Overview
Being in pain is not easy and may have serious impact on your work, your personal and family life, your daily activities and routine, your mental and emotional well-being.
Chronic Pain is a disease and reduces the quality of life
At Athens Medical Group we have a long and rich history of offering sophisticated and multi-disciplinary therapeutic approach to pain management.
Our team is led by certified doctors dedicated to reducing and eliminating pain and providing the most advanced treatment options in a supportive, compassionate environment.
Our doctors are pioneers in the application of invasive pain management techniques, such as nerve blocks, epidural injections, Radiofrequencies, Intraspinal drug delivery systems and neurostimulation.
We work together with other medical specialties, such as Oncology, Radiology, Neurosurgery, Orthopedics, Spine Surgery and Vascular Surgery in order to provide you a holistic approach and ensure optimal improvement of your quality of life.
What We Treat
At Athens Medical Group we provide comprehensive treatment and care for all forms of pain, from the simplest to the most complex ones.
More specifically we treat:
Chronic Pain
Chronic pain is one that persists beyond the usual time required to recover from acute illness or for a wound to heal. That period of time is more than three or six months from the onset of the disease.
Chronic pain is distinguished into nociceptive (pain due to a nerve response only to painful or traumatic stimuli), neuropathic (pain due to a central or peripheral nervous system injury) or mixed (combination of both).
Chronic pain may be superficial (skin or superficial tissue damage) or deep.
Deep chronic pain is distinguished in physical pain (involving muscles, tendons, ligaments, vessels, joints) and visceral (organs).
Physical pain is deep and difficult to locate, while the visceral can be easy or difficult t identify, depending on whether it is projected in areas that are distant from the visceral area that is reported to suffer.
Chronic pain is also categorized as peripheral (resulting from peripheral nervous system injury or dysfunction) or central (resulting from damage or dysfunction of the central nervous system, i.e., the brain or the spinal cord).
Chronic pain is often accompanied by weakness, fatigue, anxiety, agitation, depression, withdrawal from daily activities, insomnia.
Most pain-causing conditions, such as musculoskeletal (rheumatoid arthritis, fibromyalgia, osteoarthritis), neurological (neuropathy, neuralgia, headache), gastrointestinal and urogenital disorders, may evolve into chronic pain.
Psychiatric disorders (depression, bipolar disorder) are associated with chronic pain syndromes and lead to magnification of pain stimuli.
As the pain is personalized and there is no specific pain-identification test, diagnosis is often difficult. Usually, doctors of various specialties need to work together and order a variety of examinations in order to determine the location of the pain in the organism and the disease that causes it.
The treatment of chronic pain is causative depending on the disease that caused the pain.
The aim of the care team is to deal with acute pain so that it does not evolve into chronic and if it is already chronic to act effectively and immediately so as prevent depression, social withdrawal or degradation of the patients’ quality of life.
At Athens Medical Group we offer a holistic therapeutic approach that includes medication, interventional techniques, psychological support, physiotherapy and alternative therapies.
Neuropathic Pain
Neuropathic Pain is the pain resulting as a direct consequence of an injury or disease that affects the somatosensory system.
The somatosensory system is the path that the stimulus (chemical, mechanical, and thermal) follows from the periphery to the center through all major parts of the vertebrate body and contributes to the uptake and awareness of information from the skin, the viscera and the musculoskeletal system as well as the perception of the body’s position in space (proprioception).
The somatosensory system includes upward nerve fibers from the peripheral sensory neuron to the spinal cord, brainstem, and cortex, as well as downward nerve fibers from the cortex, brainstem, and midbrain to the spinal cord.
It is distinguished into peripheral (peripheral sensory nerve fibers) and central (brain, spinal cord) somatosensory system.
Neuropathic pain is categorized according to its duration (acute or chronic), its location in the nervous system (peripheral or central) and its etiology (primary or secondary).
In contrast to the nociceptive pain suffered after healing or the restoration of inflammation, neuropathic pain due to pathological mechanisms is chronic and accompanied by anxiety, depression, sleep disturbances and poor quality of life.
In neuropathic pain, there is an increased activity in the peripheral and central nervous system , as well as a development of pathological painful symptoms such as hyperalgesia (increased sensitivity to painful stimulus), hyperaesthesia (increased sensitivity to mild stimulus), allodynia (perception of a non-painful stimulus as painful) hyperpathia (presence of hyperalgesia, hyperaesthesia, allodynia).
Non-painful symptoms such as dysaesthesia (uncomfortable or abnormal sensation with or without stimulus), paraesthesia (pathological feeling without stimulus) and also hypoaesthesia (reduced skin sensation) may also occur.
Patients with neuropathic pain describe it as caustic, stabbing, usually stable and difficult to endure. It can manifest itself as an electric shock, like stitching or biting, often accompanied by tingling, numbness and itching.
Diabetes, postherpetic neuralgia, trigeminal neuralgia, cancer, neurological diseases (multiple sclerosis), chemotherapy, radiotherapy, chronic musculoskeletal disorders, and nerve entrapment syndromes are associated with neuropathic pain.
The diagnosis is based on patient history, clinical examination and specific questionnaires used worldwide as valuable diagnostic tools.
Laboratory testing consists mainly of Quantitative Sensory Testing (QST), Neurophysiological Testing – Electroneuromyography, Pain Reflex Testing, Microneurography, Functional Neuroimaging (Pet-scan, FMRI), and Skin Biopsy.
Neuropathic pain is treated by administering medication, such as antiepileptics (pregabalin, gabapentin), antidepressants (SSRI,SNRI,TCA), opioids (tramadol, tapentadol, and oxycodone), antiarrhythmic (mexiletine) and transdermal patches of lidocaine 5% and capsaicin.8%
Nerve blocks and neurostimulation (peripheral or central) may also be part of a treatment plan.
Postherpetic Neuralgia
Postherpetic neuralgia is a syndrome of chronic peripheral neuropathic pain and is caused by neural damage induced by herpesvirus-3 (HHV-3), also known as varicella zoster virus (VZV).
The chickenpox virus, once the patient heals, remains in the nerve ganglia and can be revived. It occurs with a vesicular erythematous rash with intense itchiness and pain.
About 50% of patients with herpes zoster over 60 years old, suffer from postherpetic neuralgia, as a complication, after the rash has stopped.
The pain may persist beyond a year with serious impact on the patient’s quality of life.
The areas of the body where it is most often appears are the thorax, the lumbar region, the neck, and the trigeminal nerve distribution region.
A risk factor for its occurrence is age
An increased incidence of postherpetic neuralgia also occurs in immunocompromised individuals (corticosteroids, immunosuppressants), cancer patients and people with diabetes mellitus.
The pain of postherpetic neuralgia is mainly found in the dermatome (an area of skin that is mainly supplied by a single spinal nerve) which corresponds to the affected ganglion.
The pain is acute, burning, stabbing and pressing. The affected area usually presents allodynia, i.e. increased sensitivity even to a non-painful stimulus (caressing, touching), increased sensitivity to a painful stimulus (hyperalgesia) and increased sensitivity to touch (hyperaesthesia).
The diagnosis of postherpetic neuralgia is based on the medical history of the patient and on the clinical examination by the treating physician.
The treatment of postherpetic neuralgia requires experience and specialization of the attending physician and includes medication and interventional techniques.
The most commonly used pharmaceutical agents to treat it are antiepileptics (pregabalin, gabapentin), mild opioids (tramadol, tapentadol), antidepressants (SNRI,SSRI,TCA).
For the treatment of post-herpetic neuralgia, transdermal patches such as (lidocaine 5%) and capsaicin 8% can be applied locally to the painful area.
Difficult cases of postherpetic neuralgia are treated with neural blocks (peripheral, central) as well as neurostimulators and totally implanted intraspinal delivery systems.
Diabetic Peripheral Neuropathy
Diabetic Peripheral Neuropathy (DPN) occurs in up to 50% of the type I diabetes population. It is progressive and chronic, usually manifested as symmetrical peripheral polyneuropathy and, more rarely, as focal neuropathy.
The causes of DPN are multifactorial. It is caused by demyelination and axonal degeneration of the nerve fibers, either due to direct damage to the fibers due to the accumulation of glycosylated products – sorbitol, or by the microangiopathy of the vessels that supply them.
Uncontrolled diabetes mellitus, poor bowel hygiene, poor diet, smoking, alcohol, increased body weight, hypertension, hyperlipidaemia are the main risk factors for DPN.
There are many classifications about DPN, but the two most common types are acute neuropathies due to hyperglycemia and improved by the return of normal glucose levels and chronic sensory-motor neuropathy, which is the most common form of DPN.
A 10-26% of the DPN population experiences moderate to severe pain, usually located in the lower extremities and the soles, and is rarely found in the upper limbs.
The pain is caustic, intensifies in the evening and is accompanied by numbness, pins and needles in the legs. Pain can coexist with increased sensitivity (hypersensitivity) or reduced sensitivity (hypoaesthesia), with allodynia, paraesthesia, and often becomes paroxysmal during sleep.
There may also be disorders of the autonomic nervous system, i.e. sweating, vasomotor disorders, and trophic skin edema.
The diagnosis is made by excluding other causes of polyneuropathy (neurological disease, hypothyroidism, vitamin B12 deficiency, and uremia).
Neurological examination and history of diabetes mellitus facilitate diagnosis, while electromyography, nerve and skin biopsy could serve as complementary to the diagnostic test.
In order to prevent DPN, the following recommendations are given:
- Periodic check and maintenance of blood glucose levels
- Maintenance of glycosylated hemoglobin at tolerable levels (HbA1C of less than 7%)
- Good limb hygiene
- Cholesterol and blood pressure regulation
- Proper nutrition, exercise, alcohol and smoking cessation.
The first step in treating DPN is to regulate blood glucose levels at normal levels and to correct other metabolic disorders.
The pain caused by DPN is managed with the administration of medication as well as with invasive methods.
Medication includes anti-epileptics (pregabalin, gabapentin), serotonin-noradrenaline reuptake inhibitors (duloxetine, venlafaxine), and tricyclic antidepressants (amitriptyline), antiarrhythmic agents (mexiletine), mild opioids (tramadol, oxycodone, tapentadol) 8% capsaicin patches.
If medication proves insufficient, then interventional techniques, neurostimulation (transdermal, spinal cord) may be applied.
Lumbago – Sciatica (Lower Back Pain)
Lumbago is a general term used to describe pain in the low back, with or without reflection at the lower extremity due to pressure of a nerve or its root (sciatica).
Based on the duration of symptoms, lower back pain can be acute, lasting less than 4 weeks, subacute, with a duration of 4-12 weeks, and chronic, lasting more than 12 weeks.
Depending on the etiology, low back pain is classified as non-specific and specific.
Non-specific is the lower back pain whose cause is unclear and is usually associated with benign musculoskeletal problems (muscle or tissue stretching/sprain, spinal cord burdening).
Specific is the lower back pain that is attributed to specific pathological causes, which can be mechanical (vertebral fractures, spinal disc herniation, spondylolysis), inflammatory (rheumatoid, psoriatic, ankylosing arthritis), metabolic (osteoporosis, osteopenia), neoplasmatic (primary or secondary bone cancers) and psychosomatic.
In 20% – 37% of patients with chronic low back pain there is also neuropathic pain, i.e. pain resulting from direct damage or disease of the nervous system and manifested by numbness, burning, pins and needles, tingling, itching, allodynia and feeling of electrical shock.
There are various mechanisms responsible for neuropathic pain, such as a mechanical nerve root compression from a projected intervertebral disc herniation, localized nerve damage to the degenerate disc, and the influence of inflammatory mediators.
The diagnosis is based on the patient’s history, clinical examination and neurological assessment.
Diagnostic tools include lumbar spinal scan (CT scan) while, on suspicion of neoplasm or inflammation, it is good to perform a hematological test on the levels of C-reactive protein (CRP).
Prevention of the occurrence or recurrence of lumbago and sciatica is of utmost importance and requires exercise, good physical activity, avoiding a sedentary lifestyle, good posture, body weight adjustment, avoiding severe cough-sneezing.
Treatment of acute or subacute lumbago is mainly pharmaceutical and includes the administration of paracetamol, non–steroidal anti-inflammatory drugs, muscle relaxants, mild opioids (tramadol, tapentadol). Physiotherapy is important for this group of patients. Alternative therapies such as acupuncture, ozonotherapy, siatsu may be used.
It is important that the patient learns to maintain a proper posture and a lifestyle with plenty of activity, since immobility aggravates the condition.
The treatment of chronic low back pain with a neuropathic component includes the administration of all of the aforementioned medications with the addition of antiepileptics (pregabalin) and transdermal patches such as lidocaine 5% and capsaicine 8%.
Serotonin – noradrenaline reuptake inhibitors (duloxetine, venlafaxine) may also be administered.
Epidural injection of corticosteroids has very good therapeutic results in the management of low back pain.
Radiofrequencies is the treatment of choice for facet-joint syndrome.
At Athens Medical Group we have great experience with applying such invasive techniques in patients with lumbago – sciatica, helping them to avoid surgery.
Surgery is indicated when conservative treatments fail, or when the patient progressively develops functional limitations or neurological symptoms commonly associated with severe disk herniation and spinal cord compression (urinary or fecal incontinence, lower limb muscle weakness).
Fibromyalgia
Fibromyalgia is a musculoskeletal pain syndrome characterized by widespread pain with particular sensitivity in 18 specific anatomical points of the body, known as tender points.
The tender points are distributed symmetrically in the anterior and posterior surfaces of the body (neck, trapezoid-suprarachial-thoracic-medial gluteus muscle, knee-elbow joint, lumbar joint).
Fibromyalgia is a generalized disorder and with the main feature of pain intensity deteriorated by stress.
It is associated with dysfunction of the neuroendocrine and immune system, physical fatigue, cognitive disorders, sleep disorders, headache, depression, psychological disorders and is therefore no longer seen as a single disease but as a Central Sensitivity Syndrome.
Symptoms of fibromyalgia include morning stiffness, weakness, cramps, reduction of movement, while pain can be acute or stabbing, daily, paroxysmal and may coexist with allodynia, hyperalgesia, and numbness.
Usually, fibromyalgia may coexist with other conditions such as irritable bowel, urinary disorders, cystitis, restless legs syndrome, temporomandibular joint dysfunction.
Fibromyalgia is of unknown origin. Genetic, environmental, psychological factors are perceived as causes, while post-traumatic stress is likely to contribute to its occurrence. It is more common in women and is associated with neurotransmitter dysfunction, decreased serotonin levels and higher levels of the P peptide.
Fibromyalgia may be primary or secondary when a rheumatic (lupus erythematosus, rheumatoid arthritis), inflammatory or endocrine disease exists.
The diagnosis of fibromyalgia is based on the history of widespread musculoskeletal pain, lasting at least three months after an underlying pathological cause has been excluded. The presence of at least 11 out of 18 tender points is oriented towards the diagnosis of fibromyalgia but is no longer a necessary criterion.
To exclude other pathological causes of widespread musculoskeletal pain, the laboratory tests performed are red blood cell counts, erythrocyte sedimentation rate, rheumatoid control (rheumatoid factor, anti-nuclear antibodies), and thyroid hormones.
Therapy is pharmaceutical using analgesics (paracetamol, non steroidal anti-inflammatory), mild opioids (tramadol, oxycodone, and tapentadol), muscle relaxants, antidepressants (tricyclics), serotonin / serotonin- noradrenaline reuptake inhibitors, anti-epileptics (pregabalin, gabapentin).
Repeating sessions with trigger points has great results.
Mild aerobic exercise (swimming, hydrotherapy), acupuncture, reflexology, psychological support, psychotherapy, cognitive behavioral therapy, are all complementary to medication with good results.
Myofascial Pain Syndrome
Myofascial pain syndrome is a neuromuscular disease that affects the muscles and the fascia.
It is a regional chronic pain syndrome and is characterized by the presence of one or more painful trigger points.
The trigger points are distinguished according to their location into primary and secondary (satellite) and, depending on the symptoms they produce, they may be active or latent.
The primary trigger points are located centrally in the region of the neuromuscular junction (nerve entry point in the muscle), while the satellite in the adhesions of the muscle (more peripheral).
Active trigger points are very sensitive to pressure, but they also cause automatic muscle pain, while the latent ones cause pain only when palpated.
The trigger points are located along a stretched muscular bundle (palpable nodules), near the point of the neuromuscular junction. By applying pressure on the firing point, the pain of the patient is reproduced, while causing contraction of the tension muscle and reflex pain in a neighboring area.
Myofascial syndrome may affect distinct, individual muscle groups in multiple and different anatomical regions of the body, often resulting in a variety of local symptoms.
The pain is constant, acute, deep, accompanied by a reduction in the range of movement in the affected area and aggravated by stress. Pain persists or worsens and usually does not retreat automatically.
In chronic cases, it is accompanied by muscle weakness or atrophy, and often symptoms of autonomic nervous system disorder (sweating, local temperature changes, local swelling).
Myofascial syndrome is caused by overuse or strain of the affected muscle, recurrent injuries of a muscle group, poor posture or problematic motion patterns, prolonged immobility of the muscle, exposure to cold or moisture. Bone-spinal pathological conditions, such as spondyloarthropathy and degenerative osteoarthritis, may lead to the onset of the syndrome. Even hormonal disorders (dysmenorrhea, menopause) can cause the syndrome to develop.
The diagnosis of the Myofascial Pain Syndrome, after having excluded other pathological causes of musculoskeletal pain, is a clinical one. The palpation of even a single trigger point, during the clinical examination of the patient, is diagnostic.
Medications used to treat myofascial syndrome include non-steroidal anti-inflammatory, muscle relaxants, spasmolytic agents, antiepileptics (pregabalin), antidepressants (mainly serotonin-noradrenaline reuptake inhibitors), and mild opioids (tramadol).
Interventional deactivation of trigger points with local anesthetic / corticosteroid / wet needle is of primary importance.
Trigeminal Neuralgia
Trigeminal neuralgia is a syndrome of chronic neuropathic pain disorder of the face associated with trigeminal nerve. It mainly affects people aged 50-70, of which 60% are women.
The trigeminal nerve is responsible for sensitivity in the face, as well as functions such as biting and chewing. It is divided into three major branches, the ophthalmic nerve, the maxillary nerve and the mandibular nerve, which are distributed in the facial area.
Trigeminal neuralgia is a painful syndrome of unknown etiology. The most likely cause is the compression of the trigeminal nerve from a neighboring major vessel. It is usually the superior cerebellar artery, but sometimes the posterior superior and inferior cerebellar as well as the vertebral artery may be involved in the pathogenesis of the syndrome.
Compression of the trigeminal nerve causes its demyelination and release of ectopic impulses. Secondarily, trigeminal neuralgia may be the result of trigeminal demyelination due to multiple sclerosis or nerve compression by a tumor.
The pain of trigeminal neuralgia is acute, jabbing and described as electric shock or as “stabbing”. Pain is usually unilateral in the distribution of trigeminal branches, although in of 3% of patients, it is bilateral. The onset of pain as well as the recovery from it are sudden and abrupt.
In between the painful episodes, the patient is free of intense symptoms, and sometimes remains a milder, caustic pain between seizures, remains.
Seizures may last for several seconds or several minutes, and the duration of neuralgia may be days, weeks or months.
Over time and without proper treatment, painful seizures become more intense and more frequent.
Pain emanates from the cold, from untoward stimuli (light touch), as well as during speech, chewing, swallowing, washing the face, brushing the teeth, laughing.
For the diagnosis of trigeminal neuralgia, the physician performs a thorough neurological examination to see whether the painful syndrome involves the trigeminal nerve.
Magnetic resonance imaging is often necessary to exclude the possibility of multiple sclerosis or secondary trigeminal pressure from a tumor. Sometimes magnetic angiography is also useful to indicate a possible vascular pressure of the trigeminal nerve.
The treatment of trigeminal neuralgia is pharmaceutical and interventional. Administration of anticonvulsants (carbamazepine, gabapentin, pregabalin) is particularly beneficial, as electrical triggers of the trigeminal nerve are reduced. Spasmolytic agents, mild opioids or strong opioids may be used to relieve pain.
Invasive techniques are applied after the problem has been properly assessed. These treatments are proposed by the World Institute of Pain and are applied at the Athens Medical Group’s Pain Center in trigeminal neuralgia cases that do not respond effectively to medication.
The invasive treatments include botox (onabotulinumtoxinA) injections, to reduce the pain from trigeminal neuralgia, and surgical operations aiming at removing or relocating blood vessels that put pressure on the trigeminal nerve.
Disease – Damage – Injury Of The Nervous System
Damage of the nervous system is manifested by a variety of symptoms.
Patients who have a stroke with residual neurological sequelae, spinal cord injury or multiple sclerosis may experience spasticity or loose paralysis, reduced or complete loss of sensation or mobility, severe pain, hyperalgesia, hyperaesthesia, hyperpathia, dysaesthesia, paraesthesia, allodynia.
The therapeutic approach includes the administration of pharmaceutical agents for the treatment of neuropathic pain such as antiepileptics (pregabalin, gabapentin), serotonin-noradrenaline reuptake inhibitors (duloxetine, venlafaxine), and serotonin reuptake inhibitors, mild opioids (tramadol, oxycodone, and tapentadol) or strong opioids (fentanyl)
Simple analgesics (acetaminophen, non-steroidal anti-inflammatory) are used in the case of parallel nociceptive musculoskeletal pain.
In cases of spasticity, the delivery of baclofen into the lumbar subarachnoid space, with the help of an implantable pump, has very good therapeutic effects. This is the technique of choice for this group of patients and in Athens Medical Center has been used since 2000.
When medication fails, invasive techniques may be of choice. According to international guidelines, the techniques that are simpler and safer for the patient should always be preferred.
Neurostimulation
Spinal cord neurostimulation has very good results and is the interventional technique of choice. In Athens Medical center our doctors have a great experience in this interventional technique.
Under the x-ray test, one or more electrodes are placed in the epidural space and periodic electrical stimuli are delivered from a microscopic generator.
Pulse intensity is adjusted to irritate the nerve endings responsible for reducing the transfer of painful stimuli from the periphery to the center.
In addition, activation of central mechanisms that inhibit pain, facilitates the achievement of analgesia by the neurostimulation technique.
As a clinical outcome, the use of neurostimulation causes paraesthesia (painless slight stinging) in the area, manifesting the painful symptomatology and significantly reducing pain intensity.
Neurostimulation is a valuable tool in the hands of our experienced doctors. A trial period (3-4 days) is needed prior the permanent implantation of the device to see if there is a positive response of the patient to the treatment.
Spinal cord neurostimulation is applied with very good results in cases of mixed (neuropathic and nociceptive pain after spinal surgery, as well as in cases of chronic neuropathic pain due to progressive disease of the nervous system (Reflex Sympathetic Dystrophy).
