Now, zap that pain with new technology

When former seaman Subhash Moharir developed severe lower back pain over six years back, he promptly got a diagnosis of "slipped disc" and, even more promptly, underwent a corrective spine surgery. His pain was gone -- only to return with a vengeance three years later. This time, the diagnosis wasn't easy as he visited multiple doctors for an opinion over the next two years.A neurologist in Mumbai last year detected the cause for his movement-limiting pain: nerves coming out of the vertebrae had got entangled in the fusing of sacral vertebra S1 and the last lumbar vertebra L5 bones during his surgery. A spine surgery that he had initially thought was successful had left a severe scar that made movement difficult for the 67-year-old Moharir.
He started taking pain medications to help alleviate the symptoms. "But, every week, my pain seemed to worsen, and an opiate was added to my daily medicines,'' he said, adding that the pain would return after a few hours. An unwelcome side-effect of the medication was that he felt sluggish, dizzy and foggy for most part of the day, and lost confidence to drive his car. There also was a fear of such potent painkillers affecting his liver and kidneys.
This is when doctors suggested an implant that would significantly reduce the pain. "I took a trial of the spinal cord stimulator for three days in April and was convinced about it,'' he said. He now walks 1 km daily and plans to increase it to 3 km every morning. The pain has completely gone away (“it has reduced by over 70%”) but he doesn't need to take any pill.
Embedded device
In medical parlance, Moharir underwent neuromodulation for pain management. Neuromodulation is essentially the use of electrical stimulation or chemical agents to "alter" nerve activity in specific sites in the body so that the patient gets full function back. In the last couple of decades, it has been used to treat individuals who suffer from severe chronic illnesses due to persistent pain, spasticity, movement disorders, epilepsy, ischaemia, cardiac, bowel and bladder dysfunction, spinal injury and some psychiatric disorders such as depression and obsessive-compulsive disorders.
Neuromodulation is increasing in popularity in the West, but it is still in a nascent stage in India. For instance, 20 spinal cord stimulation devices are implanted every year in India as compared to thousands in the US. “There is little awareness as well as fear among patients about such techniques,” said Dr Preeti Doshi, who fixed the neuro pain modulator device for Moharir.
Cost a deterrent
But as a study done by her last year showed, one of the main reasons for the slow growth of neuromodulation is cost. Moharir paid over Rs 10 lakh from his pocket as there is no insurance clearance yet for some of the neuromodulation procedures.
The study, published in ‘Neuromodulation’, a medical journal brought out by the International Neuromodulation Society, interviewed pain practitioners across the country to find out that: barriers to the use of neuromodulation are cost (85%), lack of awareness (68%) and lack of trained doctor/personnel (59%). “More than 50% of the respondents also expressed difficulty of access to neuromodulation therapies for pain and acceptance by patients,’’ said Dr Doshi.
In India, there are around 1,300 active pain physicians and around 30 neurosurgeons practising interventional pain medicine. This translates into one physician per 1 million of the population compared to one physician per 61,000 people in the US.
Global meet in Mumbai
Last week, members of the International Neuromodulation Society descended in Mumbai to spread awareness about neuromodulation and its likely future applications --that range from intractable angina pain to sleep apnea to chronic headaches to stroke-related pain management.
Dr Robert M Levy, immediate past president of the International Neuromodulation Society, said, “When people think about neuromodulation, they think of chronic pain. We can beautifully fix movement disorders or Parkinsonism tremors. We routinely treat patients with epilepsy, paralysis due to stroke, spinal cord injuries, among others, and significantly restore function.” He said there are many conditions such as urinary or fecal incontinence that destroy people’s confidence, “but we can help them get back to social situations”.
The international society’s mission in India is to make people aware about treatment. Only two medical devices companies sell neuromodulators in India, adding to the cost factor. “People need to realise that in the long run, such devices are cost-effective because the patient stops having recurring costs of medicines and repeated hospitalisation,’’ said Dr Levy.
Dr Konstantin Slavin from the University of Illinois in Chicago said, “The unique thing about India is that it has a remarkable size and remarkable access to technology, but there is lack of awareness about neuromodulation.’’ He said the health system needs to take cognisance of it because a person who is bedridden or unable to move can become functional again and contribute to society.
Dr Doshi spoke about a 30-year-old patient who had withdrawn into a shell because of bladder dysfunction. “She was unable to void her bladder completely, leading to frequent urinary tract infection. After several treatment modalities failed, she got neuromodulation that completely treated the condition,’’ she added.