Multidimensional approach to pain management possible, effective
Approaches to chronic pain management aim to solve a list of other challenges that patients may face apart from pain reduction, Prof Michael Nicholas from the University of Sydney discussed in the recently concluded 7th Association of South-East Asian Pain Societies (ASEAPS) Congress 2017 in Yangon, Myanmar.
Among these other objectives are reducing distress and improving mood, improving functional abilities, discontinuing the use of medication, and facilitating the return of the patients to their jobs. Such a myriad of issues, Prof Nicholas argues, is highly unlikely to be solved by a single modality.
Unfortunately, this is the logic on which traditional views to pain relief are built on. In his talk, Prof Nicholas referenced a study by Simpson in the British Journal of Anaesthesiology: “An improvement in physical, psychological, and social function and sleep may occur secondary to analgesia.”
This claim, and others of its kind, is not founded on solid evidence, Prof Nicholas contends. “What’s the evidence that if we rein the pain down a bit that function improves?” he asks.
Indeed, several studies have shown that analgesia does not necessarily result in functional improvement.
For instance, a study by Sator-Katzenschlager et al., published in Anesthesia & Analgesia, reports that despite huge improvements in pain scores, patients did not report improvements in mood and psychological well-being.
A spike in the number of similar conclusions has led pain scientists to question whether the intensity of chronic pain is the correct metric that clinicians should use. Stein wrote in a 2000 article, in the journal Current Opinion in Anesthesiology, that pain and pain behaviours were affected by factors not limited to nociception.
Prof Nicholas is of the same opinion. He advocates an alternative, multidimensional approach to pain relief. After all, pain, in reality, is complex with several contributing factors and resultant phenomena.
In the traditional approach, treatments are arranged on a ladder where those higher up are considered only after the failure of the previous options. In the alternative approach, physicians consider all possible factors that may contribute to the symptoms, then subsequently craft an appropriate treatment plan. This may mean incorporating cognitive behavioural therapies to address psychosocial factors.
To illustrate, Prof Nicholas showed the case of Rod, a 52-year-old male, and Jill, a 47-year-old female. Both have had failed back surgery with persisting pain in their lower backs and legs. Compared to Jill, Rod showed significantly poorer signs of depression, self-efficacy and catastrophising.
As a result, both received the Dorsal Column Stimulator treatment. Rod, however, received additional medication rationalization and reduction, as well as a pain management programme. While Jill responded well to the Stimulator, Rod showed no such improvements initially.
However, after receiving both additional interventions, Rod showed improvements, in magnitudes similar to Jill’s, across the board in terms of pain, distress, disability, self-efficacy and catastrophising.
While these emphasize the efficacy and viability of a multidimensional approach, enlisting the participation of healthcare practitioners, those with first-hand involvement in the actual pain management of the patients, is still a challenge.
“The healthcare providers, they also have to know what the plan is and support it because if they don’t, things will go south. That’s our major challenge, I would say,” Prof Nichols concludes.