The IAHPC Manual of Palliative Care
2nd Edition
III. PAIN CON'T
Table of Contents
LOCAL ANAESTHETIC AND NERVE BLOCKS
1. Local Infiltration
- painful bone metastases
- infiltration with local anaesthetic for palpable bone metastases
- addition of corticosteroid will prolong the effect
- neuromas
- injection with local anaesthetic
- addition of a long-acting corticosteroid preparation will prolong the effect
- myofascial pain
- is characterised by local pain and tenderness in muscles, associated with pain radiating in a non-dermatomal distribution
- there are local trigger points, palpation of which produce or aggravate the symptoms
- injection of the trigger point with local anaesthetic, with or without corticosteroid, usually produces complete relief
2. Peripheral Nerve Blocks
- peripheral nerve blocks
- the only peripheral nerve block performed frequently is that of intercostal nerves for chest and abdominal wall pain
- severe limb pain, which in the past might have been treated with plexus blocks, can now be treated with measures that are more selective for sensory nerves
(epidural local anaesthetic) and pain (spinal opioids)
- autonomic nerve blocks
- a coeliac plexus block is indicated for severe pain from disease in upper abdominal viscera
- provides immediate relief of pain for about 80% of patients
- relief lasts a number of months for most
- a lumbar sympathetic plexus block is of benefit for some patients with pelvic visceral pain or sympathetic type pain in the lower limb
3. Spinal nerve blocks
- Epidural anaesthetic blocks
- injection of local anaesthetic into the epidural space will provide excellent analgesia over several spinal segments
- either by a single injection or by the temporary or permanent placement of a catheter in the epidural space at the desired level
- Neurolytic blocks
- injection of alcohol or phenol into the epidural or subarachnoid space
- motor and autonomic nerves may also be damaged, causing limb weakness or paralysis and bladder or bowel dysfunction
- neurolytic blocks have been largely replaced by epidural anaesthetic blocks and intraspinal opioid drugs, which produce the same benefits without the attendant
risks
PHYSICAL THERAPIES FOR PAIN
Surgery
- surgical internal fixation for metastases to long bones is indicated for
- pathological fracture
- medullary lesion > 50% diameter of bone
- cortical lesion > 50% cortical width eroded
- lesions causing persisting pain after radiotherapy
- pain related to visceral obstruction
- oesophageal: laser resection, endo-oesophageal tube
- intestinal: bypass surgery
- colonic: bypass surgery, defunctioning colostomy
- biliary: bypass surgery, stenting
- urinary: ureteric stenting, percutaneous nephrostomy
Heat Therapy
- relieves pain as a counter-irritant and by direct effect on the tissues treated
- the sensation of heat acts to reduce the transmission of pain signals in the dorsal horn of the spinal cord and may also induce inhibitory stimuli from the
brain stem
- the local effects of heat include muscle relaxation, increased blood flow and tissue compliance
- heat therapy is of particular benefit in the treatment of muscle spasm, myofascial pain and the general musculoskeletal discomfort associated with immobility
and debility
- heat therapy to superficial tissues is achieved with hot packs, hot water bottles, electric heating pads or radiant heat lamps
- heating of deeper tissues may be achieved with ultrasound, short wave diathermy and microwave treatment
- heat therapy can cause tissue damage and should not be used
- near metal or plastic prostheses or areas where bone cement has been used
- in areas where there is diminished sensation or paralysis or where tissues are ischaemic
- where there is infection
- directly over tumour tissue
Electrical Therapy: Transcutaneous Electrical Nerve Stimulation (TENS)
- involves electrical stimulation of nerves, using electrodes applied to the skin
- causes electrical activity in the large afferent fibres that override pain signals in the dorsal horn or the spinal cord
- electrode placement and choice of frequency and intensity of stimulation should be performed by an experienced operator
- optimal settings are different for each patient
- when operating, TENS produces paraesthesiae in the painful area
- is useful in treating mild to moderate musculoskeletal pain but is ineffective against visceral pain
- is contraindicated in patients with a cardiac pacemaker
- results in a high initial response rate, although only 15-20% of patients will obtain long-term benefit
- if successful, it will reduce the requirement for systemic analgesics and has the advantages of being cheap, easy to use and relatively free of complications
Topical counter-irritants
- act by stimulating neuronal activity that inhibits the passage of pain signals in the dorsal horn of the spinal cord
- heat and cold therapy and massage relieve pain by counter-irritation
- commercially available analgesic ointments work in the same way
- capsaicin cream causes transient burning or stinging and may act partly by counter- irritation
Acupuncture
- is used to relieve pain by mechanisms that are incompletely understood
- involves needle insertion at classical acupuncture points or in painful areas
- its role in the treatment of pain in the palliative care setting is not defined
- it is relatively cheap and safe and, if successful, will reduce the requirement for systemic analgesics
Mechanical Therapies
- massage: can relieve pain due to muscle spasm, myofascial syndromes or the general musculoskeletal discomfort associated with immobility and
debility
- exercise: passive and active exercises may improve pain control and lessen the general musculoskeletal discomfort associated with inactivity
or debility
- hydrotherapy is particularly useful for patients with pain related to weight bearing
- manipulation: physical manipulation by chiropractors, osteopaths and physiotherapists is the most commonly practised treatment for non-malignant
back pain
- patients with cancer often seek such treatment but manipulation should be performed with great care in the presence of vertebral metastases
- orthotic devices: braces and supporting devices will relieve and prevent pain by stabilising or immobilising painful tissues are of particular
benefit for pain related to movement and weight bearing
- mobility aids: walking sticks, crutches and walking frames are of value in preventing pain associated with movement and walking
- immobilisation: patients suffering severe pain despite the use of optimal analgesia and the physical supports described above may be forced
to accept the use of a wheelchair or bed rest
PSYCHOSOCIAL ASPECTS OF PAIN CONTROL |
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- psychosocial factors can play an important role in the aggravation (or amelioration) of pain
- psychosocial factors must be assessed in the evaluation of any patient with chronic pain, necessitating a multidisciplinary approach
- unrecognised or untreated psychosocial problems may lead to unrelieved pain
- pain unrelieved by apparently appropriate therapy should prompt a search for unrecognised psychosocial problems
Psychological distress
- is often described in terms of just anxiety or depression but may manifest in a number of other ways including anger and frustration, hopelessness and helplessness,
denial, grief, sadness or withdrawal
- management is primarily directed at facilitating the patient's adaptive and coping mechanisms
- if successful, may have a profound effect on both pain control and quality of life
- in palliative care, supportive counselling in a caring, considerate and unhurried manner is the mainstay of treatment
Psychological therapy for pain
- psychological approaches to the treatment of pain in palliative care include
- general psychological supportive care
- providing information
- support groups
- relaxation therapy
- meditation
- distraction therapy
- coping skills, training
- cognitive therapy
- anxiolytics, antidepressants
- brief psychotherapy
- hypnosis
- more complex techniques used for chronic non-malignant pain are of limited value in the palliative care
- operant techniques
- cognitive-behavioural therapy
Social Problems
- treatment or resolution of social problems may greatly facilitate pain control
- supportive counselling to facilitate coping is the mainstay of treatment
- practical assistance such as the provision of aids for daily living and accessing community resources and services
- assistance with financial and legal matters
Cultural Issues
- patients of differing cultural backgrounds vary greatly in their response to pain
- management of cultural issues that might cause or aggravate pain is primarily preventive
- palliative care should be conducted in a culturally appropriate and sensitive manner
- language barriers can complicate the treatment of pain and professional interpreters should be used
Spiritual and Religious Concerns
ANTICANCER THERAPY FOR PAIN
For palliative care patients with cancer, the appropriate and judicious use of anticancer therapy is sometimes the most effective means of controlling pain, even
for patients with very advanced disease
Radiotherapy
- is a most effective means of controlling pain due to local tumour infiltration
- for each individual patient, the potential benefits must be weighed against the possible adverse effects as well as the inconvenience of transporting the patient
to and from a radiotherapy facility
- the concept of "radioresistant tumours" relates to radiocurability of the cancer and not to palliative radiotherapy
- local pain due to tumour infiltration usually responds to local radiotherapy, irrespective of the histological type or tissue of origin of the tumour
- palliative radiotherapy should employ the minimum dose of radiotherapy required to achieve the desired result, given in the minimum number of treatment fractions
Chemotherapy
- can be considered for palliation of pain in patients with chemosensitive tumours and widespread disease
- chemotherapy given for the palliation of pain should be geared to produce manageable and acceptable side effects
- single agents or combination chemotherapy in reduced doses may be appropriate
REFERENCES
Books
1. Doyle D, Hanks G, Cherny N and Calman K (eds). The Oxford Textbook of Palliative Medicine. 3rd edition. Oxford University Press, 2003.
2. Woodruff R. Palliative Medicine. Evidence based symptomatic and supportive care for patients with advanced cancer. 4th edition. Oxford University
Press, 2004
3. Twycross R, Wilcock A, Charlesworth S and Dickman A. Palliative Care Formulary 2nd edition. Radcliffe Medical Press, 2002
4. McQuay H and Moore R. An evidence-based resource for pain relief. Oxford University Press, 1998
5. Dworkin R and Breitbart W (eds). Psychosocial Aspects of Pain. A Handbook for Health Care Providers. International Association for the Study
of Pain (IASP), 2004
6. Bruera E and Portenoy R (eds). Cancer Pain: Assessment and Management. Cambridge University Press, 2003
7. Yarbro CH, Frogge MH and Goodman M (eds). Cancer Symptom Management, 3rd edition.
Jones and Bartlett Publishers, 2004
Systematic and Cochrane reviews
8. Allard, P., et al. (2001). Educational interventions to improve cancer pain control: a systematic review. Journal of Palliative Medicine 4,
191-203.
9. Goudas, L., et al. (2001). Management of cancer pain. Rockville, MD: Agency for Healthcare Research and Quality. www.ahrq.gov
10. Carr, D., et al. (2002). Management of Cancer Symptoms: Pain, Depression, and Fatigue. Evidence Report/Technology Assessment No. 61. Rockville,
MD: Agency for Healthcare Research and Quality. www.ahrq.gov
11. Quigley, C. (2002). Hydromorphone for acute and chronic pain (Cochrane Review). Cochrane Database of Systematic Reviews CD003447.
12. Quigley, C. (2003). A systematic review of hydromorphone in acute and chronic pain. Journal of Pain and Symptom Management 25, 169-78.
13. McQuay, H.J., et al. (1996). A systematic review of antidepressants in neuropathic pain. Pain 68, 217-27.
14. Fishbain, D. (2000). Evidence-based data on pain relief with antidepressants. Annals of Medicine 32, 305-16.
15. Collins, S.L., et al. (2000). Antidepressants and anticonvulsants for diabetic neuropathy and postherpetic neuralgia: a quantitative systematic
review. Journal of Pain and Symptom Management 20, 449-58.
16. McQuay, H., et al. (1995). Anticonvulsant drugs for management of pain: a systematic review. British Medical Journal 311, 1047-52.
17. Wiffen, P., et al. (2000). Anticonvulsant drugs for acute and chronic pain (Cochrane Review).Cochrane Database of Systematic Reviews CD001133.
18. Kalso, E., et al. (1998). Systemic local-anaesthetic-type drugs in chronic pain: a systematic review. European Journal of Pain 2, 3-14.
19. Bell, R., Eccleston, C. and Kalso, E. (2003). Ketamine as an adjuvant to opioids for cancer pain (Cochrane Review). Cochrane Database of
Systematic Reviews CD003351.
20. Bloomfield, D.J. (1998). Should bisphosphonates be part of the standard therapy of patients with multiple myeloma or bone metastases from
other cancers? An evidence-based review. Journal of Clinical Oncology 16, 1218-25.
21. Djulbegovic, B., et al. (2002). Bisphosphonates in multiple myeloma (Cochrane Review). Cochrane Database of Systematic Reviews CD003188.
22. Wong, R. and Wiffen, P.J. (2002). Bisphosphonates for the relief of pain secondary to bone metastases (Cochrane Review). Cochrane Database
of Systematic Reviews CD002068.
23. Campbell, F.A., et al. (2001). Are cannabinoids an effective and safe treatment option in the management of pain? A qualitative systematic
review. British Medical Journal 323, 13-6.
24. Zaza, C. and Baine, N. (2002). Cancer pain and psychosocial factors. A critical review of the literature. Journal of Pain and Symptom Management
24, 526-42.
Internet Resources
Management of Cancer Pain. Agency for Healthcare Research and Quality. www.ahrq.gov
Palliative Care Formulary. www.palliativedrugs.net
Cancer Pain. National Comprehensive Cancer Network. www.nccn.org
Department of Pain Medicine and Palliative Care at Beth Israel Medical Center. www.StopPain.org
Shaare Zedek Cancer Pain and Palliative Medicine Reference Database. www.chernydatabase.org
University of Utah Hypermedia Assistant for Cancer Pain Management (includes AHCPR Cancer Pain Guidelines). www.painresearch.utah.edu/cancerpain/
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