Postherpetic Neuralgia – Time heals… We are here if it fails…

What causes Postherpetic Neuralgia (PHN)?

Herpes Zoster infection (Shingles) is caused by the reactivation of the virus which causes chickenpox. If one has had chickenpox before, the virus that causes it remains inside the body in an inactive state till it gets an opportunity to spread once again. The reactivation may happen as one ages or as a result of reduced immunity. The virus spreads along a nerve producing the typical rash of Herpes Zoster in the area supplied by the nerve. Rash generally heals in 2-4 weeks and is accompanied by pain, numbness, itching and altered sensitivity in the area.

One out of five patients with Herpes Zoster may still have persisting pain after 120 days (90 days as per WHO) of rash onset and this condition is referred to as Postherpetic Neuralgia. In PHN the nerve cells can get damaged leading to increased excitability and persisting pain. Approximately 50% of patients recover within a year and the course is variable in the remaining. In one study it was observed that the proportion of patients with spontaneous resolution of pain decreased with increasing time since the onset of herpes zoster.

Who are at risk for developing persisting pain/Postherpetic Neuralgia after the Herpes Zoster (Shingles) infection?

The risk factors can be viewed as those relating to the

• Risk of developing Herpes Zoster infection– such as increasing age and low immunity. Low immunity may be secondary to diseases such as cancer or medications used to suppress immunity such as those used in organ transplant, treatment of inflammatory arthritis and chemotherapy. 
• Risk of persisting / non resolving pain– Pain preceding the onset of rash, severe pain at the time of rash onset, widespread rash and older age have been associated as risk factors for persisting pain (PHN). 

Early use of antiviral agents (within 72 hours of rash onset) & corticosteroids (if indicated), early aggressive pain control may offer some protection, reducing the risk of developing PHN after Herpes Zoster infection.

What are the symptoms of Postherpetic Neuralgia?

PHN generally presents as burning, shooting, throbbing or electric shock like pain occurring spontaneously or in response to stimuli such as touch. Commonly involved areas include the chest wall (thoracic dermatomes) and around the eye (ophthalmic branch of the trigeminal nerve). Pain may be more severe at night time and during periods of stress. The affected area may

• Be hypersensitive with daily activities such as taking bath, wearing clothes becoming difficult as the touch of clothes or water is painful. This is known as allodynia where non painful stimuli become painful. 
• Feel itchy
• Feel weak (muscle weakness)
• Develop skin pigmentation and scarring in the area of rash 

How is Postherpetic Neuralgia diagnosed?

PHN is rare in the age group below 50 years and incidence increases after the age of 60 years. Generally the diagnosis can be made clinically as most patients would give the history of Herpes Zoster Infection/ typical painful rash in the affected area. In many cases the persisting skin colour changes and scarring also aid the diagnosis. The rash generally involves only one side and does not cross the midline.

Which medications can help to reduce the pain in Postherpetic Neuralgia?

Different types of medication are used to control pain in PHN and these include:

Neuropathic Agents

PHN pain does not respond well to the usual painkiller and special types of painkillers known as the neuropathic painkillers may be required. This includes medications such as 

• Anticonvulsants
• Antidepressants

These are well known painkillers commonly used for nerve pain. The choice of drugs best suited for an individual is made after a thorough assessment and taking into account a number of factors such as age of patient, pain severity, other medical problems, general health etc. The dose of the selected medications is increased gradually giving the body a chance to adapt and reducing the side effects. These medications may take a few weeks to produce their full effects and hence it is important that you stick to the schedule recommended by your pain physician. Often a combination of different agents is utilised to maximise your gains and to keep the individual drug doses low so that the side effects are minimised. These medications not only help with the pain but can also help in improving sleep, mood, and quality of life.

Opioids

This class includes morphine like drugs which are often used for severe pain, in combination with the above mentioned medications. Opioids can be classified as weak opioids (like tramadol) and strong opioids (fentanyl patches, morphine, oxycodone etc). Some of these are available in long acting and short acting formulations. These drugs are best prescribed by a specialist who is well versed with the available options and the limitations /advantages of each of them. It is important that you adhere to the schedule as prescribed by your pain specialist. Whilst deciding on medications the side effects should be kept in mind and discussed with the patients. Sometimes the side effects are used as an advantage like sedation with night time medications to improve sleep. 

Topical agents

These have the advantage of fewer side effects and are sometimes used preferentially in the elderly/ frail patients and when side effects of oral medications limit their usage. They include various types of gels, creams and patches. Some contain local anaesthetic and soothing agents. Local anaesthetic patches may be especially useful in cases of increased sensitivity to stimuli such as touch. Unfortunately some of the topical options such as 8% capsaicin patch are not available in India as yet.  A one off 60 minute application of Capsaicin 8% patch can provide significant pain reduction for a few months.

What other treatment options are available for pain control in Postherpetic Neuralgia?

A number of options are available to control PHN pain apart from the medications and these include: 

Drug infusions- These are commonly used in cases with severe pain, especially when the other measures have not been successful. They work by reducing the sensitivity of the nerves transmitting the pain signals. These infusions are generally administered in day care setting which means that you do not have to stay in the hospital overnight. These are low risk options with the potential of significantly reducing the pain for weeks/ months. They can help reduce the requirement of other regular strong medications thereby reducing the side effects. 

Nerve blocks, Dorsal Root Ganglion Block and Epidural injections can be considered based on the pain severity and the site involved. These procedures involve injection of local anaesthetic and steroids to reduce the pain and sensitivity of the nerves. They are generally performed as a day case using x-ray or ultrasound guidance with no requirement for overnight hospital stay. In severe acute cases however hospital stay may be required if continuous epidural drugs are administered to control the pain.

Sympathetic nerve blocks including stellate ganglion block are used for severe uncontrolled pain. Initially a diagnostic block is performed to assess if these special nerves (called the sympathetic nerves) are involved in transmitting the pain signals to the brain. These nerves do not carry pain signals normally but can get involved in chronic pain conditions. If the response to the diagnostic block is positive then other ways of prolonging the effect can be considered. Depending on the duration of the effect, these blocks and hence they may need to be repeated. 

Pulsed radiofrequency lesioning (PRF) is a safe, non-destructive modality that can help in reducing the PHN pain. This treatment is performed as a day case, using special equipment and requires  x-ray or ultrasound guidance. The treatment  involves modulating the way pain signals are transmitted and processed and the resulting pain relief can last for weeks/ months.

Neuromodulation including Peripheral Nerve Stimulation, Peripheral Nerve Field Stimulation ― Peripheral Nerve Stimulation (PNS) in a non invasive treatment that is performed by placing the stimulating electrode in close proximity to the involved peripheral nerve. The nerve can be easily located using ultrasound in most cases, with the stimulation performed transcutaneously. More invasive methods may involve placing electrodes through the skin or in the spine (Spinal cord Stimulators). In Peripheral Nerve Field Stimulation (PNFS), stimulating electrodes are placed below the skin (percutaneously) close to the painful area and are removed once the treatment has been performed.

Tags >> Post Herpes Zoster Pain Treatment, Post Herpetic Neuralgia, Postherpetic Neuralgia

Plantar fasciitis (Joggers Heel)

• Tags: Plantar fasciitis treatment in gurgaon, Pain Management in Gurgaon

What is Plantar fascia?

Plantar fascia is a long, thin strong band of tissue in the sole of foot, extending from the heel to the front of the foot. It acts like a shock absorber and supports the foot arch.

What causes plantar fasciitis?

It is believed that plantar fasciitis is caused by damage or irritation of plantar fascia due to excessive strain resulting in heel pain and stiffness. The pain is most often felt below the heel close to the site of attachment of plantar fascia to the heel bone. In majority of cases a specific cause or reason cannot be identified although certain factors can predispose one to the development of this condition. These include

• Obesity
• Constantly being on your feet, especially on a hard surface
• New/ increased activity or repetitive impact activity such as running/sports (especially involving hard surfaces /courts)
• Tight calf muscles
• High foot arches or flat feet

What are the symptoms of plantar fasciitis?

Plantar fasciitis is most common in people between the ages of 40 to 60 years, although it can occur at any age. It is twice as common in women compared to men.

Common symptoms of plantar fasciitis include:

• Sharp, burning or aching pain on the bottom of the foot near the heel. It can extend till the arch area of the foot.
• Pain with the first few steps in the morning or after period of rest. The pain generally subsides after a few minutes of walking 
• Increased pain after exercise or activity

How is plantar fasciitis diagnosed?

The diagnosis is made clinically based on the history and examination findings. In clinic ultrasound scan can help confirm the diagnosis.

X-rays are used for ruling out other causes of heel pain, such as fractures or arthritis. Heel spurs (small piece of bone that can grow on the underside of the heel bone) are often seen on an x-ray. Approximately 3 in10 people have a heel spur and few of them have heel pain

Magnetic resonance imaging (MRI) scan is sometimes requested to confirm diagnosis and rule out other conditions with similar presentation. 

What are the treatment options for plantar fasciitis?

Plantar fasciitis is commonly described in the literature as a self-limiting condition. A significant number of patients with improve within 10-12 months, although it can be disabling and impact negatively on the quality of life. Treatment options include

• Rest/ Activity modification. Decreasing or stopping the activities that make the pain worse especially activities such as running/ step aerobics where the feet pound on hard surfaces
• Ice. Rolling your foot over a cold water bottle or ice can help. Applying ice wrapped in a towel to the affected area helps reduce pain. This can be repeated 3 to 4 times in a day. Avoid using for too long or applying directly to the skin as it can cause ice burns.
• Nonsteroidal anti-inflammatory medication. Drugs such as ibuprofen or naproxen reduce pain and inflammation. These should be used as advised by your doctor.
• Exercise. Plantar fasciitis is aggravated by tight feet and calf muscles. Stretching the plantar fascia and the calf muscles several times a day, can help to relieve the pain. Night splints work by creating a constant mild stretch of the plantar fascia and they do need to be worn for some time before the effects become apparent. Tolerability can be an issue and in some cases even putting them on for 10 min before betting out of bed in the morning can be helpful in reducing the early morning symptoms.
• Weight management – healthy body weight can help by reduce the load on the plantar fascia.
• Supportive shoes and orthotics can help in reducing the impact / heel irritation especially in individuals with flat feet. Avoid walking barefoot and use supportive footwear with a stiff outer sole and a shock absorbing insole. Custom made orthotics are more likely to be better tolerated although there is no strong evidence to show that custom made orthotics lead to more improvement.
• Extracorporeal shockwave therapy (ESWT)– this option is utilised more for runners as there is some evidence of effectiveness in this subgroup.
• CORTISONE/ STEROID INJECTIONS – this is a common treatment choice for patients not resolving to simple measures. There is moderate quality evidence demonstrating the short term beneficial effects of these injections. It is best to perform the injections under ultrasound guidance as this increase the accuracy of injections. Using low doses of steroid can help limit the potential local side effects. You may be asked to avoid running and other high impact activities for some time (approx. 2 weeks) after the injection.
• PRP injections. Platelets are one of the blood components. They help in clotting and contain growth factors which promote the healing process. PRP is prepared from one’s own blood by placing it in a spinning machine to separate the platelets.  Growth factors released from the platelets influence and accelerate the repair process, utilising body’s natural healing ability. These injections are best performed under ultrasound guidance and have the potential of providing prolonged relief.
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Treatment modalities in chronic pain in Delhi

Pain, no matter how trivial, is an unwelcome guest. It can be associated with undue suffering and disability which everyone would like to avoid. It is helpful to understand the types of pain one may experience. Pain can be categorized as acute or chronic pain.

Acute pain is the pain that is present after an injury until healing occurs. Pain in this situation is a protective response bringing our attention to the affected area and helping us protect, rest the affected tissue providing an opportunity for healing. As the tissue heals, the pain gradually abates.

Chronic or persisting pain is pain that persists even after the usual time required for healing. It is important to understand that chronic pain does not always signify on-going damage. Nerves have a memory (plasticity in medical terms) whereby they develop changes which remain even after the original inciting problem is corrected. A simple example to explain this is persisting leg pain even after amputation of the affected part. There are numerous mechanisms to explain this and your doctor can help you understand these better.

Impact of chronic pain is not limited to the involved person but also affects their loved ones and family members. The longer it persists the more chances that it will have an impact on multiple aspect of your life including your ability to work, sleeping pattern, mood, social life, relationship with family and friends etc. Hence it is important to take corrective measures to reverse or control the condition as soon as possible.

The management varies depending on the actual pathology, severity, co morbidities, patient preferences, available resources/ expertise and many other factors. At your first consultation with me you can expect a detailed assessment including history, examination and review of investigations. This is aimed at identifying the underlying reason for pain, so that an appropriate personalised management plan can be made. Some more tests may be requested as necessary. Close liaison with specialists in other fields such as neurology and surgery is maintained to formulate the best plan tailored to your condition and requirements. Some of the common pain treatment modalities include:

 

Medical management

I normally review your current medications and any existing medical problems prior to suggesting new medications or changes to current medications. Therefore it is a good idea to carry a detailed list of your medications and make of list of the ones you may have tried previously. Doses of medications tried previously are equally important as some medications if not used in right doses for the required duration are unlikely to be effective.

Different types of pain may need treatment with different medications, for example pain of inflammatory origin maybe be effectively managed with anti-inflammatory medication and pain due to irritation of nerve may need medication which help to desensitize the nerves. Hence the importance of identifying the likely pain generators prior to prescribing medications.

 

Interventional procedures

In certain situations I suggest procedures such as

·         Injections/ radiofrequency procedures that help to reduce the pain signals being transmitted by the nerves to your brain

·         Injections directly into a joint space/ around the area of problem such as a tendon or bursa which can help reduce the inflammation more effectively than medications taken orally. These procedures along with being therapeutic may also help the consultant confirm diagnosis

Regenerative medicine has opened new avenues where cells from your body are used to promote healing and reduce pain. Awareness of options such as Platelet-Rich Plasma (PRP) and stem cells is increasing and new research in this area is improving our understanding day by day.

Some interventional procedures can be done in the outpatient setting, whereas others will require a day case admission. This depends on the procedure being performed and your general health, other medical problems. We aim to reduce your pain as much as possible by offering you most appropriate interventions keeping your goals and preferences in mind and with an integrated multi speciality team approach based on biopsychosocial model of pain you have best chances of managing your pain.

 

Role of Physiotherapy

There are few common elements in management of most chronic pain situations like weakness accompanied by disuse of affected part for long time will require gradual mobilization and strengthening. A good chronic pain physiotherapist offers more than

physiotherapy. They play an important role in

·         Patient education regarding their condition, do’s and don’ts specific to their condition,

·         Setting realistic goals-dividing exercises into smaller achievable steps

·         Help patients understand and implement pacing of activities

·         Promoting compliance, increasing confidence and making you self reliant

·         Challenging your unhelpful thoughts, mitigating any false believes and minimising catastrophisation

 

Role of Psychology

Chronic pain can generate significant distress, anxiety and depression and all these, in turn, can magnify perceived pain. This is a normal human reaction which is often more visible to friends and family. Addressing these factors can help in reducing perceived pain and in improving quality of life. Psychologists can help you by challenging maladaptive beliefs, attitudes and emotions. They can help by

·         Teaching coping and self-help strategies

·         Relaxation techniques- these can be a useful tool especially in dealing with sleep disturbances and periods of increased pain

·         Cognitive Behavioural Therapy (CBT)

Consult Best Pain Specialist In Delhi, Dr. Amod Manocha.

Tags = Pain Specialist In Delhi, Best Pain Specialist In Delhi, Pain Managment in Delhi

Pancreatic Cancer Pain Management Coeliac Plexus & Splanchnic Nerve Blocks

Tag: Pancreatic Cancer, Pain Management in Gurgaon

What causes pain in pancreatic cancer?

One of the common presenting complaints of cancer is pain. Often pain is the reason behind a series of investigations culminating in the eventual diagnosis. Nearly 75% of pancreatic cancer patients suffer from pain at the time of diagnosis and this increases to over 90% in advanced stages.

The pain may be moderate to severe with adverse effect on quality of life, functional ability and mood. Most patients complain of intermittent or constant, deep pain in the upper part of tummy just below the ribcage. It may be squeezing, cramping, sharp, burning or aching in character. Pain is often more on the left and can spread towards the back. It is often aggravated by oral intake of fluids or solids.

Pain management in pancreatic cancer can be challenging because of the aggressive nature of the disease. There is evidence supporting earlier treatment of pain, so it’s better to seek help early.

Pain in cancer may be related to

• Cancer itself due to

• Increased pressure or the blockage of pancreatic ducts
• Inflammation of the pancreas /nearby areas

• Pressure/ spread to the neighbouring structures such as

• Nerves (in approximately 70–90% of cases)
• Blockage of the duodenum (the first part of the small intestine) impeding the flow of food
• Liver
• Bowel or peritoneum (inner covering of the tummy)
• Bone (not very common)

• Other associated problems such as constipation and digestion issues
• Distension of abdomen due to increased fluid (ascites)
• Irritation of diaphragm leading to the shoulder pain
• Side effect of treatments such as chemotherapy, radiotherapy, surgery (as in peripheral neuropathy (nerve damage)  /enteritis)
• An unrelated coincidental problem such as arthritis of joints of the spine 

What are Splanchnic nerves and Coeliac plexus?

Coeliac plexus is a network of nerves located in upper part of tummy (abdomen) just behind the pancreas. It lies deep in the tummy in front of spine and around a big blood vessel called aorta. This network of nerves plays an important role in sending messages from the upper abdominal organs to the brain.

Splanchnic nerves are a group of nerves located on both sides of the spine. They are closely related to the Coeliac ganglion and carry pain information from organs in your abdomen to the brain.

What kinds of procedures are performed to reduce pain in pancreatic cancer and how can they help?

The below mentioned procedures are utilised not only for pancreatic cancer but also for other upper abdominal cancers such as those of  liver, gall bladder, stomach, some parts of intestine. These can also help in some non-cancer pains such as in chronic pancreatitis.

These procedures may not be a permanent cure for the pain but have the potential to offer significant & lasting relief. Nerve blocks work well for some people, but they don’t work for everyone and may take some time to show the full effects.

These procedures can be classified as

• Diagnostic blocks– Blocking the coeliac plexus of the splanchnic nerves imvolves injecting local anaesthetic with or without steroids around these nerves to interrupt the pain signals being sent to the brain. This can reduce the pain one perceives and help in predicting if other procedures such as neurolysis will work or not.
• Neurolytic blocks– these procedures involve use of chemicals such as alcohol / phenol to achieve prolonged interruption of pain signals being transmitted by nerves.
• Radiofrequency procedures for splanchnic nerves– these procedures utilise radiofrequency energy to heat the needle tip which in turn reduces the pain signals being transmitted to th e brain.

Which intervention and approach is most suitable for a patient will depend on individual factors such as the extent of disease, concomitant problems such as breathing issues or ascites, ability to lie on the tummy/ back etc. Sometimes multidisciplinary review is required (such as reviewing the scans with radiologists) for deciding on the most suitable option.

Depending on the approach chosen the procedure may require for the patient to lie on their back or tummy for a period of approximately 45 min to an hour. A guiding modality is used to accurately place the needles close to the target nerves. This may include

• X Ray (Fluoroscopy) guidance
• Ultrasound guidance
• CT guidance
• Endoscopic guidance
• OR a combination of above mentioned modalities

Once the needles are in the correct place a dye may be used to assess how the medications would spread and to confirm the accurate placement of needles. An attempt is then made to reduce the pain signals being transmitted by these nerves via radiofrequency or drugs.

How much pain relief can be expected after the procedure and for how long will it last for?

The pain relief after the injection can vary depending on the cause of pain, location and extent of disease. In some studies it has been observed that the outcomes are better if the block is performed soon after the onset of pain asin advanced disease large tumours can act as mechanical barrier preventing the spread of the drugs hence achieving only partial relief.

These procedures have the potential of reducing the pain and the medication requirement for medium term. Overall, 70%–80% of patients undergoing these procedures report decreased pain for 1–6 months.

What are the risks of having these procedures?

No intervention is risk free. The decision to perform or not perform an intervention is taken by evaluating the risk/benefit ratio. The risks will vary depending on the intervention chosen and the patients medical issues. When performing these procedures, precautions are taken to reduce the risks as much as possible such as performing the procedure under guidance (x-ray, ultrasound, CT etc), use of contrast (dye) to assess the spread of medications and use of electrical stimulation in radiofrequency procedures etc.

Common side effects of these procedures include local pain (96%), lowering of blood pressure (10%) and loose stools (44%). Fortunately most of the common side effects are short lasting.

Some of the risks can be serious. Studies have reported the risk of serious adverse events as approximately 2%. It is best to discuss these with your treating doctor as the list of these can be long and vary with the intervention chosen.

What else can be done to reduce the pain?

Painkillers Medications

Different types of pain killers can be used based on the type of pain and other medical problems. Often the painkillers dose needs to be changed or new ones need to be added as the disease changes.

Morphine and Morphine like drugs (collectively known as Opioids) are one of the strongest pain killers. Other drugs in this class include fentanyl and oxycodone. These painkillers can be given by different routes lincluding orally, intravenously (directly into the veins), subcutaneously (below the skin) or as patches.  Oral medications also come in a slow release form which provide more consistent pain relieve throughout the day. These drugs have often been in the limelight due to the wrong reasons such as addiction/ abuse potential and hence the social taboos associated with their use. Patients often do a disservice to themselves by harbouring preconceived notions and putting up barriers. It is important that you openly discuss any such issues with your Pain Specialist. 

Other types of pain may require different class of pain killers such as anti-inflammatories for pain due to inflammation, neuropathic medications such as gabapentin and pregabalin for nerve type of pain etc.

As with any other medication there are side effects associated with all these medications and these can be dealt with in most cases by patient education, pre-emptive action, use of medications and lifestyle modification.

Pain control in cancer is not just about medications or injections… there is more to it. To achieve a satisfactory control it often requires addressing the concomitant factors which can serve to enhance the pain experienced. For example

• Relationship between one’s emotional state such as low mood /anxiety and pain is well known. These factors can magnify the perceived pain and hence addressing them is important. Relaxation therapies such as meditation, mindfulness may help in managing thoughts, coping with feelings and produce a calming effect.
• Abdominal and back pain worsen with coexisting problems like constipation and abdominal distension and hence the importance of addressing these.

Refractory end of life pain can be dealt by delivering pain killers directly into the spine by using intrathecal/ epidural route.

Neuropathic pain treatment in Delhi, pain management centre in Delhi

The increasing number of pain management centres in Delhi is a proof of chaning times and increasing awareness about pain management options. Neuropathic or nerve pain is one of the common reasons for pain clinic consultation.

Nerves act as the conduction pathways transmitting signals to and from the brain. Sensations including pain are transmitted as chemical and electrical signals to the brain where the pain is actually perceived. When the nerve become damaged or dysfucntional they start generating pain signals themselves. This category of pain is defined as neuropathic pain. Neuropathic pain can be severe, debelitating and you need to choose experienced doctors when it comes to neuropathic pain treatment in Delhi.

Let us first learn what causes neuropathic pain

Neuropathic pain is mainly caused by nervous system damage/dysfunction. Manyfactors and conditions can predispose to development of neuropathic pain. Some of the common reasons include:

• Diabetes mellitus leading to a condition known as polyneuropathy where multiple nerves of the peripheral nervous system are affected
• Certain Medications
• Nerve compression
• Nutritional deficiencies
• Neoplasms
• Chronic Alcoholism
• Toxin exposure
• Immunological diseases
• Infections
• Idiopathic

Treatment Modalities

It is important to consult the best centres for neuropathic pain treatment in Delhi where the team understands your pain and has extensive experience in diagnosis and management of all linds of neuropathic pain. Neuropathic pain increases the excitability of the neves, receptors and produces changes in the spinal cord such as those in N methyl D aspartate or NMDA receptor. Moreover, there is an imbalance between the excitatory and inhibitory systems further increasing the perceived pain.

If the predisposing factors or the preexisting damage isunmodifiable then the focus shifts to stopping the condition from worsening, pharmacological management and symptom/ pain control.

• In case of diabetic polyneuropathy, management of blood sugar level along with exercise and medication is helpful especially in type 1 diabetes
• In case of vitamin deficiency, vitamin administration and diet changes are recommended.
• In cases of nerve entrapments local injections can help if providing relief
• Along with management of the pain, it is equally important to alleviate other associated symptoms such as sleep disturbances and low mood.
• Pharmacological Management:Use of tricyclic antidepressants, anticonvulsants, opioids, topical numbing agents and patcheshelp in managing the symptoms of neuropathic pain. Interventions such as Nerve blocks, sodium channel blocking agents andneuromodulation is often utilised in combination with pharmacotherapy. These may not remove the causative factors but they certainly help in management of the pain.

It is essential to consult the best pain management centre in Delhi where an multidisciplinary approach is used and the emphasis is on improving quality of life and reducing pain, discomfort.

Tags = Neuropathic Pain treatment in Delhi, Pain Specialist in Delhi, Best pain specialist in Delhi, best Pain Specialist in South Delhi, Pain Clinic in Gurgaon, Pain Specialist in Gurgaon