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Ironically as a population we are now expected to live longer and this combined with improved cancer survival rates means it is likely that more individuals will require thoracotomy surgery. Therefore we will face the challenge of dealing with a significant chronic pain issue for many years to come. As clinicians we must strive to deliver the best treatment options for our patients. We must be aware of the high probability that at least one-in-five individuals will develop post-thoracotomy pain syndrome (PTPS) so we should be aware of the physical and psychological impact it will have on those concerned. It is hoped that after this overview individuals who are not familiar with PTPS will recognise the condition sooner and appreciate that there are several treatment options.
There are many reasons why thoracic surgery may be required. Video-assisted or open procedures for lung biopsy, pneumothorax or lung resection are techniques used daily. Very often when these individuals head home from hospital they are often left in analgesic limbo, where they struggle to deal with significant surgery and frequently with inappropriate or sometimes no analgesics planning. In the weeks that follow, the focus of care is centred on the surgical outcome, pain management is seen as ‘short-lived’ consequence of the surgery.
More often than not patients are so relieved to hear the result of the surgery the fear of persistent pain seems fictitious. In fact many feel as if it is their ‘obligation’ to suffer, as they are ‘lucky to be alive’. Yet the pain continues. It may be several weeks or months later that they attend their GP and reveal the impact the chronic pain is having on their daily function.
What should we do?
While there are limited evidence-based clinical guidelines to help plan treatment, it is clear that if we can improve awareness surrounding acute pain management then individuals can have an improved outcome. There are many perioperative analgesic regimes and surgical techniques aimed at reducing the occurrence and severity of acute postoperative pain. This is very important in controlling the cascade of biochemical events associated with the development of chronic pain. It has proven very useful in the short-term and sets the bar for future developments.
GPs, thoracic surgeons and pain physicians must be familiar with the range of conservative and interventional options available from the simple trigger point injection, intercostal nerve blocks, advanced radiofrequency denervation and neuromodulation. Modern medicine means we have more specialist areas than ever before, however, the art of communication between these specialists is sometimes lost. While pain management is a relatively new discipline there are many treatment options to deal with PTPS. The problem is spreading the gospel!
Diagnosis of PTPS
PTPS is not always unambiguously derived from the clinical history or physical examination, therefore additional examination or investigation is often indicated. As with any clinical situation a complete history and examination is important to understand the nature of the symptoms and to identify any possible physical signs. Unfortunately there are few patient or surgical factors that can help identify those individuals more at risk. Table 1 highlights some common causes that the GP could consider.
Exclusion of red flags is a very important element of the diagnosis and investigations should focus around clinical suspicion.
Investigation could include:
a) In the event of a collapsed vertebra, an x-ray of the spinal column may sufficient. Along with a clinical history of a trauma, with or without a history of osteoporosis, the diagnostics can be completed.
b) MRI could be necessary to rule out malignant causes of the pain or metastases. This is particularly important if there is a history of malignancy, or in cases of acute development of severe pain or progressive pain symptoms including the development of symptoms suggestive of neurological impairment.
c) A thoracic x-ray can be useful in the event of thoracic wall pathology. If there are abnormalities, the patient should be referred to a pulmonary physician for further evaluation.
d) Additional work-up could include CT-scan or pelvic ultrasound if there is abdominal element to the symptoms.
e) Blood tests for biomarkers, liver function and full blood screen including coagulation and infective screening should always be considered.
This not an exhaustive list and each case needs to be considered individually.
Conservative treatment options
Pain aggravated by movement usually indicates a role for agents such as regular paracetamol, tramadol, codeine or non-steroidal inflammatory agents once these are not contraindicated. The dual action of tapentadol (an opioid and noradrenaline reuptake inhibitor) has been shown to be very useful in providing analgesia while offering steady analgesic in PPTS. In general the choice of the agents and the dosage required needs to be established in most cases.
If features of neuropathic pain (burning/pins and needles, etc) are present then one should consider pregabalin or gabapentin as a treatment option. These agents may take a number of weeks to control the situation and may need the dose titration
Hypersensitivity over healed scar tissue would suggest a role for lignocaine patches. Transcutaneous electrical nerve stimulation (TENS) is an option for the treatment of thoracic radicular pain. Hydrotherapy and acupuncture can be considered depending on the degree of pain intensity. Physical therapy is usually applied in the form of manual therapy and can be very helpful
Interventional pain procedures
For individuals who fail or respond poorly to oral medication pain procedures can offer the control they require to improve their functional capacity and quality-of-life. Referral to a pain consultant can often be of great value. Table 2 outlines some of the possible options that exist.
For example, intercoastal nerve injection can provide 50 per cent improvement very quickly. The option of using advanced radiofrequency denervation (RF) can be considered depending on the outcome following the injections. Good results are reported following RF treatment in thoracic radicular pain management. A significant and prolonged (>12 months) reduction in pain can be expected in 52-to-70 per cent cases. The more segments involved, the effectiveness of the treatment is smaller. Other targeted injections to the facet joint, thoracic nerve roots or infiltration to the scar site can make a significant difference for each individual. Details and outcome are outlined in the reference papers at the end of this article.
PTPS is a very challenging chronic pain condition that affects many patients on a daily basis. All healthcare providers working in this area ought to be alert to the possibility of this syndrome and must be prepared to recognise the treatment options. GPs, surgeons and pain physicians must be familiar with the range of conservative and interventional options from the simple intercostal blocks to neuromodulation. When treatment is utilised rationally, they have the most probability to alleviate pain and finally to improve the quality-of-life for patients.
Hegarty D (2017) Post Thoracotomy Pain Syndrome: What Pain Management Options do we have? J Surge Transplant Sci 5(3): 1059.
Hegarty D (2017) Post Thoracotomy Pain Management: time to spread the gospel! J Surg Transplant Sci 5(3): 1058.
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is an experience that affects, and is affected by, both the mind and the body. It involves the perception of a painful stimulus by the nervous system and the reaction of the individual patient to this.
It is increasingly recognised that pain encompasses not only physical aspects, but also a psychological component. Understanding pain fully involves understanding the psychological factors that influence the perception of pain, in addition to just the pathological mechanisms of pain conduction.
Psychological aspects that often lead to pain intensification have been found to include:
Distress surrounding change in body function
A patient’s perception of pain following a cruciate tear may be intensified by the fear that they may not be able to play sport again.
Fear of pain
Patients may anticipate or expect pain, such as when a dressing is being changed, which has previously been painful. The fear of pain may lead to the pain sensation being more severe than the local trauma should precipitate.
Feelings of helplessness and dependency
Patients with pain that is disabling may be further burdened by a sense of helplessness and dependency on others. This is often seen in pain at end-of-life, where overall distress about burdening family members can lead to pain intensification.
Mood disturbance and anxiety
Often, where patients are hormonal, or perhaps intensely hungry, their pain — irrespective of the location — may become more severe. This is thought to be a psychological phenomenon, such that when the mood disturbance or hunger is reversed, the pain will recede.
Social and spiritual aspects are also considered to impact on the experience of pain.
Experience in palliative care has taught this author that often, patients experience physical pain as a result of social changes, including a sense of loss of their role in a family, loss of their career or loss of their interpreted status in society. Spiritual aspects that contribute to physical pain may include a patient’s distress at the search for the meaning of their illness or injury.
Chronic pain may be associated with significant changes in lifestyle, functional ability and personality. Management is challenging, as it requires careful assessment, not only of the intensity and nature of pain, but also of the degree of psychological distress that is present. In essence, pain is a subjective experience and the severity of an individual’s pain is relative to their own perception and tolerance.
Accurate assessment of a patient’s perceived pain is recommended before a decision is made on the choice of analgesic to administer. The natural history of the patient’s pain should always be assessed.
Figure 1 is a useful pain assessment tool, which combines two well-known pain assessment tools — a numerical rating scale (NRS), and a visual analogue scale (VAS). The patient can demonstrate their pain in a number of ways:
1) A number between 0 and 10 can be chosen, with 0 indicating no pain, and 10 indicating the most severe pain possible.
2) A colour on the scale from green (no pain) to deep red (severe pain) can be selected.
3) One of the faces that express mild-to-severe symptoms of pain can be chosen, as patients may identify best with an expression, rather than a number or colour.
This is a universal pain scale, as it can be used for pain assessment in children, as well as in individuals with learning difficulties. Those with speech difficulties, for example due to aphasia or dysphasia, can point to the tool to describe their pain. The use of colour, as well as ‘happy’-‘sad’ faces and numbers, makes this tool visually appealing and adaptable to different patient needs.
LESS PAIN patient interview
It is important to listen to patients when discussing pain and ask careful, targeted questions. Often, patients will use familiar expressions to describe their pain, and these may not always be accurate. For example, often a patient will report that they are ‘in pain all the time’.
It is important to explore such statements further with the patient. Careful questions should be asked to establish the true level and frequency of pain — including questions about the patient’s lifestyle and mood and how their pain affects them.
The University College London School of Pharmacy has devised an effective questioning tool — ‘LESS PAIN’ — to enable fruitful conversations about pain by asking eight key questions.
The LESS PAIN tool (see Figure 2) has been developed to aid in the assessment of pain and to guide the provision of appropriate pain relieving interventions.
Mild-to-moderate pain can be managed in the community setting, using basic non-pharmacological pain management advice and over-the-counter analgesics.
Particularly where pain is thought to have a psychological component, non-pharmacological interventions play an important role in the management and resolution of pain. ‘Comfort therapy’ is a broad term which refers to the provision of soothing therapies that often aid with emotional distress or psychological factors, towards improving pain control.
Examples of comfort therapy include:
Companionship (where patients experience heightened pain due to feeling lonely or isolated).
Lotions/massage therapy (demonstrated to reduce anxiety).
Meditation (mindfulness has demonstrated analgesic benefit).
Music, art, or drama therapy.
Pastoral counselling (particularly for those with spiritual distresses).
Individual, family or group counselling.
Transcutaneous electrical nerve stimulation (TENS; thought to provide relaxation and reduce psychological distress).
The World Health Organisation (WHO) Pain Ladder (Figure 3) was originally designed for relief from cancer pain, but the step-wise approach has been used for relief of non-cancer pain as well. The pain ladder suggests using non-opioids and adjuvants initially, including paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and topical agents.
Importantly, if one ‘Step 1’ agent is not found to control pain, an alternative from this Step can be used, unless contraindicated. As a general rule, topical analgesic agents are the least likely to cause side-effects due to their limited systemic absorption. Paracetamol is also very well tolerated by the young, as well as the elderly, and is a useful choice for patients who are unable to take NSAIDs.
Use of NSAIDs is cautioned in patients with a history of cardiac disease, asthma, renal impairment or gastric ulceration. As a general rule, their utility decreases with increasing age, given that cardiac disease, renal impairment and gastric ulceration are all associated with increasing age.
Certain over-the-counter preparations also contain codeine, which is a weak opioid that may be introduced at Step 2 of the WHO Pain Ladder. The codeine content of over-the-counter products differs, with the best-known products containing codeine as follows:
Solpadeine (soluble/capsules): 8mg of codeine per tablet.
Nurofen Plus: 12.9mg of codeine per tablet.
As per the national guidelines, codeine products should only be used when necessary and only when a non-opioid analgesic, eg, paracetamol, aspirin or ibuprofen, have not proven sufficient to relieve symptoms. If recommended, codeine medicines should be used for the shortest time possible and for no longer than three days without medical supervision.