delivery for cancer pain, peripheral nerve stimulator, DRG stimulators, deep brain stimulation and so on are few of the advanced technologies. These are usually reserved for very refractory patients as these are very expensive and require an implant to be placed in the body.
What’s your advice to common people experiencing any kind of pain?
Prevention is better than cure. An ounce of prevention takes you a long way. Chronic pain is increasing because of our changing sedentary and stressful lifestyles. My advice to the masses is that there is no alternative to a healthy lifestyle. Stay physically active, eat well, feel well and entertain yourself. If you want to enjoy 23 hours of your day, you have to give your body one hour each day. So, exercise/walk for an hour a day. If you cannot take out one hour at one stretch, split this hour into three or four parts. Everyone can take out this much time for themselves, it’s not difficult and definitely not impossible.
Why Doctor Babita
Dr Babita Ghai, Professor, Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, was nominated and selected for the prestigious post of editorial board member of the Pain Research Forum, a publication of the International Association of the Study of Pain. She has a 23-year post MD teaching and research experience with pain management, regional anaesthesia, paediatric anaesthesia, obstetric anaesthesia, education and policy creation. Her speciality is chronic low back pain.