http://www.educationwithoutbarriers.com/

Education Without Barriers, Delhi (2025)

02/11/2025

Not Every Elbow Pain Is Tennis Elbow | Ultrasound-Guided Injection in Elbow Pain secondary to Rheumatoid Arthritis.

Not every elbow pain is “Tennis Elbow.”

Here’s a real case where Rheumatoid Arthritis had damaged the elbow joint, leading to deformity and deep-seated pain — not the typical tendon issue most expect.

Watch how ultrasound changed everything:
💡 Revealed synovial hypertrophy, joint effusion, and erosions
💡 Guided precise intra-articular injection
💡 Direct injections work well with localised pains in RA joints

Elbow injections are often underused — yet, in skilled hands, they can provide excellent outcomes for selected cases of rheumatoid, post-traumatic, or degenerative joint pain.

📍 When anatomy changes, only ultrasound skill keeps accuracy alive.

That’s why modern pain specialists and rheumatologists must master image-guided techniques.

🎥 Case performed by Dr. Amod Manocha, Pain Specialist – International Pain Centre, Delhi

23/10/2025

PART 2
Evidence-Based Outcomes for BARBOTAGE:
👩‍⚕️⚕️ By Dr. Ichcha Muku | International Pain Centre

Short-Term Efficacy – Excellent:
• Significant pain reduction at 2 months (VAS 5.5→2.9, p ESWT alone (improved VAS, decreased calcium size)
• Barbotage + bursal steroid > bursal steroid alone

Predictors of better outcomes
• Gärtner Type II/III calcifications (vs. Type I)
o Type II: Clearly circumscribed, dense with fragments OR soft contour/dense
o Type III: Heterogeneous, fluffy, translucent without precise circumscription
• Resorptive phase deposits (softer)
• Larger deposits (≥1 cm)—though higher eventual surgical rates

No Predictive Value: Initial deposit size, BMI, Age

Clinical Advantages
✓ Safe: 7% minor complication rate
✓ Accurate: Real-time ultrasound guidance
✓ Quick: 20-45 minute outpatient procedure
✓ Cost-effective: Less expensive than surgery
✓ Minimaly invasive: Alternative to open surgery

Key Clinical Pearls
🔑 Ultrasound-guided barbotage is a safe and effective second-line treatment after ≥3 months failed conservative therapy
🔑 Document calcification morphology (Gärtner type, Uhthoff phase)—predicts response
🔑 Continue lavage until backflow clear to minimize residual calcium/bursitis risk
🔑 Consider prophylactic intra-bursal steroid; avoid intra-tendinous injection
🔑 Set realistic expectations nearly half require additional interventions within 1 year
🔑 Structured rehabilitation at 4-14 days: progressive ROM and eccentric strengthening

23/10/2025

🎓 Fellowship in Pain Medicine – Train with Royal College Standards under Dr. Amod Manocha {FFPMRCA (UK), FRCA (UK), PgD MSK Ultrasound (UK), PgD Rheumatology (UK), EDRA)}

Here’s your opportunity to train in one of India’s leading multidisciplinary pain centres.
The Fellowship in Pain Medicine at the International Pain Centre (IPC), New Delhi, is a comprehensive, full-time clinical and procedural training program, personally mentored by Dr. Amod Manocha, who trained in the UK and holds Royal College qualifications in Anaesthesia and Pain Medicine.

✅ Curriculum aligned with Royal College–style training
✅ Hands-on exposure to advanced pain interventions
✅ Multidisciplinary approach to complex pain conditions
✅ Evidence-based, structured mentorship

🩺 Only one fellowship seat is available. Selection is based on interview.

For those still exploring whether Pain Medicine is the right path —
👀 OBSERVERSHIP OPPORTUNITIES available to experience real-world pain practice.

📩 Interested candidates can send their CV and a brief statement of interest to: 👉 education@internationalpaincentre.com
📍 Location: International Pain Centre, A-10, Neeti Bagh, New Delhi – 110049
📞 Contact: +91-9993336525
🌐 Website: www.internationalpaincentre.com

Learn more about Dr. Manocha’s background and training philosophy:
🌐 https://www.removemypain.com/dr-amod-manocha

22/10/2025

Ultrasound-Guided Barbotage for Calcific Tendinitis: A Comprehensive Clinical Guide
👩‍⚕️⚕️ By Dr. Ichcha Muku | International Pain Centre

What is Barbotage?
Ultrasound-guided percutaneous lavage (UGPL), commonly known as barbotage, is a minimally invasive pain specialty intervention performed in outpatient settings for treating hydroxyapatite deposition disease (HADD), most commonly presenting as calcific tendinitis of the rotator cuff tendons, particularly the supraspinatus.
Mechanism of Action: Mechanical fenestration (perforation) of calcium deposits is the core therapeutic element, accelerating the natural resorption process through needle fragmentation and saline lavage

When to Perform Barbotage?
Indications
• Shoulder pain (including night-time pain when lying on affected shoulder) duration ≥3 months after failure of conservative therapy (physical therapy/NSAIDs)
• Painful arc with positive impingement signs
• Calcifications ≥5 mm diameter on radiography and ultrasound
• Morphological appearance of Molé type A, B, or C (not type D dystrophic)

Contraindications:
Absolute:
• Active local/systemic infection
• Anaphylaxis to injectates (lidocaine, corticosteroids)
Relative:
• Pre-existing tear in the affected tendon
• Coagulopathies and anticoagulation therapy
• Recent corticosteroid injection (< 3 months)

Understanding Calcification Classifications
Uhthoff's Stages (Disease Phase):
1. Pre-calcific Stage: Tendon metaplasia, asymptomatic
2. Calcific Stage:
• Formative phase (1-6 years): Usually asymptomatic, chronic mild pain
• Resorptive phase (3 weeks-6 months): Severe acute pain, vascularization, inflammatory response
3. Post-calcific Stage: Collagen remodeling, symptom resolution

Clinical Pearl: Barbotage is particularly effective during the resorptive phase when deposits are softer and more amenable to aspiration.

Gärtner Classification (Radiographic Morphology):
• Type I: Well-circumscribed, dense, homogeneous (formative phase)
• Type II: Clearly circumscribed, dense with fragments OR soft contour/dense
• Type III: Heterogeneous, fluffy, translucent without precise circumscription (resorptive phase)

Evidence: Patients with Gärtner Type II/III calcifications show superior outcomes with barbotage compared to Type I.

Ultrasound Morphology (Procedural Planning):
• Hard calcifications: Hyperechoic with strong posterior acoustic shadow → longer procedure, double-needle technique preferred
• Soft calcifications: Homogeneously hyperechoic, almost isoechoic to tendon, minimal/no shadow → intermediate difficulty
• Fluid calcifications: Thin peripheral hyperechoic rim with hypoechoic/anechoic core → easiest to aspirate, shorter procedure, single-needle technique.

Procedural Techniques:
• Needle insertion technique:
Single-Needle Technique (preferred for fluid calcifications):
• Insert 16-18 gauge needle into center of calcific deposit horizontally
• Attach 5 mL syringe containing 4 mL normal saline
• Pulse technique: Push plunger to inject saline, then release to allow backflow of calcium into syringe
• Exchange syringes when saline becomes cloudy with calcium
• Continue lavage until backflow is clear
• Total saline volume: 20-50 mL

Double-Needle Technique (preferred for hard calcifications):
• Insert 2 × 16-18 gauge needles as parallel as possible to transducer
• Needle tips 2-3 mm apart
• Inject saline through one needle with free drainage from the other
• Allows greater fragmentation and lower saline pressures

Clinical Trial Evidence: A 2017 prospective RCT (211 patients) found no significant difference in clinical outcomes between single vs. double-needle techniques up to 1 year. Single-needle was faster for fluid calcifications (p=0.024), double-needle faster for hard calcifications (p

16/10/2025

Slipping Rib Syndrome – Frequently Missed, Often distressing

I recently treated a 13-year-old boy who had been unable to attend school for almost two years because of persistent chest and upper abdominal pain. He had undergone multiple investigations and treatments elsewhere, but with no relief and lack of a convincing diagnosis — a situation that’s all too common with Slipping Rib Syndrome.

By the time he came to us, he and his family were understandably frustrated and keen to avoid surgery. After a targeted assessment, we offered a non-surgical, minimally invasive treatment approach, and he finally experienced meaningful relief.

This case reflects a broader issue — the condition mimics cardiac, gastric and musculoskeletal disorders, leading to repeated referrals and delayed diagnosis.
In my latest blog, I’ve explained:
✔ Why Slipping Rib Syndrome is often overlooked
✔ Key symptoms and diagnostic pointers
✔ When to suspect it in persistent chest/rib pain
✔ Effective non-surgical treatment options

If you're a clinician, therapist, or someone dealing with unexplained rib or chest pain, this could offer much-needed clarity.

🔗 Read the full article here:
https://www.removemypain.com/blog/slipping-rib-syndrome/

hashtag hashtag hashtag hashtag hashtag hashtag hashtag

10/10/2025

MORPHOLOGICAL CLASSIFICATION OF COCCYX

Postacchinni and Massobrio initially classified the morphological variants into four types to which two more types were further added by Nathan et al (1,2). This is based on standing lateral X-rays.

• Type I: present in over half of people; coccyx has a gentle ventral curvature as a continuation of the natural curvature of the sacrum and a caudally pointing apex;
• Type II: (8-32%): more prominent ventral curvature with coccyx apex pointing anteriorly
• Type III: (4-16%): acute anterior angulation of the coccyx but no subluxation
• Type IV: (1-9%): focal anterior angulation with anterior subluxation
• Type V: (1-11%): posteriorly angulated coccyx
• Type VI: (1-6%): scoliotic deformity or lateral deviation of coccyx

Key Takeaways:
• Types II, III, and IV – more prone to become painful
• Anterior subluxation is a rare lesion- seen in type III and type IV patterns.
• Posterior subluxation - type I configuration

References:
1. Nathan ST, Fisher BE, Roberts CS. Coccydynia. J Bone Joint Surg Br. 2010;92-B(12):1622e1627. https://doi.org/10.1302/0301-620X.92B12.25486.
2. Postacchini F, Massobrio M. Idiopathic coccygodynia. Analysis of fifty-one operative cases and a radiographic study of the normal coccyx. J Bone Joint Surg Am. 1983;65(8):1116e1124.

11/09/2025

💉 Epidural Steroid Injections: Why Dose & Cumulative Exposure (Number of injections x Dose per injection) Matter

By Dr. Ichcha Muku | International Pain Centre

Choosing the right steroid dose is about more than just pain relief — it’s about long-term safety. Here’s what every clinician should keep in mind 👇

1️. Dosing of Steroids: Go Low, Stay Effective
💡 More isn’t always better. Lower doses can work just as well — with fewer risks.
Steroid Dose Range Clinical Insight
Dexamethasone 4–12 mg ✅ 4 mg = 12 mg in pain relief. No added benefit with higher dose.
Methylprednisolone 40–80 mg 👍 40 mg = 80/120 mg. Lower risks at 40 mg.
Triamcinolone 5–40 mg 📌 Often 10 mg is enough. Higher ≠ better.
________________________________________

2️. Cumulative Dose & Bone Health
⚠ High-dose, repeated injections = higher risk of bone loss & fractures.
• Postmenopausal women:
o 200 mg/year or >400 mg/3 years → 🚨 Increased fracture risk
• Healthy men:
o 3 grams total lifetime → 🚫 Bone mineral density loss
________________________________________

3️. Recommended Cumulative Limits (Carelon Guidelines, 2025)
💊 Based on Carelon Guidelines (Effective July 26, 2025), here are the corrected recommendations for the maximum cumulative dose per region after three injections (with no timeline frame):
Steroid Max Cumulative Dose
Methylprednisolone 240 mg
Triamcinolone 120 mg
Dexamethasone 45 mg
________________________________________

4️. Frequency & Interval of Injections
📅 Best practice recommendations:
• ⏱ No more than 3 injections in 6 months
• 🔄 Max 4-6 per year (esp. particulate steroids)
• 🕒 At least 3 weeks apart
• ✅ Repeat within 3 months if acute pain persists
________________________________________

5️. Special Considerations
• Diabetes: Hyperglycemia peaks same day, lasts 2–4 days → Prefer lower dose
• Blood Pressure & IOP: May rise temporarily (48–72 hrs).
• HPA Axis: Suppression risk increases with dose & duration, especially with long-acting agents.
________________________________________

💡 Takeaway: More isn’t always better. The lowest effective dose combined with careful monitoring leads to safer outcomes for your spine and bones.

# EpiduralSteroidsDosing

References:
1. Cumulative Lifetime Steroid Exposure via Epidural Administration Byron J. Schneider, MD1; Ryan Mattie, MD2; and Clark C. Smith, MD, MPH3 on behalf of the Spine Intervention Society’s Patient Safety Committee July 2019
2. Mattie R, Miller DC, Smith CC; Spine Intervention Society’s Patient Safety Committee. Annual maximum dose of epidural steroid injection. Spine Intervention Society FactFinders for Patient Safety. June 2019
3. Kerezoudis, P., Rinaldo, L., Alvi, M. A., Hunt, C. L., Qu, W., Maus, T. P., & Bydon, M. (2018). The effect of epidural steroid injections on bone mineral density and vertebral fracture risk: A systematic review and critical appraisal of current literature. Pain Medicine (United States), 19(3), March 2018
4. Carelon Medical Benefits Management, Inc. Interventional Pain Management: Clinical Appropriateness Guidelines. Doc ID: MSK01-0725.1, Effective July 26, 2025; Revised October 28, 2024. carelon.com
5. Kennedy DJ, Schneider BJ, Smuck M, Plastaras CT, Rittenberg JD, Conger A, et al. SIS-Endorsed NASS Coverage Policy Recommendations: Epidural Steroid Injections and Selective Spinal Nerve Blocks. Spine J. 2020;20(7):969-89

11/09/2025

Done With Workshops? Master Ultrasound-Guided Pain Interventions 1-to1

Are you tired of attending endless workshops where you watch from the back of a crowded hall and leave with more confusion than clarity?

It’s time for a new way to learn.
👉 1-to-1, personalized ultrasound-guided pain intervention training designed for doctors who want real skills, real confidence, and real results.

🚀 In this video, Dr. Amod Manocha, UK-trained Pain Specialist, breaks down:
Why workshops often fail to deliver true mastery
How 1-to-1 ultrasound training accelerates your learning curve
The step-by-step skills you’ll actually take home and use in practice
Why mentorship and guided feedback beat lectures every time
This is not about “attending another course.”
This is about transforming the way you diagnose and treat pain patients using ultrasound-guided interventions.

📌 Who is this for?
Doctors in:
Pain Medicine
Anaesthesia
Orthopaedics
Sports Medicine
Rheumatology
General Physicians
Emergency Medicine
Radiology
…who are ready to move beyond theory and actually master procedures.

💡 If you’ve ever left a workshop thinking “I still don’t feel confident to do this on my own,” this training is for you.

👉 For more information & 1-to-1 training opportunities:
📞 +91-9993336525
Email: educaiton@internationalpaincentre.com
🌐 internationalpaincentre.com | removemypain.com Ieducationwithoutbarriers.com

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👉 Follow Dr. Amod Manocha:
Instagram: https://www.instagram.com/internationalpaincentre/

29/08/2025

वो बात जो Bollywood ने सालों पहले समझाई थी… पर हमने कभी गौर नहीं किया 🎥” 🌿

We’ve all sung “Jai Jai Shiv Shankar, kaata lage na khumaar…” at parties.
But hidden in those lyrics is Cannabis pharmacology simplified!

👉 Cannabis isn’t just about “nasha.”
It has two key components:
CBD (Cannabidiol): Pain relief, calm, relaxation — without the “high.” 🌱
THC (Tetrahydrocannabinol): The part responsible for euphoria, dizziness, visual distortion, sedation, and disorientation.

💡 In pain & palliative care, we often harness CBD and carefully balance THC to:
✅ Relieve pain without the high
✅ Improve sleep & appetite
✅ Support patients where standard medicines may not help

Bollywood may have sung about the side effects 🎶, but modern medicine uses science to choose the right component, for the right patient, at the right time.

👉 Whether you’re a doctor, a patient, or just curious — remember:
Cannabis in medicine = relief, not recreation.

📩 If you’d like to know more about safe and evidence-based medical use of cannabis in pain or palliative care, connect with us at
International Pain Centre.
📞 +91 999 333 6525
🌐 www.internationalpaincentre.com

📲 Follow us on Instagram https://www.instagram.com/internationalpaincentre/
Cannabis In Medicine CBD vs THC, Pain Management, PalliativeCare, Medical Education, Doctors, pain doctor, Pain, Pain Specialist

24/08/2025

💊 Buprenorphine Transdermal Patch in Pain Management

🔹 Introduction
• Semi-synthetic opioid derived from thebaine
• In clinical use for over 30 years
• Acts as a non-selective mixed agonist–antagonist opioid receptor modulator
• Unique pharmacodynamic profile – allows for potent analgesia with fewer side effects
o partial agonist with a very high binding affinity for the µ-opioid receptor,
o antagonist for the δ- and κ-opioid receptors,
o agonist for the opioid receptor-like 1 receptor
• Available as transdermal patches (5, 10 & 20 mcg/hr)
• 25–100 times more potent than morphine
________________________________________

🔹 Advantages of Buprenorphine Transdermal System (TDS)
✨ Sustained Pain Relief
✨ Fewer Side Effects
• Ceiling effect on respiratory depression & euphoria
• Lower addiction potential, less constipation
• No effect on sphincter of Oddi
• Minimal impact on hypothalamic–pituitary–adrenal axis → less risk of hypogonadism
✨ Convenience & Compliance- Once-weekly, non-invasive, reliable
✨ Metabolic Benefits
• Avoids first-pass metabolism
• Safe in elderly & patients with renal/hepatic impairment (no dose adjustments required)
________________________________________

🔹 Practical Aspects for Healthcare Professionals
Indications:
• Opioid-responsive pain not controlled by non-opioid analgesics
• Effective in both nociceptive and neuropathic pain

Dosage & Administration:
• Opioid-naïve: Start with 5 mcg/hr patch
• Converting from other opioids: Discontinue all other around-the-clock opioids. Buprenorphine has the potential to precipitate withdrawal, so caution is needed.
o Prior Total Daily Dose of Opioid < 30 mg of Oral Morphine Equivalents - initiate treatment with buprenorphine patch 5 mcg/hour
o Prior Total Daily Dose of Opioid Between 30 mg - 80 mg of Oral Morphine Equivalents: start with 10 mcg/hour buprenorphine patch.
o Prior Total Daily Dose of Opioid Greater than 80 mg of Oral Morphine Equivalents per Day: buprenorphine patch 20 mcg/hour may not provide adequate analgesia for patients requiring greater than 80 mg/day oral morphine equivalents. Consider use of alternate analgesics.

Titration & Maintenance:
• Minimum titration interval: 72 hrs
• Max dose: 20 mcg/hr (due to QTc risk)

Discontinuation:
• Do not stop abruptly → taper gradually every 7 days

Application:
• Apply to non-irritated, intact skin (upper arm, chest, upper back, or side of chest)

________________________________________
🔹 Contraindications & Precautions
❌ Severe respiratory depression
❌ Severe bronchial asthma (unmonitored setting)
❌ GI obstruction
❌ Severe hepatic failure
❌ Long QT syndrome, certain antiarrhythmics

⚠️ Caution with:
• Benzodiazepines
• CYP3A4 inhibitors
• Serotonergic drugs
• Avoid with mixed agonist/antagonist analgesics (may reduce effect or precipitate withdrawal)
________________________________________

✅ Conclusion
The buprenorphine transdermal patch is a valuable and safe option for managing chronic pain. With its unique pharmacological profile, favorable side-effect spectrum, and convenient once-weekly application, it is particularly suitable for:
• Elderly patients
• Renal or hepatic impairment
• Patients requiring long-term opioid therapy

21/08/2025

BUPRENORPHINE (BUPOXONE) Webinar

We are pleased to invite you to our upcoming webinar session on:

Topic: Transdermal Buprenorphine Patch: A Modern Approach to Chronic Pain Management

📅 Date: 21/08/2025
🕒 Time: 07:30 – 08:30 PM
📍 Link: https://streamgo.in/Bupoxone/

✨ Highlights: Chronic pain management • Practical insights • Q&A session

📲 The attached invite also contains details of the Speaker, Moderator, Panelists, and the registration link.

We look forward to your valuable participation.

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