At the recent PainSA Pain Academy held in Nelspruit July 2019, a range of topics were covered under the 2019 International Association for the Study of Pain (IASP) 2019 theme of Pain in the Most Vulnerable.
Christa du Toit, a private nurse practitioner, presented on ‘Grandpa’s Pain: Psychological and Spiritual Pain in The Elderly’. According to Statistics SA 2018-midyear population estimates, South Africa’s population in 2018 was 57,73m of which 4,98m people were over the age of 60 years. The proportion of the elderly, 60 years and older, increased 8.1% in 2018.
She explained that the definition ‘older adults’ varies from country to country and is based around psychological, psychosocial and cultural issues. In the USA, age is just a number while in SA, being old is perceived as someone possessing knowledge and wisdom.
Regarding care for the aged, she said experience shows that home-based care is preferred to institutional care. Independence is crucial to well-being in old age. “Research on the biology and neurobiology of pain has shown 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.
“Religious beliefs and practices may be important resources for coping with illness and may contribute to mental pathology in some cases. It is important that religion and spirituality must be defined because these terms have ambiguous meanings.”
‘Grandma’s Pain: Physical Pain in the Elderly’ was covered by Dr Jackie Goldswain, a specialist physician in private practice. She explained that pain can exacerbate anger and depression. In the elderly, it is also important that the administration of medication is properly managed and kept strictly to the prescribed doses.
Counselling should be provided in cases of chronic pain to manage expectations in the long term, especially with treatment such as the up-titration of Pregabalin and Gabapentin which can take up to six weeks at effective doses to modify pain. The financial implications of follow ups should be discussed and the side effects explained with any new treatment.
“Patients are not static, and neither are their diseases. History is key in diagnosing and recognising the correct pain management, follow up and continued counselling are as important as initiating treatment,” she said.
Dr Monique Fischer, a Senior Medical Officer in Anesthesia at Rob Ferreira Hospital, highlighted the importance of pain management in children. She explained that studies have shown that, contrary to popular belief, small babies are able to experience pain, premature babies even more so. The untreated pain can cause physiological abnormalities, and can have an impact on their emotional development.
There are various medications that can be given as procedural pain relievers, and there are also many non-pharmacological methods to improve their pain experience. No child is too young to be given pain relief, and all medical professionals should strive to make their patients as comfortable as possible, regardless of their age.
Elzette Kruger is a physiotherapist in private practice. Her presentation covered ‘Pain In Adult Hemiplegia And Spinal Cord Injury (SCI) Patients’. She said that pain is extremely common after SCI and can persist for years after injury and it is often difficult to provide adequate relief. The prevalence of pain in SCI patients encompasses 75-85% of cases. The main attributes to pain is considered musculoskeletal in origin. In treatment, eliciting pain is counter-productive in patients with a neurological condition.
A South African study on factors influencing the functional ability of SCI patients concluded that 42% of cases complained of back pain. Leg and shoulder pain were less frequently involved. With musculoskeletal pain as the highest contributor to pain in SCI patients, it is important to make the distinction between acute pain mainly due to the specific acquired injury, and chronic pain stemming from overuse and abuse type activities sprouting from living with a paraplegia or quadriplegia.
Cecily Partridge noted in the book Neurological Physiotherapy, that SCI shoulder pain is frequently due to poor co-ordination of muscle contractions, leading to malalignment of the shoulder complex, causing impingement and therefore pain. Improving selective activity is essential. Supported resting of the upper limbs will support pain relieve.
On the other hand, it is important to note that when treating SCI patients with musculoskeletal pain, those who had unusually long periods of unconsciousness, have a tendency to develop heterotopic ossification due to the loss of perceived pain. Patricia Davis said that repeated traumatisation of soft tissues that are relatively immobile or previously immobilised – especially muscle – can cause heterotopic ossification.
Pain in patients with a spinal cord injury is much more common than, for example, patients’ post stroke. In neurological conditions, such as hemiplegia post stroke, it seems as with therapeutic intervention, repetitive microtrauma to the musculoskeletal structures can be avoided. Maintenance of normal physiological movements and gliding of the muscles, fascia, joints, skin and nerve tissue might limit the development of central neuropathic pain.
Care should be taken to facilitate as much normal afferent input to the CNS before the development of pain whilst the acute phase post-stroke subsides. The capacity of nociceptive afferents to induce a state of central sensitization is the main contributor to the outcome of central pain management. In adults with neurological challenges, the prevention of pain and the management of both the absence and the presence of pain is of utmost importance.
‘Principles of Palliation in Life Threatening Conditions” was covered by Landi Bezuidenhout, a palliative care nurse. She presented the World Health Organisation’s and the International Association of Hospice and Palliative Care’s definitions of palliative care, and used a case study to illustrate the practical application of palliative care principles. She highlighted some myths about cancer care:
Myth: Hospice care is just for the elderly.
Fact: Hospice serves anyone facing a life-limiting illness, regardless of age.
Myth: Only the person who is ill can benefit from palliative care.
Fact: Palliative care is designed to help the family and friends of the person who is ill as well. If someone close to you has a terminal or progressive illness, it can have a big impact on you.
Myth: Palliative care is just about helping people relieve pain and other physical symptoms
Fact: The aim of palliative care is to help people with any terminal or complex, progressive illness to have the best quality of life.
Myth: Palliative care and hospice care is only for people with cancer.
Fact: People with any terminal or progressive illness can benefit from palliative care at different points of their illness.
Dr Tarin Penberthy, an anaesthetist and interventional pain practitioner, and PainSA council member, covered the topic ‘Interventional Pain Procedures for Cancer Pain’. The IASP had a Global Year theme of Cancer Pain in 2008. They stated that more than 10 million people worldwide were diagnosed with cancer each year.
Pain is usually associated cancer and can be difficult to treat. It can occur at any point during the course of the illness:
- Workup e.g. biopsies
- Treatment (chemotherapy, radiotherapy, surgery)
- Advancing of the cancer
- Cancer survivors
- Other non-cancer chronic pain conditions
There is a delicate balance in cancer pain treatment which is affected by a range of interfering factors such as patients’ general condition, co-medication and the nature of the pain (nociceptive vs neuropathic vs visceral). Problems with pharmacological treatments include pain that is refractory to medical management, patients’ may experience intolerable side effects or patients who do not want to take medications. This is where interventional pain management could be used.
Interventional pain procedures can treat nociceptive pain (e.g. kyphoplasty or vertebroplasty, medial branch facet nerve blocks), neuropathic pain (e.g. specific nerve blocks, stellate ganglion block, lumbar plexus block, Intrathecal / epidural administration of medications, spinal cord stimulators) and visceral pain (sympathetic blocks of the splanchnic nerve, coeliac plexus, hypogastric plexus, impar ganglion).
Nerve blocks can be done as either diagnostic or therapeutic. Diagnostic nerve blocks are done with local anaesthetic to help diagnose which nerve is causing pain or whether the pain is of visceral or somatic origin (e.g. sympathetic nerve blocks). Therapeutic nerve blocks can be done with the addition of a corticosteroid to the local anaesthetic or with neurolysis, which can be by radiofrequency or chemical ablation.
Dershnee Devan, an occupational therapist and PainSA council member, covered the “Role of Perceived Injustice in Chronic Pain, What is Our Role as Healthcare Providers”. She explained that patients often ask: ‘Why is this happening to me?’. They can be frustrated and angry based on the pain they are experiencing, as well as due to external issues such as medical aid benefits being exceeded or family tensions. “Care givers are part of this social context and may need to discuss external issues with patients as well.”
She said that Doctor Google can be a challenge. Patients may already have diagnosed their ailment and decided on the treatment needed. Therefore patient-clinician communication is important. She then looked at factors that affect development of a therapeutic relationship with patients as well as contextual modulators.
Many aspects of the patient’s context which include the clinician’s interaction with the patient can contribute to a nocebo effect in chronic pain clients. She concluded by looking at the various roles that healthcare providers play with the treatment context and how this may affect treatment outcomes. Two case studies were then discussed to illustrate the ethical challenges we face as clinicians. END