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Submitted by PatientsEngage on 27 September 2020

While teleconsultation has immense benefits, it can be limiting for patients with chronic pain where a physical examination may be necessary to reach correct diagnosis, avers Dr Mary Abraham, Pain & Palliative Care Specialist.

The year 2020 has been the year of the SARS Covid-19 pandemic. It has been and still is an unprecedented situation that has transformed the lives of people all over the world. Besides the physical suffering it has inflicted, it has also affected the emotional, social, financial and spiritual lives of people. The prolonged lockdown and the new norms which includes social distancing, has changed the very lifestyle and social behaviour of people. People, especially, the aged ones are wary of visiting their healthcare provider for health issues unless it is an emergency or a life-threatening situation.

Patient with chronic pain

One segment of the population who has been affected by the pandemic dos and don’ts is the patient suffering with chronic pain. During the lockdown and subsequent unlock period, all routine pain consultations and interventional procedures for pain were cancelled. Patients also felt that it was better to bear pain than visit a hospital and contract the dreaded virus. Moreover, the treatment of pain, be it opioids for cancer or steroids for chronic pain, can cause suppression of the immune response of the patient and could predispose them to contract the virus.

Telemedicine consultation

In the light of these restrictions, telemedicine and video consultations for health problems has gained popularity as it safe for both the patient as well as the healthcare provider. Telemedicine is the practice of caring for patients remotely, where both the healthcare provider and the patient are not physically present with each other. It is a valuable tool to provide healthcare services and psychiatrists and clinical psychologists were already using it even before the pandemic began. Now this platform is increasingly being used by other medical specialists as well as by physiotherapists.

Untreated pain can be disastrous and can cause not only physical suffering but could also cause anxiety and depression and affect the very quality of life in these people. Delaying treatment can worsen the underlying pain condition and it is very important that they need to consult a pain specialist if not physically, at least virtually.

How useful is telemedicine for the pain specialist in the management of patients with chronic pain?

Let me illustrate this with an example.

A 70 year old lady, who had history of low back pain, pain in the knees and pain in the legs since 2 years presented in August 2020 to the pain clinic with worsening of her symptoms ever since the lockdown started. It had worsened so much that she was even unable to walk without support and could barely stand or walk for more than a couple of minutes. She had problems doing her own self-care activities like bathing and dressing etc. The pain in her leg and knee was unbearable and her sleep was disturbed. She was anxious and depressed and was dependant on her husband for doing any sort of activity. Because of the lockdown restrictions and fear of visiting a specialist in hospital, she had suffered with pain and physical limitations in sheer helplessness for the last few months.

Can this lady benefit from a teleconsultation for relief of her pain and other symptoms?

To discuss this let us see what exactly comprises a pain consultation.

A thorough assessment of patients with pain includes taking a detailed history of the patient which also includes psychosocial history and this is followed by physical examination and reviewing investigations based on which a diagnosis is reached. Physical examination is the cornerstone for the correct diagnosis of the patients with chronic pain based on which the treatment strategy can be planned out and instituted. If anything in the history, examination of the patient or investigation is missed, we may not be able to come to the correct diagnosis and, consequently, the right treatment may not be administered.

Telemedicine can be useful for obtaining the history of the patient and this can be got in great detail by just talking to the patient. In this lady, her gait was affected and that too can be seen by the doctor on the video. It is also possible to review all investigations. The main drawback of video-consultation is the physical examination of the patient. This involves feeling for painful and tender areas, spasm of muscles and performing certain tests based on which a diagnosis can be reached.

In this lady, there were tender and painful areas in her low back and buttocks. A neurological examination revealed that she had abnormal sensations in the soles of her feet and weakness of her lower leg. Based on the history, clinical examination and MRI findings, a diagnosis of degenerative spine disease with sciatica and neuropathy was made. Since it was preferable to avoid steroid injections and major spine surgery in view of the pandemic, she has been started on dry needling sessions along with physiotherapy to decrease her pain and neuropathy and improve her mobility and overall quality of life.

In this patient, besides the history and investigations, it was the physical and neurological examination that helped in clinching the diagnosis. This would not have been possible with a teleconsultation.

Cancer pain

Most of the time, pain consultations can be done virtually using telemedicine. This is especially so with cancer pain where a lot of information regarding the cause of pain can be gleaned by talking to the patient. Also, in cancer pain, the sheet anchor of pain management is the WHO pain ladder in which most of the medications can be administered orally based on the type and severity of pain.

Many types of acute pain too, such as a strained back or a pulled ligament or muscle, can also be addressed through video-consultation and these are very amenable to oral analgesics and other non-drug therapies like ice, immobilization, rest etc.

However, while treating certain types of chronic pain like shoulder pain, pain due to spine disease or nerve diseases, a physical/neurological examination is necessary to clinch the diagnosis and administer treatment as can be seen in the case quoted above. In such cases, a pure teleconsultation may not be the best practice to reach the correct diagnosis.

So, while a vast majority of patients with pain can be treated online during this pandemic which may suit the patient as well as the healthcare provider, there is a segment of patients with chronic pain in whom a physical consultation and examination may be necessary to provide relief from pain and suffering.

(Dr Mary Abraham is a Pain & Palliative Care Specialist at Max Hospital Panchsheel, and Indian Spinal Injury Centre, New Delhi.)

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