Doctor in The Pain Clinic.
Treatment of Neurological Problems
Treatment of Hip Disorders
Back Pain Treatment
Neck Pain Treatment
Treatment of Spondylosis
Arthritis And Pain Management Treatment
Treatment Of Disk Slip
Chronic Pain Management
Treatment Of Herniated Disc
Treatment of Spine Injuries
Treatment of Disc Prolapse
Spinal Cord Injury Medicine
Treatment of Muscle Pain Skeleton System
Treatment Of Foot Infection
Cancer Pain Management
Epidural And Spinal Anesthesia Techniques
Treatment of Spinal Diseases
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Multimodal pain management has become an important part of the perioperative care of patients undergoing total joint replacement. The principle of multimodal therapy is to use interventions that target several different steps of the pain pathway, allowing more effective pain control with fewer side effects. Many different protocols have shown clinical benefit. The goal of this review is to provide a concise overview of the principles and results of multimodal pain management regimens as a practical guide for the management of joint arthroplasty patients.
Multimodal denotes administering two or more than two types of medications that work with different mechanisms. The following are the techniques used:
Pre-operative Femoral Nerve Block: Prior to the surgery, a catheter is placed beside the femoral nerve for blocking it. This nerve is located in the upper thigh. Medication is delivered through the catheter for the nerve to be numbed for 24 hours. Thus, pain signals to the brain are blocked. This method reduces the use of narcotics and the consequent side effects.
Patient Controlled Analgesia (PCA): This method is also known as ‘Pain Pump’. An intravenous pump is used to administer pain relief medications, such as oxymorphone or morphine, after the surgery. The control button of the machine could be pressed, by the patient for 6 to 10 times per hour. The machine is used for two post-operative days.
Oral Medications: The oral medications include Non-Steroidal Anti-Inflammatory drugs or NSAID; such as Celebrex which is similar to aspirin, structurally. Alternatively, acetaminophen, such as Tylenol or its equivalent composition, can also be used.
Acetaminophen: It acts on the Central Prostaglandin Synthesis and relieves the patient of pain through multiple mechanisms.
Epidural Analgesia: It produces lower pain scores and involves less time for achieving physical therapy goals. However, this is subject to side effects such as dizziness, urinary retention and itchiness.
The objective of multimodal treatments is to provide quick relief to the patient and immediately so. Earlier the rehabilitation, more successful will be the knee replacement surgery.
Neck pain is fairly common among adults. It results from the soft tissues such as ligaments, muscles and tendons. It can result from spasms and muscle strain from neck problems such as disc degeneration and spinal stenosis. Be it a chronic pain or a sudden one, addressing it is important to get on with the daily office life.
- Computer should be at eye level: While sitting at it you must ensure that the middle of the computer screen is parallel to the eye. If it is required that you bend your neck to view the screen, then you should adjust the screen, without bending your neck. This happens most often while working with a laptop. The chair length can be adjusted to fix this problem.
- Refrain from neck straining while typing: If typing requires straining the neck, it should be ensured that the same doesn’t happen. This is the case while texting in a mobile. A better solution is to fix this is to take the mobile at a level which does not require the neck bend down. It will ensure that the joints and discs of the neck are not stressed.
- Use headset: If the work demands longer time on the phone, instead of bending the neck it makes sense to use a headset. Practicing the chin tuck exercise can help in this case. This exercise can strengthen the soft muscles of the neck. It also maintains the alignment of the head and the shoulder.
- Stay hydrated: Enough hydration is necessary to ensure spinal alignment and disc height. Hydration also takes a eases the spine and relaxes the soft muscles. A practice of adequate hydration throughout the day can help stop the degeneration of the cervical disc. While drinking water is a matter of practice, keeping a water bottle serves as a constant reminder to drink it throughout the day. Keeping an alarm after 2 hours also serves as a constant reminder to drink water.
- Carrying weight: One common mistake committed by most people is to carry weight with one hand. Since the load doesn’t distribute evenly, it strains the neck muscles causing pain. It should be ensured that the office briefcase or the heavy purse is carried with equal stress on both the shoulders. This will ensure a painless day at the office.
- Maintaining a good posture: Poor sitting or walking posture is often the cause of neck pain. While sitting it should be ensured that the back is straight and rests in the chair once in awhile. The neck and head should fall in a line while working.
The shoulder is one of the most important joints in the body that uses a ball and socket to join the arm to the rest of the body. Any pain can make it difficult to carry out motion in a comfortable manner. The shoulder consists of the long arm bone called the humerus, the collar bone or the clavicle, as well as the shoulder blade called the scapula.
A layer of cartilage provides essential padding to the bones in this area and its two main joints. There are a number of issues that can cause shoulder pain. Let us get to know the six most common ones.
* Rotator Cuff Injury: This is the most common cause of shoulder pain and it occurs when the four muscles or the tendons are injured. These muscles and tendons usually control the movement of the arm. This injury can involve strains and tears which may also be caused by constant lifting of heavy objects.
* Rotator Cuff Tendinitis: This condition affects the tendons and muscles that help in moving the arm freely. This usually happens due to inflammation in the tendons. It is commonly experienced by patients who are actively involved in sports and other heavy physical pursuits in their line of work.
* Frozen Shoulder: This is a debilitating condition that restricts the free movement of the arm and is also known as adhesive capsulitis. When the shoulder tissues become too thick, it leads to the growth of scar tissue that hinders proper movement and causes pain.
* Osteoarthritis: Osteoarthritis is a condition that comes as part of aging bones that also become hollow and brittle over the passage of time, which leads to joint and bone pains in various parts of the body. It is a degenerative disease that is caused due to prolonged wear and tear as well as other factors including family history and sports injury.
* Bursitis: This condition is known to affect the fluid filled sacs that lie in between the joints. These are known as bursae. When the bursae suffers from swelling, the effect usually shows up as pain in the joints.
* Tendon Sheath Inflammation: The fibrous tissue that connects the bones and the muscles is called a tendon. The presence of the tendon makes it possible to pursue activities like running, jumping, lifting, gripping and more. It is protected by a sheath known as synovium, which also lubricates the same. Any injury or tear to this sheath can cause shoulder pain.
Acute and persistent pain that does not abate and gets even worse should be treated with immediate medical intervention.
Elbow pain may be caused due to a variety of reasons from injuries to fractures and ligament pulls or tears. This is most commonly experienced by people who are into sports, including those who play tennis, golf and other such sports that require intense arm movements.
- Medial Epicondylitis: This condition creates pain in the inner tendon within the elbow and is usually termed as 'golfer's elbow'. It basically occurs due to the constant swinging and throwing motion that a sports person may indulge in. When these movements are repeated on a constant basis, there is wear and tear as well as acute pain in the area. Also, an injury to the wrist can cause this pain in the elbow.
- Lateral Epicondylitis: This condition is commonly known as 'tennis elbow'. The affected area under this condition includes the outside tendons of the elbow. This is caused due to swinging, hitting, hammering and punching motions that are repeated too often. It is commonly experienced by cooks, artists, carpenters, automobile workers, and plumbers and people who use heavy tools.
- Olecranon Bursitis: This condition is also known as 'student's elbow' and usually occurs due to constant writing and gripping motion which affects the bursae. These are small fluid filled sacs that lubricate the joints even as the protection happens. The symptoms include swelling and pain. There is also risk of infection and redness in this condition.
- Osteoarthritis: The cartilage of the joints gets affected in this condition which is the connective tissue that exists in the joints. This condition causes wear and tear of the joints and bones which leads to pain in the various areas including the elbow. Medication and physiotherapy are good measures for treatment.
- Fracture: Sometimes, dislocation or fracture may lead to pain in the outstretched arm or elbow. Dislocation may take place when a bone moves from its aligned spot. The symptoms will include obvious swelling and acute pain in the elbow.
- Ligament Damage: Strains and sprains in the ligaments within the elbow joint can lead to this damaging condition. Torn or stretched ligaments are the most common outcomes in this kind of injury and damage.
To find out which reason may be the culprit behind your elbow pain, you will need to see a general physician or an orthopaedic specialist who will run you through a series of tests and examinations including X rays, MRI scans and others in order to ascertain the cause and treatment.
Being flexible is not always about doing splits or doing some random bending. It is about achieving a level of mobility that will not hold you back from doing whatever you are able to do. Most people think that stretching or flexing your muscles and body as the first method to defend you from pain. But if stretching and flexing can be done correctly, it can lengthen one's muscles and give one relief from pains and aches. Stretching is also done to increase the functional range of one's joints and muscles. There are various ways by which one can stretch their muscles. However, the question which looms over here is which is the correct procedure and which is the wrong one.
The Wrong Vs the Right Way: Before discussing about the correct way, let us talk about the various wrong ways in which stretching can be done. The first rule is that if stretching is causing you pain or if it is hurting you, then you are probably taking it too far. A muscle needs to relax as much as possible, if it needs to stretch. If one is stretching so hard that he or she cannot relax then the muscle will not lengthen. Stretching should never be painful.
One should also avoid stretching for an insufficient length of time. Only a few seconds of stretching will not hold the therapeutic effects of stretching.
The following methods are few of the correct ways to stretch:
- Always start with the warm muscles. Warm your muscles by doing some aerobic movement or by applying heat with the help of a warm bath.
- After warming your muscles, monitor your level of discomfort. Let it go once you feel pain.
- Hold any stretch for at least 30 seconds.
Stretching the Correct Muscle: There are muscles, which need to be stretched and there are muscles, which should not be. So getting to know the correct muscles to be stretched is as important as knowing the correct procedure to stretch your muscles. Every muscle, which does not hurt should not be stretched. There are different types of muscles that cause pain like stiff, tight, short muscles and long muscles. Muscles that are tight should only be subjected to stretching. Stretching muscles that are too long is not a good idea.
Using Physiotherapists: Most people who cannot determine which muscle should be stretched and which should not be should consult a physiotherapist. Physiotherapists can quickly and easily diagnose muscular issues. They will also show ways to stretch which are most effective for particular needs.
Stretching should be made a part of one's life. It is a way by which one can become their healthiest self and avoid muscular imbalances.
- Traumatic Brain Injury - Happens due to trauma
- Anoxic/Hypoxic brain injury - Happens due to decreased blood or oxygen supply to the brain.
- Ischemic or hemorrhagic cerebrovascular accident (commonly referred to as stroke) - Happens due to clots occluding the blood vessels in the brain or due to bleeding of blood vessels in the brain
- Brain tumors and metastasis (spreading of cancer) to the brain
- Vascular malformations of the brain such as Arteriovenous malformation, aneurysm etc -
- Brain infections
- Autoimmune conditions such as Multiple Sclerosis and auto-immune encephalitis -
- Toxic/metabolic causes such as post transplantation, sepsis, liver failure and kidney failure
- Basically any injury or illness that affects your brain function for a prolonged period of time causing temporary or permanant damage
Usually individuals affected by these conditions can have a number of symptoms directly related to the brain injury such as
- One-sided or both sided weakness and numbness of the arms and legs
- Pain and tightness of the arms and legs
- Difficulty with speech
- Impaired consciousness (i.e. impaired arousal)
- Cognitive impairment such as memory problems, slow thinking skills, problems with attention
- Changes in their behavior such as aggression
- Changes in their mood such as depression and anxiety
- Difficulty in swallowing
- Bladder and bowel incontinence
- Visual problem
- Hearing problem
There are medical complications that can be noted a few weeks or months after a brain injury. Some common ones include
- Urinary tract infection
- Deep vein thrombosis – blood clot in the veins of your arms and legs
- Pulmonary embolus – blood clot in your lungs
- Pressure ulcers
- Heterotopic ossification – a condition which causes stiffness of your joints
- Post-stroke shoulder pain – shoulder pain in the weak arm
- Spasticity – tightness of the muscles of the affected arm and leg
- Paroxysmal sympathetic hyperactivity – a condition which causes fluctuations in your blood pressure, heart rate, and also causes abnormal stiffness of the arms and legs
- Hydrocephalus – a condition where fluid builds up in your brain
HOW REHABILITATION CAN HELP?
A comprehensive, interdisciplinary team approach (i.e. care being provided by various disciplines in a coordinated fashion) with Physician (Physiatrist), Physiotherapist, Occupational Therapist, Speech and Language Therapist, Neuropsychologist, Nutritionist and a Nurse can help reduce your symptoms directly related to the injury as well as prevent and treat common medical complications post brain injury. Not all patients will require all services and usually, a combination of these services is required for an individual patient.
Patients can be evaluated by the Physician first to determine the nature and severity of the medical condition then come up with a treatment plan that best suits them. Depending on the patient’s symptoms and medical complications (listed above), the treatment plan will include recommending therapy services, prescribing medications and performing injections. Medications are commonly prescribed for medical complications as well as to reduce symptoms directly related to brain injury such as arm and leg weakness, muscle tightness, speech impairment, mood and behavior issues, cognitive impairment and impaired arousal. The physician performs injections such as tendon injections, joint injections for joint or muscle pain as well as Botulinum toxin (commonly referred as Botox injections) and nerve block injections to help relieve muscle and tendon tightness.
A Physiotherapist will focus on various physical exercises to improve weakness in the arms and legs, improve their walking and balance and to reduce muscle tightness. They might use physical modalities to reduce pain and inflammation, muscle and tendon tightness and prevent muscle atrophy. They can also fit you with an orthosis to reduce muscle tightness as well as improve your walking and arm function.
An Occupational Therapist will focus on various physical activities required for daily living for patients with severe physical and/or cognitive impairment and also teach cognitive exercises thereby compensating the cognitive deficits. Visual Training exercises are provided to individuals with visual impairment due to the neurological problem. The final phase of treatment involves patient training for successful community integration (education, employment etc).
A Speech Language Pathologist (commonly referred to as a Speech and Language Therapist), will evaluate the patient’s speech, communication and swallowing skills. The treatment plan is broken down after an initial evaluation. The program will vary depending on the extent of the injury, the stage of recovery, and the individual’s particular areas of difficulty. Specific retraining and compensatory exercises are taught to improve the above skills. However, the major focus is on helping the individual gain back his/her quality of life.
A Neuropsychologist evaluates patients with depression and anxiety, that is commonly seen after any major life-changing illness or injury and guides them through the process of rehabilitation thereby improving their quality of life through motivation and counseling. Performing an in-depth cognitive assessment and planning cognitive re-training exercises and compensatory strategies is also a major treatment aspect of a Neuropsychologist.
Malnutrition or undernourishment is a common problem in this population. For optimal recovery, a Nutritionist recommends an appropriate intake of nutrition.
A Rehabilitation Nurse trains patients with central nervous system injury to manage their bowel and bladder independently. Performing and training wound care management for patients with pressure ulcers are also handled by a Rehabilitation Nurse.
EXPECTATIONS OF RECOVERY
Depending on the severity and chronicity (time duration since injury/illness) of the injury/illness, your recovery time may differ. Complete neurological recovery is often possible if the injury is mild to moderate. In the case of a moderate to severe injury, a complete neurological recovery may not be possible and therefore the goal will be to help you be as independent as possible and integrate you into the community despite your physical and/or cognitive limitation. If the injury is too severe, then the goal would be to improve your quality of life by helping you be as independent as possible with your day to day living, decrease pain and prevent complications.
Total knee replacement is arguably one of the most successful of Orthopaedic surgeries. The success has been documented at various scientific platforms and Journals.
However there are still many myths in the mind of the lay person who is suffering from this crippling problem and prevents them from getting treated for the same.
- Myth : Everyone suffers from Knee arthritis, I should learn to live with it.
Fact: If the Knee pain due to arthritis is so much that is affects activities of daily life, and you find yourself refusing to participate in routine social activities, Knee replacement could be the best option to bring back the lost zeal in your life.
- Myth: I am too young for this surgery
Fact : Joint Replacement is no longer just dependent on the age. Recent advances in materials and design have vastly extended the boundaries for joint replacement.
- Myth: I am too overweight for this surgery
Fact : Surgery is not dependent on the weight, but on the overall medical condition of the person. In fact after the surgery, the ease of movement means losing weight may become easier.
- Myth: I should try to postpone the surgery as much as possible.
Fact : Severity of Knee arthritis can sometimes be so crippling that even small daily activities like going for a walk in the garden , shopping at the market or in the mall can become unbearable. This causes a great loss in the quality of life for that person. Pulling on in such circumstances is not only physically more challenging but may cause emotional issues and depression. In such circumstances joint replacement can be a life changing surgery