Highlights of PainSA Polokwane Academy
PainSA hosted a recent Pain Academy in Polokwane. Presenters covered the International Association for the Study of Pain’s (IASP) 2019 theme: “Pain in the Most Vulnerable”.
Dr Ensa Johnson, senior lecturer at the University of Pretoria, covered the topic: Cerebral Palsy, Down’s Syndrome: How to communicate pain effectively and manage pain appropriately in the child with cognitive impairment.
Dr Johnson discussed why pain communication is important for appropriate pain management and gave background on Augmentative and Alternative Communication (AAC) and its use in healthcare. She shared ideas on supporting children to communicate and manage their pain by way of verbal and non-verbal communication. This, she said, includes symbols that enable children to more accurately communicate the level of pain severity as well as communicating their fears and needs.
Dr Johnson explained that pain is difficult to describe and measure in a subjective manner. Pain measurement strategies include:
• Behavioural measures: This is the way children react in response to pain and this differs from child to child.
• Biological measures: How a child’s body responds to pain.
• Non-verbal communication.
She said it was previously believed that children, and people with disabilities who cannot speak, do not feel pain or may have very high pain thresholds (Bottos & Chambers, 2006). This assumption that “patients who cannot speak have no pain” was further highlighted in McCafferey’s definition of pain which stated that “Pain is whatever the patient says it is and occurs whenever the patient says it does”, (McCafferey, 1968). Clinicians have overlooked other signs such as behavioural changes, but this has lately changed as they do acknowledge that changes in patients’ behaviour could be an indication of pain.
Dr Johnson explained that children with different types of disabilities such as Cerebral Palsy, Down Syndrome and Autism Spectrum Disorders, have unique pain experiences associated with their specific disabilities. They also usually present communication difficulties. As a result, these patients need appropriate pain-relieving treatment (Bottos & Chambers, 2006).
“AAC supplements the way people communicate when they cannot speak clearly enough to be understood by those around them. AAC strategies include a wide range of communication methods: gestures, symbols, communication boards, and assistive communication device,” she said.
Dr Tshepo Shikwane, a palliative care doctor working at a hospital in Pietersburg, presented on the topic: Principles of Palliation in Cancer Care. He noted that the World Health Organisation (WHO) defines palliative care as “The active total care of patients whose disease is not responsive to curative treatment. It covers the control of pain, associated symptoms, and of psychological, social and spiritual problems, is paramount”.
WHO states that palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with a life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
Dr Shikwane said that therapies intended to prolong life such as chemotherapy, radiotherapy can assist in managing distressing symptoms. Other principles of palliative care include affirming life and regarding dying as a normal process – and neither hastening nor postponing death.
Dr Shikwane emphasised the need for the provision of early palliative care; if provided early it may improve patients and caregivers Quality of Life (QoL) and preparation of End of Life (EOL) period. It may also reduce the use of healthcare resources (and indirectly costs) in the EOL and it can further reduce aggressive EOL care.
Dershnee Devan, an occupational therapist and PainSA council member, covered ‘The role of contextual factors in chronic pain, and our role as health care providers’. She explained that patient expectations and their perception of treatment can lead to a perceived injustice. People suffering from pain often experience this.
She covered the three aspects of chronic pain: biological, psychological and social. Biological pain covers nociception, injury, trauma, infection, illness, cancer and nerve damage. Psychological factors include sleep, fear, anxiety, depression and coping skills. Social factors cover the patient’s medical insurer, claims against the Workers Compensation and Road Accident Fund, as well as work, family, social network and healthcare practitioners (HCP).
She also discussed strategies to prevent, minimise and extinguish the ‘Nocebo’ effect. “There is a need for optimal patient-clinician communication. This includes empathy, trust, honesty, expertise, competence and compassion,” she explained.
‘The patient will never care how much you know until they know how much you care’ – was the theme of Christa du Toit’s presentation. She is a private nurse practitioner and a PainSA council member, and presented on the topic: ‘Grandpa’s Pain: Psychological and Spiritual Pain in The Elderly’.
She said that religious beliefs and practices may be important resources for coping with illness and may even contribute to mental pathology in some cases. “HCP should be aware of patients’ religious and spiritual beliefs and seek to understand what function they serve,” she said.
“Research indicates that religiousness and spirituality consistently predicted greater social support, fewer depressive symptoms, better cognitive function and greater cooperativeness.”
“Patients categorising themselves as neither spiritual nor religious tended to have worse self-rated and observer-rated health and greater medical comorbidity. Research on the biology and neurobiology of pain has given us a relationship between spirituality and pain. There is growing recognition that persistent pain is a complex and multidimensional experience stemming from the interrelations among biological, psychological, social and spiritual factors,” she said.
Ms du Toit noted that home-based care is preferred to institutional care. “There is a need for gerontological education in South Africa. Holistic care is preferred versus specialised care.” And in people growing old, she noted: “Aging is not what the chronological or biological number does to you, but rather what you do with age.”