Back pain is a major clinical and socioeconomic problem

Currently ranked as the single leading cause of years lived with disability worldwide.
A pain physician is an allopathic practitioner who has completed his / her MBBS and MD and has taken further training in chronic pain management by means of highly skillbased minimally invasive procedures that usually target the nerves supplying the painful areas. These procedures are day care procedures done under the guidance of either live Xray (c arm fluoroscopy) or ultrasonography. These doctors have their expertise in clinical examination and diagnosis of various pain conditions, its medical management by using nonnarcotic and narcotic medications. We, the doctors at Ashirvad Institute of pain management believe in a holistic approach and aim at a cure rather than just “management” of the pain.
  • Neck pain (Radiculopathy / myofascial pain)
  • Back pain (Radiculopathy, facetogenic pain, disc bulge / prolapse, failed back surgery, SI joint, coccygodynia)
  • Shoulder pain (frozen shoulder)
  • Knee pain (osteoarthritis)
  • Headache and orofacial pain (Migraines, trigeminal neuralgia, occipital neuralgia, chronic tension type headache)
  • Complex regional pain syndrome (upper or lower limb, abdomen)
  • Acute herpes zoster or chronic post herpetic neuralgia pain
  • Postsurgical / post traumatic/ post chemotherapy / post radiotherapy neuropathic pain
  • Pelvic pain (interstitial cystitis/ rectal / perineal pain/ endometriosis)
  • Cancer pain
  • Central pain syndromes (post stroke pain/ spinal cord injury/ phantom limb pain)
  • Myofascial pain / chronic fatigue syndrome/ fibromyalgia

  • We also treat some painless conditions like persistent hiccups/ vertigo/ blepharospasm
Apart from the nerve treatments we follow each pain patient with a treatment that targets all the muscles involved in the process of pain generation by using a de novo technique called ultrasound guided dry needling (USGDN). We are practicing it for last 16 years in almost all variety of pain patients with great success in refractory pain conditions too.

Pain is a sensation that the body uses to alert us to bodily injury and let us know what’s happening in any part of the body. Injuries (cut, crush, burn etc), surgery, illnesses, deprivation of blood supply, inflammation, and even chemical changes, anything that can cause tissue damage, will cause pain. But in chronic pain, there may not be obvious tissue injury, yet the brain perceives certain symptoms as if there is a damage in the body. Patients can describe sensations of aching, pulling, tearing, electrical shocks, burning, insect crawling or ants biting sensation to name a few when.
It may have adverse effects on functional activities and social and psychological well-being.

It is not necessary that tissue injury should always precede pain. Sometimes the pain experienced may be disproportionate to the tissue injury, which means that even a trivial injury can result in severe pain. The contrary may also be true and a severe injury may not always cause too much pain. Pain is, thus, not just a signal of an injury travelling up to the brain but is a biopsychosocial phenomenon.
Biological – This aspect is the damage to the body (tissue damage) that is converted to an electrical impulse that travels upwards to the brain through nerves that carry pain sensation and where it is perceived as an unpleasant sensation.
Psychological – This is the emotional (also called affective) aspect of pain and is much more complex., it is an emotional experience as well that ensures we pay attention to it. The actual pain perceived and experienced by the person is always a subjective experience and, as such, it is also a psychological conclusion of a perceived physical event of injury. Each individual forms a personalized concept of pain based on the learning and understanding of the unpleasantness of pain through life experiences and drawing his/her own conclusions about it.
Social Factors – This influences a person’s response to pain. Certain societies will place a high value on a stoic (brave) acceptance of pain while other societies may have no such notions or the reverse might hold true. By a process of constant learning in a social perspective, individual behavior gets modeled by the societal norms.
Central sensitization. The pain pathway is not a passive, static, bundle of cables that just convey the sensation of pain but is a functionally dynamic system that is subject to modulation. All along the pain pathway right from spinal cord level up to the brain there are many interconnections to the rest of CNS which become activated when pain becomes chronic. The constant traffic of impulses in the pain pathway in persistent or chronic pain causes a state of hyperactivity which has the potential to become autonomous and sustain itself. The modulations from these interconnections in the pain pathway have the capacity to multiply pain several times. Conversely, mindfulness, meditation and similar techniques can be helpful in attenuating the pain. Thus, pain involves a very complex interplay in the nervous system which plays a pivotal role in the sensing of pain by the receptors in the periphery, its transmission through nerves and spinal cord and finally its perception in the brain.
Pain is a very personalized sensation. Pain can have multiple causes, and people respond to it in multiple and individual ways. The pain that one person just pushes aside might be incapacitating to someone else. This is because pain perception involves not just the body but also the mind and a complex interaction of other factors like psychological, emotional and social influences
There are many ways to classify pain. The 2 main types of pain are:
Acute and chronic. Acute pain starts suddenly, is short lasting and resolves within a specific duration, usually well within a few days. Its purpose is highly protective, and it alerts us to injury and protects us from further harm and is easily amenable to treatment. It is usually well localized, which implies that we typically know exactly where, why and how it hurts. For eg., we feel pain at the location of an injury (cut, scrape, burn, fracture), surgical incision, toothache, or abdominal pain (appendicitis in lower abdomen, pancreatitis, cholecystitis in upper abdomen etc. Chronic pain: When pain lasts more than 3 months it is called chronic pain. Sometimes it may result from a progression of acute pain but more often than not, the cause may be lost in history in that we might have forgotten the injury or illness that initiated it or it might have been too trivial to notice. chronic pain appears to be a disease of the nerves that carry pain sensation in addition to peripheral involvement. Chronic pain does not seem to have any protective action; on the contrary, the distress from it causes disability and disruption of activities of life.
Yes!
Most patients, when they get some pain would go to family physician, physiotherapist, general physician, orthopedic surgeon, a neurologist etc. It is only when their pain does not respond to treatment by these doctors that they get referred to a pain specialist or they will try to find one through personal contacts or on the internet. (More than 70-80% of patients who come to our clinic are referred by our previous patients). The most important feature of treatment by any pain specialist is that we focus on the main cause of pain and its treatments and then once the patient is comfortable, we turn our attention to the disease causing the pain and its treatment.
When the patient reaches our clinic, our protocol is as follows:
  1. Detailed history that includes the following:
    • History specific to the pain which includes the intensity, quality, duration, constancy of pain along with a pain diagram which is a pictorial representation of the location of pain. The distress caused by pain is also documented.
    • We also document the effect of pain on the activities of daily life, like limitations in the duration of standing, walking and sitting, or any other activity. This documentation helps for comparison with post treatment improvement.
    • Previous pain history and any previous pain interventions
    • Any other pains elsewhere in the body.
    • General medical history to understand any possible contribution from the associated conditions (comorbidities) and drug interaction
    • A brief psychological profile of the patient, whether there is a tendency to get stressed out in general or whether there are any tensions in personal or professional life.
  2. Examination – History is followed by a thorough examination to delineate the painful areas, tender areas, hypersensitive areas and whether they correspond with patient’s description. We particularly document limitations of movements and pain on movement with still and video pictures. The privacy of the patient is ensured by avoiding photography of the face unless of course it is a facial pain in which case we will ensure that the patient has no objections by taking a prior consent.
  3. Investigations – The available investigations are scrutinized and if necessary new investigations which are relevant to the present pain will be prescribed. We routinely ask for blood tests to look for any deficiencies particularly of vitamin B12 and D3 which are almost invariably low in Indian pain patients. We also might ask for C reactive protein which will indicate if there are some inflammatory processes that might explain the cause of pain.
The information from the above is usually sufficient to arrive at a probable working diagnosis. Additional investigations like X-Ray, CT, MRI etc will be asked for if we require further confirmation. History and examination itself takes about an hour in most patients. We then discuss the probable diagnosis and probable treatments with the patient and the family. In patients with severe pains the treatment may be started on the same day but usually patients are given a later appointment for treatment.
Our approach to treatment is mainly shaped by our understanding of pain itself; it differs from all other pain specialists not just in India but all over the world. This difference has come about because of our experiences with our initial patients from 2003-2006 and confirmed time and again till date. We have published extensively on these concepts (2-21). It can be summed up briefly as follows:
  • All chronic pains develop a neuropathic component over time
  • All neuropathic pains have a component of neuro-myo-pathy whereby the neuropathic process involves the nerves that supply muscles (motor nerves)
  • Neuromyopathy causes major changes in the muscle which give rise to all symptoms associated with neuropathy
  • Therefore, unless muscles, which are the main game players in ALL chronic pains are addressed as a priority, chronic pains are unlikely to respond fully and will keep recurring.
  • So, we treat sensory neuropathy (and the motor neuropathy as well) by addressing the involved nerves and then specifically address consequences of motor neuropathy by treating the associated muscle involvement.
  • The understanding that muscle is the expressor of many pains has uncovered another vital aspect of chronic pain which is poorly understood.  This is the physiological connection between mind and muscle. There appears to be a veritable freeway between the mind and muscle probably because the muscle is the prime mover for the execution of the fright, flight or fight reflex. The muscles are the first responders in this situation and are equipped with adequate nerve supply which not only propels the muscle into action but also dilates the blood vessels so that the muscle has adequate nutrition to perform quick action.  As a result of this, every emotion will have some action on the muscle. Anger, fear, anxiety resentment or even continuous work tensions will all increase muscle tension. In pain patients this seems to center around the areas of preexisting pain to increase pains.  When the mind is stressed, the muscles will be held painfully tight, and the converse is also true. Most patients will report that when they are calm, their pain levels are low but mental stress exacerbates their pain. What happens in the muscle is continuously communicated to the CNS at both conscious (cognition) and unconscious (proprioception essential for maintaining posture balance etc.) levels. Muscle is the via media through which the mind influences pain, exacerbating it by increased spasm of muscle which was hitherto quiet or decreasing pain by mindfulness, autosuggestion to relax the painful muscles or yogasanas which divert the focus the mind to the posture, or meditative practices which focus the mind inwards, away from the painful area of the body.
  • Our treatment integrates the two-fold targets of addressing the muscle specifically as also addressing the mind, be it with counseling, mindfulness, yoga or a psychiatry referral. The most important aspect of this is to empower the patient by introducing her/him to the power of his/her own mind in influencing pain.