One of the rooms in the Children’s Pain Unit at La Paz University Hospital in Madrid. :: ALBERTO FERRERAS
A third of patients will suffer pain for the rest of their lives. Experts now use multidisciplinary treatments to combat it and encourage people not to suffer in silence
To eliminate the taboos that exist around the subject of pain, the silence that many patients maintain because they don’t want people to think they are cowardly and the resignation of those who think it is logical to suffer pain when one is ill. These are the tasks faced by experts who want to demonstrate that pain can be avoided, or at least greatly reduced, in this day and age when there are plenty of pharmaceutical products and techniques which are capable of doing so. What is needed, they say, is a change in the way people think, for the benefit of patients who suffer pain.
“Pain takes away a person’s dignity, it reduces their quality of life and it means that patients don’t feel that that their condition is improving. That is why it is important to treat it as another constant”, explains oncologist Ana Mañas, who is the president of the clinical committee which runs the award-winning ‘Hospital sin Dolor’ (Hospital without Pain) programme at La Paz University Hospital in Madrid. This hospital measures and treats pain in all of its patients, whether that pain is acute, chronic or has been caused by medical procedures. “When someone is admitted to hospital their temperature, blood pressure, breathing and pulse are monitored every day and we do exactly the same with pain. It is measured and evaluated so it can be treated. Pain is the fifth constant,” says Dr. Mañas.
Different scales are used for the measurement. The simplest are one-dimensional, such as analogical visual or verbal numbers, in which a number - generally from 0 to 10- is used to describe the intensity of pain which is felt at that moment. There are also multidimensional scales which do not only measure the intensity of the pain but also evaluate the repercussions of it, whether these are psychological, personal, or in terms of work. “These scales are very useful for analysing how pain evolves over time and to check the efficiency, or lack of efficiency, of the treatments which are being applied”, says Dr. José María Muñoz, the head of the Pain Unit at La Paz hospital.
To measure pain in children who are too young to talk, this hospital has created the first evaluation scale in Spanish. It is called ‘Llanto’ (which translates as Crying) and is a simple table from which the medical professionals can tell the intensity of the pain which is being suffered by their youngest patients. “To do this, we studied a series of changes in the physiological and vegetative behaviour which are repeated in children who are suffering from a determinate pain. From these changes we can measure the intensity from 0 to 10”, explains Dr. Francisco Reinoso, coordinator of the Childrens Pain Unit at the hospital in Madrid. This system of measurement changes when the pain is chronic, because in those cases the effects on the patient’s quality of life are evaluated, given that when there is pain for more than three months it causes sensitivity in the nervous system. This is something like the pain in a ‘phantom limb’, when somebody says they can feel pain in an arm or leg which has been amputated. “This happens a great deal in traumatic amputations. It is as if the nervous system becomes blocked in that final scenario, so if the limb was hurting at that moment the pain can continue for up to a year afterwards” explains Dr. Reinoso.
Dr. Fernando Martínez Pintor, who is the director of the University Institute of Rheumatology at the Policlínica Barcelona, says that when doctors talk about chronic pain, “we are referring to pain that has existed for at least six months. Often, patients think that when we talk about chronic pain we mean pain that will last all their lives, in other words as a concept of the future, but it is exactly the opposite. It is a pain that has been suffered for at least half a year, independently of the fact that the patient improves, and the pain can be removed in a short period of time”.
More than eight million people in Spain are affected by this type of pain, according to figures from the Spanish Pain Society, and in 35 per cent of cases it is skeletal muscular, most frequently back pain. Among children, one in every three has suffered chronic pain, in this case a pain that lasts for more than three months. About 35 per cent is of primary origin - with no apparent cause - and in five per cent of cases it is intense. The most common examples are headaches, stomach aches, and pain in the extremities.
Dr. Muñoz of La Paz Hospital, says that whenever possible, with chronic pain and also acute pain, it is important to treat what is causing it, whether it is a degenerative osteoarticular problem, a neurological process or an oncological illness. However, in many patients the pain can be considered an illness in itself and it should be treated specifically. “To do that, we normally carry out the treatment in stages, beginning with the administration of straightforward analgesics and continuing with more powerful or invasive procedures so that, depending on the response to these measures, we can adapt the treatment to each specific patient on an individual basis,” he explains.
“If we try to cure a patient with just one type of medication, we are doomed to failure. At a recent meeting in San Diego to examine fibromyalgia in great detail - two per cent of the population is affected by it - they came to the conclusion that at the moment medication is only effective in 25 per cent of cases. Because of this, we have to carry out multidisciplinary treatments, which can range from precautionary measures and special diets to exercises, and a programme to help patients readapt to making effort. This may include relaxation techniques, acupuncture, improving sleep quality, psychotherapy to cope with the pain and such debilitating fatigue. It may be cognitive behavioural therapy or hypnotherapy may be used”, adds Dr. Martínez Pintor.
State of mind
Pain that continues over time has a considerable effect on a patient’s state of mind, quality of life and personal relationships and for this reason experts agree that it is “fundamental” to look after the patient’s psychological wellbeing. “In 55 per cent of cases this pain will have a negative effect on the patient’s state of mind, although we have to say that neither depression nor anxiety are the first symptom suffered by patients with chronic pain; they tend to appear when he or she has spent years battling pain. We would say that they are comorbidities in a patient with chronic pain”, says this expert from Policlínica Barcelona.
“When someone is suffering from pain it can lead to a series of negative thought patterns of a catastrophic nature and these, with or without cause, perpetuate the sensation of pain. That is the reason the cognitive and behavioural treatments are so important”, stresses Dr. Reinoso.
In the case of children, pain with an intensity of 10 can be reduced to 7 when the youngster is visited by a friend or sees a film that he or she likes, for example. Complementary techniques such as the use of games, music therapy, physical activity such as Reiki or art therapy are also used to improve the state of mind through altering the pain threshold.
It is also important to pay attention to the feelings which are generated by the pain, as these are much less visible in chronic patients. “In this case the patient is more vulnerable to depression and passivity. With children, they might ignore their toys or even their mother and father”, explains the expert from the Childrens’ Pain Unit at La Paz Hospital.
With the use of these techniques, the success rate of the Pain Units (to which patients are referred by their GPs) is very high. “We can confirm that most patients experience some pain relief, although we cannot say that it can be eliminated altogether in all cases. The treatment of acute pain tends to be successful in most patients and a quick and almost complete control is usually achieved. However, with patients suffering chronic pain we have to set realistic goals, and we can nearly always succeed in improving the situation although the problem is not completely eliminated. In those cases, it is important that the different specialists, nurses, psychologists etc. work together and use different measures to improve the situation and the quality of life for the patient. Once the situation is stabilised, patients can often be released from hospital and monitored by their GP, who can refer them to the Pain Unit again if this should become necessary”, emphasizes Dr. Muñoz of La Paz University Hospital.