Total Pain and Its Application to the Assessment and Management of Pain in a Client with a Life-limiting Illness - Essay Example

RUNNING HEAD: Total Pain Management Concept of “total pain” and its application to the assessment and management of pain in a client with a life-limiting illness Introduction Pain is a major health concern that affects each and every person in the world at some point of time in the lifespan. Infact, it is one of the most common causes of seeking medical attention (Farkas, 2005). Pain is caused by many different etiologies. While most of the causes of pain are temporary and allow relief of pain, many conditions cause chronic pain and have no definitive treatment (Farkas, 2005). Pain which lasts for longer duration of time and has no definitive treatment cripples the sufferer not only physically, but also emotionally and psychologically. Infact, such a pain can affect the function and financial aspects of the individual, affecting quality of life and satisfaction. Thus, it can be said description of pain involves not just 'physical' aspect but also 'emotional', 'social', 'spiritual', 'psychological' and 'financial' aspects (Waddell et al; cited in National health Service, 2006) (refer appendix). Hence, it is imperative that any treatment instituted for pain must involve all these aspects and not just the 'part of body' having pain. This means that 'total pain' is treated rather than just 'physical' pain. This is more so in case where the patient is suffering from life limiting illnesses like cancer, multiple sclerosis and Aquired Immunodeficiency Syndrome or AIDS. This essay will explore the concept of total pain in conjunction with various theories about pain, pathophysiology of pain, methods of assessment and various aspects of management of pain in people with 'life limiting’ illnesses. Definition of Pain Pain is a symptom that arises out of injury or illness in a part of the body. There is no clear cut definition for pain, although it may be defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (IASP; cited in NHS, 2006, p.3). Sudden pain that lasts for brief duration of time is known as acute pain and pain that lasts for more than 3 months is known as chronic pain (Farkas, 2005). According to IASP (1986; cited in NHS, 2006, p.4), chronic pain is "pain without apparent biological value that has persisted beyond normal tissue healing time." When pain arises from skin and muscles as in fibromyalgia and chronic back pain, it is termed as general somatic pain and when it arises from internal organs, it is called visceral pain. There are many other causes of pain like bone pathologies, peripheral neuropathies and muscle cramps. Pain in certain life limiting conditions like cancer, AIDS, advanced congestive heart failure, end stage organ failure, advanced chronic pulmonary obstructive disease, multiple sclerosis and amyotrophic lateral sclerosis is known as chronic malignant pain and can be disgusting (Delphi Study, 2007). The goal of management in these patients must be pain relief so that the patients can live with comfort as long as they live. The type of pain relief must be "holistic" in the purview of holistic nursing. To facilitate holistic pain management, to integration of complementary or alternative modalities of treatment into current clinical practice must be made to meet the spiritual, physiological and psychological needs of the patient (Frisch, 2001). Theories of pain There are various theories which have been put forward to understand perception of pain. While the sensory model of pain hypothesizes that pain emerges from only physical factors, the psychogenic model argues that pain is more a psychological phenomena rather than just physiologic process. However, current theorists hypothesize that pain has both a physiological and psychological aspects and that both these components must be included while proposing models for pain. Such a theory was actually proposed by the Gate control model, according to which, cells of the spinal cord which act as transmitters of nociceptive information are “gates” of pain transmission which get opened during activity in small diameter afferent nerve fibers and get closed when there is activity in large-diameter afferent fibers. Thus the position of the gate is controlled by both these fibers and the amount of pain is dependent on the position of the gate (Pain management, 2003). According to motivational model of pain, pain is a symptom that is basically exaggerated for certain benefits by the malingering-conscious mind. Opponents of motivational model argue that malingering of pain is rare in those with chronic pain. The Operant conditioning model of pain proposes that reinforcement of various pain behaviors is more a gradual and unintended process rather than conscious malingering. The Classic model or respondent conditioning model is of a different opinion and hypothesizes that frequent pairing of a nociceptive stimulus with neural stimulus can cause eliciting of pain just by the neural stimulus. According to the social model of pain perception, behaviors of pain can be acquired through modeling and observation. This model holds good for children (Pain management, 2003). According to the cognitive-behavioral model of pain, cognitive factors which are based on learned expectations play an important role in perception of pain (Pain management, 2003). Thus there are many models of pain which have been put forth to understand the process of perception and expression of pain. Pathophysiology of pain Though mechanisms of perception of pain in the central nervous system are not fully elucidated, certain pathways and neurotransmitters of pain have been identified, based on which many drugs have been developed to gain some control of pain. Injury or disease of tissue causes some chemical changes and alterations in the pH leading to activation of nociceptive or pain receptors (Regan, 2000). These receptors are distributed in various somatic structures like skin, connective tissue, joints and bones and visceral structures like liver and gastrointestinal tract. The main chemical mediators of pain transduction are serotonin, bradykinin, prostaglandin, potassium, histamine and substance P (Wood, 2008).. From the nociceptive receptors, pain signals are transmitted through the C fibers and A-delta fibers of peripheral sensory nerve to the dorsal horn cells of the spinal cord. Neurotransmitters involved in this process are glutamate, adenosine triphosphate, bradykinin, substance P, nitrous oxide and calcitonin gene-related peptide. From the dorsal horn cells, ascending pain pathways pick up the signals and traverse through the spinal cord and medulla to reach the reticular system, somatosensory cortex and limbic system the brain, activating multiple cortical areas and causing of eliciting of various response (Wood, 2008). This is called perception of pain. Certain pathways in the spinal cord, known as descending modulatory pain pathways can cause modulation of pain through excitation or inhibition of pain signals. The modulation is achieved through several neurotransmitters. While this mechanism holds good for acute pain, the pathophysiology of chronic pain is different and infact complex. Modulation of chronic pain occurs due to rapid and long-term changes in some parts of the CNS. Also, the ‘wind up’ mechanism which is nothing but hypersensitivity or hyperexcitability to prolonged noxious stimulation makes a person experience chronic pain (Wood, 2008). Both acute and chronic pain mechanisms are involved in the perception of pain in life-limiting illnesses like cancer and treatments need to be instituted based on the understanding of these mechanisms. Assessment of pain It is essential to assess pain properly to facilitate effective management. Assessment of pain involves appropriate pain history, detailed physical examination and specific diagnostic tests (Bird, 2005). History would include detailed description of pain including, onset, intensity, site and relieving and aggravating factors. Effects of pain on the physical, functional, psychological, emotional, social and financial aspects of life is essential to understand the extent to which pain has impacted the living of the patient. Physical examination should be elaborate and involve general and systemic examination and specific pain evaluation (Manias, Botti & Bucknall, 2002). Based on these examinations, appropriate diagnostic tests may be performed to ascertain the etiology and impact of pain. One important aspect of pain assessment is the evaluation of intensity of pain for which several tools have been developed. Important tools which have been studied and proved to be useful are the McGill Pain Questionnaire, the Short-form McGill Pain Questionnaire, the Brief Pain Inventory, the Massachusetts General Hospital Pain Center's Pain Assessment Form, the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials or IMMPACT, Neuropathic Pain Screening Tools (Breivik, Borchgrevink, Allen, et al, 2008). No pain- Non-communicative Patient's Pain Assessment Instrument, Dolopus-2 Scale, and Mccaffery and Pasero Initial assessment Tool (National Health Service or NHS, 2006) (refer appendix). Which tool is the most useful scale for assessment of pain is debatable and much discussed topic. Infact, the variety of assessment tools has made it difficult to compare and contrast results of pain management (Scottish Intercollegiate Guidelines Network or SIGN, 2008). According to the European Association of Palliative Care (cited in SIGN, 2008), useful scales to assess pain are verbal rating scales, visual analogue scales and numerical rating scales. These scales are useful even in those with cognitive impairment. SIGN (2008) proposes that Brief Pain Inventory and McGill Pain Questionnaire are validated tools even in different cultures along with the benefits of incorporation of verbal rating and numerical rating scales. Those with severe cognitive impairment may be assessed with Pain Assessment Checklist for seniors with Limited Ability to Communicate (PASLAC) or Doloplus-2 (SIGN, 2008). Whenever possible, self-assessment tools are ideal for pain evaluation (SIGN, 2008). Another important aspect regarding pain assessment is the frequency of pain assessment. According to SIGN (2008), frequent pain assessment, atleast once day is critical until subsidence of pain. Pain management As discussed before, for those with terminal illness, holistic approach of pain management is crucial. The most widely employed method of pain relief is pharmacotherapy. There are many categories of medicines available to bring about pain relief. WHO's Pain Relief Ladder (WHO, 2009) is a useful guide to prescribe pharmacotherapy for pain. There are 3 steps in this ladder and the lowest step is that of mild pain. The next step is the moderate pain. This pain is worse than mild pain and it affects functions of the individual. The presence of pain cannot be ignored. This pain goes away with treatment and seldom reappears. The uppermost step is that of severe pain. This pain interferes with most of the daily living activities. The individual may need treatment for many weeks, months or even years. According to this guide, the first drugs which must be recommended for pain are non-opioids like paracetamol and non-steroidal anti-inflammatory drugs or NSAIDs like aspirin and ibuprofen (Alkhenizan, Librach & Beyene, 2004). These medications are of no treatment value in neuropathic pain (Regan, 2000). If treatment with above medications is not effective, the treatment must be stepped up to mild opioids like codeine and then to strong opioids like morphine, hydrocodone, oxycodone, methadone, hydromorphone and fentanyl until the patient is relieved of pain. Generally, pain is associated with anxiety and fears, adjuvants like anti-anxiety drugs may be given. Anticonvulsants like gabapentin, pregabalin, topiramate, lamotrigine, tiagabine, zonisamide and clonazepam are useful to control pain in some neuropathic conditions (Poole, 2008). Certain anti-depressants like amytriptyline, nortriptyline and fluoxetine are useful adjuncts in chronic pain management. Drugs given to relieve pain must be given every 3-6 hours, round the clock. According to the WHO, the 'ladder approach' treatment allows a patient to get the right drug with the right dose at the right time in the most effective manner and at the least possible cost (WHO, 2009). This ladder has been declared useful even by SIGN (SIGN, 2008). For those who have failed to respond to medical therapy, non-pharmacological modes of treatment may be tried. Radiation therapy is an excellent and durable method of treatment for resistant metastatic bone pain (Regan, 2000). Pain which is not responsive to medicines or radiation therapy (for bone cancer pain), must be treated with surgical methods. Bone pains of cancer, neuropathic pains and visceral organ pains in malignancy will need surgical intervention for relief of pain at some stage or the other (Regan, 2008). Surgical implantation is one such method. Intrathecal delivery involves creation of small pocket under the skin in which an infusion pump is placed that delivers pain-relieving drug into the intrathecal space by means of a catheter (Mitten, 2001). This mode of drug delivery involves lesser dosage of medication and thus there are fewer side effects. In spinal cord stimulant implantation, low-level electrical signals to block specific nerves in the spinal cord are sent by a surgically-implanted device in the body so that pain signals are not transmitted to the brain and is useful in neuropathic conditions (Brenman, 2007). Injection of local anesthetics into nerves or their plexus with or without steroids can decrease pain for some time. One good example of this technique of pain relief is regional blocks using epidural steroid injections for leg pain due to radicular referred pain (Callin and Bennett, 2008). Other than pharmacological, radiotherapy and surgical intervention, there are many other approaches to pain relief. Regular exercise improves muscle tone, flexibility and strength and thus can diminish pain in the long run. Exercise is said to act by causing release endorphins which are natural pain killers of the body. Some of the useful forms of exercises are yoga, walking and swimming (Brenman, 2007). Other than exercise, there are many alternative therapies that have come up for the treatment of chronic pain though there is not much evidence to support these forms of treatment; the therapies claim to alleviate pain. Mind-Body therapies are the most common non-pharmacological approaches to chronic pain. These therapies adopt the mind's ability to take over the symptoms of the body. Some of the therapies which fit into this category are meditation, relaxation techniques, biofeedback, guided imagery, visualization and hypnosis. In visualization, the patient is asked to close his/her eyes and makeup a visual image of pain by creating a shape and size and adding color and motion to it. Then, this image is gradually replaced with a much more pleasant image and of smaller size. In electromyographic feedback, there is information about muscle tension in the body, so that the patient learns to control the muscle tension, thus alleviating pain. Self hypnosis and hypnotherapy decrease pain by blocking pain by means of refocusing strategies. Meditation and yoga are relaxation techniques and they are more useful in stress-related pain. Yoga also gently strengthens the muscles of the body (Brenman, 2007). 'Total pain' management This involves holistic approach in managing pain wherein the patient will be considered as a bio-psycho-social-spiritual being and all aspects and concerns of the patient will be considered during evaluation, assessment and treatment. Such a type of care involves the surrounding and family of the patient. Holistic care is critical in those who are terminally ill because pain in such individuals not only affects the physical well being of the patient, but also the emotional and function well being (Breivik et al, 2008). Such management is possible when physicians and non-physician clinicians work together to reduce pain, improve function and develop self-management skills (Rudin, 2001). Holistic care of a patient in chronic pain promotes effective and proper ways of communication, co-operation between nurse and client, shared understanding, health promotion and informed consent (Hamilton & Price, 2007, p. 221). Holistic assessment enables the nurse to comprehend of the individual’s precise pain. This type of assessment is normally based on deductive reasoning. Diversity of factors that determine bio-psycho-social-spiritual functioning are assessed (Hamilton & Price, 2007). Conclusion Pain management in those with 'life limiting' illness must have a different approach as far as assessment and treatment is concerned, because pain in these patients affects not only the physical well but also the emotional, psychological and spiritual aspects of life. Viewing human being as a bio-psycho-social-spiritual body allows clinicians to deliver holistic pain management care that facilitates these terminally ill patients live in peace. There is no single pain management strategy that is magical and works in every body. Hence, trial of various pain relief methods, based on various tools of assessment is critical for effective pain management. While most pains respond to pharmacological methods, bone pains of cancer will need radiation therapy and resistant bone pains, visceral pains and neuropathic pains will need surgical intervention to bring about pain relief. An understanding of mechanisms of perception of pain is crucial to institute the most appropriate treatment for a person. References Alkhenizan, A. Librach, L. & Beyene, J. (2004) NSAID’s: are they effective in treating cancer pain? European Journal of Palliative care, 11(1), 5-8. Bird, J. (2005). Assessing Pain in Older People. Nursing Standard, 19 (19), 45-52. Breivik, H., Borchgrevink, P.C., Allen, S.M., et al (2008). Assessment of pain. BJA, 101(1), 17-24. Brenman, E.K. (2007). Pain Management Guide. WebMD. Retrieved on 17th August, 2009 from http://www.webmd.com/pain-management/guide/cause-treatments Callin,S. & Bennett, M.I. (2008). Diagnosis and management of neuropathic pain in palliative care. International journal of palliative nursing, 14 (1), 16-21. Delphi Study. (2007). WHO Normative Guidelines on Pain Management. 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Chronic pain rehabilitation: principles and Practice. Wisconsin Medical Journal, 100 (5): 36-43, 66. Scottish Intercollegiate Guidelines Network (SIGN). (2008). Control of pain in adults with cancer. Retrieved on 17th August, 2009 from http://www.sign.ac.uk/pdf/SIGN106.pdf WHO. (2009). WHO's pain ladder. Retrieved on 17th August, 2009 from http://www.who.int/cancer/palliative/painladder/en/print.html Wood, S. (2008). Anatomy and physiology of pain. Nursingtimes.net. Retrieved on 24th August, 2009 from http://www.nursingtimes.net/nursing-practice-clinical-research/anatomy-and-physiology-of-pain/1860931.article Appendix (Source: NHS, 2007) Figure.1. Bio-psycho-social model for pain (Waddell et al, 1993; cited. in NHS, 2006) Read More