William Robert Lyngdoh on care of the patient with pain and palliative care
THE MANAGEMENT of pain, like management of disease, is as old as mankind. In ancient days, persons who experienced pain were interpreted to have received punishment in the form of suffering either dispensed by the gods or offered to them to appease the gods. However, most diseases e.g. infections, metabolic disorders such as diabetes, hypertension, cancer, afflict mankind spontaneously cause tremendous amount of pain and suffering without any wrong doing on the part of the afflicted person.
According to the International Association for the Study of Pain (IASP), pain is defined as “an unpleasant emotional and sensory experience associated with actual or potential tissue damage or described in terms of such damage”. It implies that even in the absence of actual tissue damage, if the patients regard their experience as pain then it should be accepted as pain.
In World War II it was noticed that the amputated patients complained of pain in the part of the limb which was not there, even after complete healing had occurred. This came to be known as phantom limb pain and these patients were thought to be mentally unstable and were referred for psychiatric evaluation. However, now it is a scientifically explained pathophysiological phenomenon which shows that these patients indeed experienced pain in the part of limb that had already been amputated. So, pain can occur in the absence of tissue damage, where central nervous system sensitization is a constant feature.
When pain continues long after the natural pathogenic course of disease has ended, or when pain lasts more than three months, a chronic pain syndrome develops. In such cases like in phantom limb phenomena, central nervous system sensitization occurs. Here, the problem lies in the nerves and not anymore in the damaged tissue. Chronic pain may be due to several causes like, low back pain, cancer pain, post surgical pain, joint pain, knee pain, muscle pain, phantom limb pain, chronic headache, trigeminal neuralgia, etc.
Low back pain, a common chronic pain syndrome, can be due to mostly facet joint pathology or disc pathology. It can be dealt with conservatively as well as by applying nerve blocks and ozone nucleolysis. Cancer pain too can be dealt with conservatively but mostly by doing interventional procedures. This usually falls under palliative care. Similarly, other types of chronic pain such as post surgical pain, joint pain, knee pain, muscle pain, chronic headache can be treated satisfactorily by applying both conservative methods and minimal interventional techniques.
These treatment methods are safe effective and based on evidence based medicine. Moreover, they provide a great deal of relief to the chronic pain patient who often suffers from depression, dependency, disability, drug abuse and also doctor shopping. Throughout the ages, physicians and healers have focused their attention on managing pain. It is however only within the past 10- 20 years that significant stride has been made to deal with chronic pain as a disease entity.
John Bonica, an army surgeon in World War II (1939-46) is considered the Father of Pain Medicine. As a result of his work several national and international organizations were formed to lead in pain research and pain management. Accordingly, International Association for the Study of Pain (IASP, 1973), American Pain Society (1977), American Academy of Hospice and Palliative Management (1988) and World Institute of Pain (WIP) were formed.
In our country we have Indian Society for Study of Pain (Indian chapter of IASP), and various WIP-endorsed courses that promote safe and best practice of pain medicine. Keeping in mind the needs of a patient in pain, Bethany Hospital Shillong has already started a pain clinic and will soon open a full-fledged one. Today, with the use of newer drugs, innovative techniques and creative procedures the chronic pain patient can see a new dawn and live a healthier and productive lifestyle.
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