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. ) JUNE 1979 P H Y S I O T H E R A P Y 45 cular a tten tio n as it does n o t depress th e CNS, b u t can produce hallucinations. T hey noted w ith interest th a t medical students receive an intensive education in pharm acology b u t know very little ab o u t physiotherapy in the m anagem ent o f pain. T h e orthopaedic workshop noted th a t 9 0 % o t o u t­ patients present w ith pain due to trau m a and sequelae or acquired conditions such as back and neck P&in which are largely undiagnosed. T h e problem s in these cases are th a t the patho-physiology is usually unknow n and it is difficult to assess pain scientifically. Some solutions th a t were proposed are to assess th e p atien t s disability, i.e. how p ain affects his life; the use o f a team ap proach w ith one person in charge of to tal care; to spend tim e on questioning, listening to and exam ining the p atien t; and th a t it is essential to overcom e in ter­ disciplinary com m unication problem s. T h e paediatric workshop concluded th a t the re ­ cognition of pain w ould depend on the age o r level of developm ent o f th e child. I t is essential to recognise pain early and explain it to th e child, a t th e sam e tim e Establishing ra p p o rt and tru st w ith th e child and parents. Tfhe cause o f acute pain should be rem oved if possible, lest it becom es chronic. C hronic pain is influenced by sensory stim ulation, environm ent and activity, and is best handled by a m ultidisciplinary approach. T he psychological overtones to organic pain and the function of pain w ere discussed. T h e group also touched on the relief of pain by m eans of physiotherapy, drugs and surgery. T h e respiratory workshop concentrated on practical m anagem ent of pain in various respiratory conditions. In injury th e value of ventilation, epidural block, in tra ­ venous m orphine, entonox, reassurance and physical support was discussed. T h e ro le of analgesics, a n ti­ inflam m atory agents, m uscle relaxants and reassurance in m anaging obstructive lung disease was stressed. In pleurisy anti-inflam m atory agents and reassurance were thought to be essential. Pain a fte r chest surgery could be controlled by C ontinuous Positive A irways Pressure, intravenous m orphine, reassurance and physical support, w hilst pain in m alig n an t disease responded best to m orphine. In all instances p h ysiotherapeutic m anage­ m ent was th o u g h t to be beneficial in handling pain. T h e neurological workshop approached th e problem from three points o f view. T he physiotherapists felt th a t chronic pain was a problem area as they could not deal adequately w ith it. T rain in g in counselling tech­ niques was necessary to develop an ap proach w here the p a tie n t w as actively involved in his m anagem ent by accepting responsibility fo r him self and his need o f his pain. T h e surgeon felt th a t acute pain should be treated enthusiastically, th a t negative aspects should n o t be highlighted in fro n t of the patient and th a t chronic pain is better m anaged by teaching coping m echanism s such as postural control. T h e p atient should be m otivated to accept personal responsibility. A psychologist felt th a t the p atien t should be accepted as a w hole person, his self esteem being respected w ithout becom ing his psychological crutch. T h e rheumatology workshop felt th a t physical m easures used to tre a t pain (such as heat and ice) should be more scientifically evaluated. M obilisation techniques w ere discused. C are should be tak en not to produce a placebo effect w hen evaluating drugs, physi­ cal m easures or o th er treatm en t m odalities. T he co n ­ clusion was th a t personal contact an d caring, such as in counselling w ere of prim e im portance. T h e anaesthesia workshop concentrated on a dis- cusion of th e pain pathw ays, th e g ate control theory of pain and m echanism s w hereby physiotherapy m odalities such as transcutaneous electrical nerve stim ulation (T E N S) is thought to be effective. T he ro le of th e b ody’s n a tu ra l opiates, th e endorphins, in blocking certain synapses was th o u g h t to be im portant. T h e final conclusion was th a t it is im p o rtan t to involve th e p atien t in th e treatm en t of his own pain. T h e neurology workshop concluded t h r t it is essential to tak e an adequate history, being careful how language is used and how th e p atien t interprets it. C om m unication about sym ptom s and treatm en t has to be full. T he p atien t has to be approached as a person w ith special reference to cultural and environm ental aspects. A gain the m ultidisciplinary approach, ensuring physi­ cal contact and rap p o rt with the p atient was stressed. Physical tre a tm e n t and T L C were thought to be im p o rt­ ant A tten tio n was draw n to the fa c t th a t pain mem ory is usually lost, but th a t th ere is easy recall of past pain. . CHRONIC PAIN Y. K . BOSM AN* M.B. In recent years there has been renew ed interest in the pathophysiology of chronic pain and m ethods of treating it. T he problem has been spotlighted by the staggering figures of lost m an-hours to th e A m erican econom y and th e colossal paym ents fo r tem p o rary and perm anent pain disability claims. C hronic pain has even been described as the m ost com m on disabling disease in the U.S.A. T his in spite of m odern science and the fact th a t pain has plagued M an since his beginning. W e are not able to m easure pain in any units since the pain experience is a subjective phenom enon, and fo r this reason assessm ent o f treatm en t is also subjective. T his and perhaps o th er reasons, are responsible fo r certain pain paradoxes; fo r exam ple som e pain studies show th a t narcotics are not analgesic in 10% o f post- * A naesthetist, T ygerberg H ospital. B.Ch. (Wits.), F.F .A . (S.A.) operative patients, and th a t placebos provide relief in 20% (A non, 1973). I t is u n d erstan d ab le th a t our tre a t­ m ent of pain is often inadequate w ith our poor u n d er­ standing o f pain physiology, fo r the latest research does not take us beyond the b arrier of the theory and we still aw ait p ro o f of w h at happens to the pain im pulse afte r it enters the central nervous system in M an. W h at are the theories of p ain ? T he textbooks still m ention th e specificity and p a tte rn theories. T he Speci­ ficity T h eo ry , put fo rw ard in the m iddle of the last century, stated th a t free nerve endings were pain recep­ tors, and stim ulation generated pain impulses w hich were carried by peripheral nerves via th e spinothalam ic tract to a pain centre in the thalam us. T h e P a tte rn T heory, p u t fo rw ard at ab o u t the tu rn o f th e century, stated th a t stim ulus intensity and central sum m ation w ere the critical determ inants in pain a p p re ­ ciation i.e. a certain spatio-tem poral p attern was neces­ sary. 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. )