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.

)