“gate-control th eo ry . . . suggests th a t p a in control may be achieved by th e enhancem ent o f n o rm al physio­ logical activities ra th e r than th e ir d isru p tio n by destruc­ tive, irreversible lesions. In p a rtic u la r it has led to attempts to control p ain by a ctiv atio n o f in h ib ito ry mechanisms. This not only refers to aspects like ph arm aco ­ logical control o f pain, o r sensory control o f p a in by using anaesthetic blocking agents b u t also to the psycho­ logical control o f p ain by m eans o f m ethods o r tech­ niques like progressive R elaxation (Jacobsen) Autogenic T rain in g (Schultz) or C oncentrative self R e la x a t io n H y p n o t i c suggestion techniques Desensitization techniques psychotherapeutic relief of anxiety or depression All these I refer to as hygiene m ethods. Grow th methods: T h ere is enough evidence th a t in term s of personality grow th b etter results can som etim es be obtained by freeing the p atien t to face up to the pain /^experience. As M aslow (1962: 97) puts it peak expe- Triences like pain are usually acute identity experiences, jUNE 1979 43 i.e. experiences th a t could assist a person to face up, not only to pain, b u t u ltim ately to him self, to see him for w h at he really is, to try an d live a really authentic existence. In such an existence pain w ould not neces­ sarily be seen as an enem y, b u t as an oppo rtu n ity for self developm ent and self-enhancem ent. F o r after all, w hat w ould life be like if th ere was no pain left? N o headaches when I have drunk too m uch, no tum m y aches w hen I have eate n too m uch. If p a in as signal, sym bol and significance disappeared, w ould n o t death be n e a r a t hand? Bibliography: 1. D egenaar, J. Some Philosophical C onsiderations on Pain. 2. M ay, R ollo (1961) Existence. Basic Books. N ew Y ork. 3. B insw anger, L. (1942) G rundform en un d E rkenntnis M enschlichen D aseins. V erlag. M ox N eihaus. 4. B akon, D . (1968) D isease, P a in and Sacrifice. 5. M elzack, R . T h e Puzzle o f P ain. Penguin Books. 6. M aslow , A. H . T ow ard a Psychology o f Being. P H Y S I O T H E R A P Y THE H O L E OF T H E RADIOTHERAPIST IN TH E CONTROL OF P A IN f H . S. K IN G * M.B. Ch.B. (W itw atersrand), M .M ed. (R a d io th e ra p y ) (U.C.T.) It is a popular m isconception that all patients with malignant disease die in great pain, in fact, fe w patients do have this problem . It can be dealt with by radiation — particularly fo r bone pain, cytotoxics, and analgesic drugs. Regular use o f drugs is better than waiting fo r pain to become severe. I shall be ado p tin g a p u rely practical ap p ro ach to this subject, as you will have heard, o r be going to hear, the philosophical, psychological and spiritual approaches. I like to th in k th a t we are aw are o f these other aspects and are able to help th e p a tie n t in these other spheres, but we are m edical personnel faced w ith the practical m anagem ent of patients w ith m alignant disease, and term inal p ain and discom fort, i Firstly, I w ould like to disperse the com m on belief Jthat all patients w ith m alignant disease necessarily die in great pain. In only a fa irly sm all p ro p o rtio n o f patients is severe p ain a problem , p articu larly in the terminal stages. O th er form s o f discom fort and distress may often be present, fo r we do n o t shuffle off this mortal coil all th a t easily, b u t even these sym ptom s can be dealt w ith if handled skilfully. For patients w ho do have pain, how ever, we have three specific m odalities — rad iatio n , cytotoxics, and analgesic drugs. R A D IA T IO N This is used very often in early disease w ith curative intent, bu t in late disease it can also be a very useful modality. Bone metastases . Breast carcinom a, bronchial carcinom a and gastro­ intestinal carcinom as can all m etastasize to bone, and R adiotherapy D ep artm en t, G ro o te Schuur H o sp ital and U niversity o f Cape Town. Paper read at P ain Sym posium , preceding 13th National C ouncil M eeting 23 - 27 A pril 1979. these are the m ost com m on cancers in the W estern w orld. In ad dition, m yelom a, m elanom a, th y ro id tum ours and a v ariety of o th e r tum ours m ay m etasta­ size to bone, and I believe ra d ia tio n to be th e m ost effective m eans o f dealing w ith this type o f pain. Pressure F o r p atien ts in w hom pressure on nerves o r o th er organs m ay cause p ain , ra d ia tio n m ay be a rapid m eans o f alleviating th e latter. T h e nerves involved m ay be th e b rachial plexus, sciatic nerve, o r those in the retro p erito n eal region. These, being local problem s, are best treated w ith a local form o f therapy, even in late disease. Enlarged organs G ross enlargem ent o r distension of organs due to tu m o u r m ay cause severe pain. T his m ay be relieved by irra d ia tio n by reducing th e bulk. CYTOTOXICS 'C y to to x ics can be used in com bination w ith irra d ia ­ tion in all these instances, b u t they are seldom effective on th e ir own except in very sensitive tum ours o r w here irra d ia tio n has already been used. H ow ever, even sensitive tum ours such as lym phom as and sem inim as, m ay need to be treated w ith irra d ia tio n if they have m etastasised to bone. ANALGESIC D R U G S P atien ts who present a problem w ith pain m ay have developed a p ro b lem because th e ir doctors are fearful o f addiction. I do n o t believe th a t this is a facto r in p atien ts w ith severe p a in due to m alignant disease. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 44 F I S I O T E R A P I E JUNIE 1979 M ild pain We usually start by drugs th a t a re not h a b it form ing; these can be very effective and o ften all th a t a p atien t m ay need, even in th e term in al stages o f th e ir illness. A spirin w ith o r w ith o u t codeine, and paracetam ol w ith o r w ith o u t codeine, m ay be p articu larly useful in old patients in w hom th e effect o f asp irin on th e stom ach needs to be avoided; dextropropoxyphene, either alone o r w ith asp irin m ay also be used. Moderate pain T ilid in e h y d ro ch lo rid e (V aloron) is useful as an added drug a t n ig h t o r a ltern atin g w ith the abovem entioned during the day if th e p ain is m oderately severe. I t is also available in drops. D ip an o n e h y d rochloride (Well- conal) is a useful o ra l p rep aratio n in th e sam e context, but can occasionally m ake patients confused. Severe pain T h e opiates m ay be given by m outh, e.g. o ral O m nopon tablets o r m o rp h in e in ch loroform exlixir. In the term in al phase o f an illness, these are m ore effective w hen com bined w ith the p henothiazines, w hich also prevent v o m iting and act as tranquillizers. M any o f you will recently have h eard D r. Cicely Saunders of St. C h risto p h er’s H ospice in London. At the H ospice they have found th a t m orp h in e is the m ost useful drug and give it in a dose range o f 5 mg (for term in al sedation only) to 60 mg fo r severe pain, and even up to 120 mg. I have used oral O m nopon in doses u p to 60 mg in p atien ts being nursed at home, w ith good control o f pain. T h e regular use o f analgesics is m ost im portant. D rugs should never be prescribed p.r.n. especially for severe pain, b u t should be given regularly w hen the p atien t experiences m inim al pain. If one w aits till the p ain is m ore severe, muscle spasm and tension have added to th e problem and the p atien t requires larger doses to elim inate th e pain. I have n o t gone into th e details o f th e m anagem ent o f th e o th e r distressing sym ptom s in term inal illness, since this w as n o t req u ired o f m e, b u t obviously the skilful m anagem ent o f these sym ptom s is m ost im ­ portant. I have also n o t discussed how, in some cir­ cum stances, we seek the assistance of th e P a in Clinic, staffed by an anaesthetist and a neurosurgeon, to helpi us cope w ith some form s o f intractable pain in w hom nerve blocks m ay be useful. I hope, how ever, th at I have given you som e practical ideas on how we, as radiotherapists/oncologists, are required to ap proach the problem of pain associated w ith m alignant disease. T H E ORTHOPAEDIC SURGEON AND CHRONIC P A IN r G E O R G E D A L L * M.B. Ch.B. (U .C.T.), Ch.M . (U.C.T.) A brief ou tlin e o f the o rth o p aed ic surgeon’s ap p ro ach to the subject was given. T h e speaker em phasised the fact th a t m ost o rth o p aed ic conditions dem anded p ro ­ longed treatm ent, and after-care could b e necessary fo r the rest o f the p a tie n t’s life. T his m ean t th at o rth o p aed ic surgeons had to develop a philosophy w hich enabled them to accept the long-term n atu re o f orth o p a e d ic treatm en t and surveillance. T h e re was often no quick cure and an understanding o f th e p a tie n t’s problem s in its en tire context was essential if the correct job satisfaction was to be achieved. A b rief classification of the causes o f orth o p aed ic pain was given and a classification o f th e causes o f low back p ain follow ed. T h is included psycho­ genic pain. M acn ab ’s approach to th e question of psychogenic p ain w as considered m ost helpful. Psycho­ genic regional pain, w ith o u t any o rg an ic pathology was rare. W h at w as fa r m ore com m on was psycho­ t A bstract of talk given at the Sym posium on Pain. * P rofessor of O rth o p aed ic Surgery, U niversity o f Cape Town. genic m agnification o f pain due to em otionally based exaggeration o f pain due to pathological disorders. R eference was m ade to referred pain and John H ilto n ’s rem ark ab le concept of th is aspect w as re­ called. H ilto n attem pted to explain the fact th a t hip pain w as often felt in the knee on th e basis th at the o b tu r a to r nerve supplied a branch to the liga- m entum teres and also branches to the in n er aspect o f the knee joint, hence the production o f so-called ‘sy m p ath etic’ pain. P ain w as often protective in n a tu re and, if absent, as in n eu ro p ath ic joints, the p atien t was liable to abuse th e use o f such a jo in t leading to com plete dis­ in teg ratio n o f the joint. In this context the danger/ o f in tra -a rtic u la r steroid injections as well as ex-' cessive analgesia was stressed as this could lead to w h a t w as considered to be an analgesic arthropathy. P a in was, therefore, not always harm ful and it was q u ite o ften necessary to convince the p atien t that this type of pain was protective and th a t its acceptance w as desirable. In conclusion, the question of total care and, in particu lar, caring fo r the p atient was reiterated. PAIN SYMPOSIUM— WORKSHOP N ine w orkshop groups were set up to discuss th e im plications o f pain, problem s encountered and som e solutions in various aspects. T he groups were each led by a physiotherapist and a medical specialist and reported back to th e plenary session after an hour. T h e obstetric workshop considered pain in this in ­ stance as fu nctional and tem porary. F o r pain control in lab o u r th e follow ing w ere ad v o cated : early re p ro ­ ductive education; psychological anaesthesia including physiotherapy, psychotherapy and general education; h u sb a n d ’s involvem ent; drugs and in d u ctio n only w hen indicated, th e p atien ts having been ta u g h t to cope with these situations. T h e pharmacology w orkshop discussed analgesic drugs and th e ir p o ten tial addictive pro p erty on depression of the c en tral nervous system (CNS). T hey concluded these should be used thoughtfully and ratio n ally in treatin g severe pain. K etam ine (ketalor) received p a rti­ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )