Patient assessment of cancer pain and commentary pain case with model answer

1. Patient assessment of cancer painand commentary pain case with model answer By Prof. SALAH IBRAHIM 2012

2. Pain is experienced in 20% of patients with early diagnosis and 50% in the inetermdiate case and in about 70% to 90% in patients with advanced disease. Other common symptoms may be present (Fatigue, weakness, nausea, constipation and delirium) Cancer pain can be controlled with good function and comfort in 90% of patients with palliative anticancer modalities combined with systemic analgesics and co-analgesics. The use of different invasive procedure can help most of the remaining patients (No cancer patient needs to live or die with unrelieved pain)

3. Importance of pain relief Pain can initiate a stress response with rise of stress hormones that was proved to depress immunity and natural killer cell activity It will affect appetite and nutrition of patients with negative nitrogen balance. Also patients with unrelieved pain can not sleep well and may become fatigued

4. Cancer pain relief is important For patient’s well being and prognosis we have to break some barriers 1- Patient related barriers: Afraid from distracting doctor from treatment of the actual tumor, is a sign that the condition gets worse, not to complain excessively, fear of addiction and side effects 2- Health care and treatment barriers: By making the treatment of pain a low priority, drug restriction, failure of proper assessment, inadequate understanding of opioids, problem of addiction and restrictive government regulations

5. To carry out your plan of management, patient assessment should include: • Assessment of patient’s pain • Assessment of patientpsychological condition • Assessment of patient social state including the family Remember that the members of the family that are going to supervise the treatment plan, sometimes their incomplete understanding or their overshooting attitude can raise problems in management

6. Pain Assessment • Site of pain: both anatomical and dermatomal, use maps • Type of pain: Taken from patient own words, burning or electrical like denotes neuropathic pain while cramping and squeezing indicates nociceptive type • Started since: Gives us duration of pain • Style of pain: whether constant pr paroxysmal • Temporal aspect: e.g cluster headache may occur at the same time of the day, every day, Rh arthritis occurs early in the morning while oseaoarthritis later in the day • Exacerbating and relieving factors: Back pain from herniated disc is relieved by recumbency while that of posterior compartment is increased by recumbency • Accompanied symptoms

7. Pain measurement Type I Objective methods Type II Subjective methods, it may be single or multidimensional

8. Type I measurementsObjective methods 1- Physiological indices Endocrinal Cardiovascular Respiratory

9. 2- Neuropharmacological • Correlation with βendorphins • Thermography 3- Neurological -Nerve conduction velocity -Position emission tomography (PET)

10. 4- Behavioural By identifying behaviors that accompany the pain experience and scoring them according to frequency of occurrence and intensity In man it includes: • Facial expression • Grimace • Limited movements • Vocal signals • Standing position • Mobility and use of supportive equibments

11. But in animals it includes: • Grimace • Licking • Limbing • Rubbing of the painful area Behavioral scale of pain (BSP) This is the simplest method adopted by pain therapists in which they assign a number according to the appearance of patient in pain

12. It proved to be reliable and valid as regard the pain intensity and emotional aspects of pain Apperance of patientScore number Sighing 2 Groaning 4 Crying 6 Shouting 8 Trembling 10 Choose the appropriate score. The scores are convenient if it is related to the condition of the patient (depressed or sleepless), state of injury and type of analgesic given

13. Type II – single dimension methods (Subjective methods) Called also self reports of pain because pain is a private sensation and no one can describe pain of other people It measures only the sensory experience of pain (intensity of pain) and ignore the emotional component which accompany pain

14. The subjective methods: 1- Verbal rating scale (VRS) It includes 5 descriptive words WordScore Mild 2 Discomforting 4 Distressing 6 Horrible 8 Excruciating 10 - It includes also the facial expression pictures scale involving 8 cartoon faces ranked according to expressed displeasure

15. 2- Numerical rating scale (NRS) The patient is asked to choose a number from 0-10 3- Visual analogue scale (VAS) The patient is asked to place a mark on a drawn 10 cm line 4- Graphic rating scale (GRS) The descriptive words of pain are placed along specific intervals and each interval has its highest and lowest values

16. Type II – multidimensional method • McGill pain questionnaire (MPQ) It measures the pain in 3 dimensions • Sensory • Affective • Evaluative The patient is presented with 20 sets of words that describe the quality of pain. It contains 14 sensory sets, 5 affective sets and 1 evaluative set

17. Each word has its scale value and the position of the word in the set is called the rank value • The scale values of the words chosen by a patient are summed to obtain pain rating index (PRI) • We have PRI for sensory, affective and evaluative classes • The sum of the 3 is called the total pain rating index (total PRI) from 1-20

18. In addition, the MPQ also contains • Style of pain • Body map • Pain intensity (present pain intensity PPI) Notice difference between PPI and PRI Then what about: • Advantage if MPQ • Disadvantages of MPQ

19. B- Multidimensional methods used in NCI pain relief unit 1- Pain description: Site of pain, type of pain, started since, style of pain, accompanied symptoms 2- Verbal rating scale No pain 0 Mild 1 Moderate 2 Severe 3 Excruciating 4 Intolerable 5

20. 3- Assessment of sleep Normal rhythm 0 Interrupted 1 Insufficient 2 Disturbed 3 Hard with hypnotics 4 No sleep 5 4- Assessment of activity In work 0 Sick leave 1 Home activity 2 Limited 3 Isolated 4 Bed ridden 5

21. 5- Psychological assessment Balanced 0 Worried 1 Anxious 2 Depressed 3 Hypochondriatic 4 Break down 5 The global score will include the previous 5 broad assessments

22. Measurement of pain in children Contains:- Self report ……….. What children say? Biological report ……….. How their bodies react? Behavioral report ………… What children do?

23. Measurement of children are discussed under 3 items :- 1- infants and preverbal 0-3 years 2- Children between 3-7 years 3- Children over 7 years

24. I – Infants and preverbal children 1- Biological methods • Blood pressure changes • Stress hormones • Metabolites (as glucose) • O2 saturation • Palmer sweating

25. 2- Behavioral methods: - CHEOPS (Children Hospital Eastern Ontario Scale) Contains 6 behaviors : 1- Crying 2-Facial expression 3- Verbal expression 4- Torso position of the trunk 5- Touch position of painful area 6- Leg position - Neonatal facial coding system (NFC)

26. 3- Combination of biological and behavioral scales. Objective pain score (OPS) Also called (Hannallah pain score) It’s a six items scale Zero score is found when : There is no BP change, no crying, no movement, patient is calm, no special posture and the presence of the state of no pain

27. Observation Criteria Points OPS scale contains 6 items

28. Observation Criteria Points

29. II- Children between 3-7 years 1- Face scale 2- Scale that uses graded color intensity sets 3- Hester’s poker chips counting 4- Counting fingers 5- Oucher scale : a combination of face scales plus vertical numerical rating scale (0-100)

30. III – Children over 7 years By using self report measures of pain 1- Visual analogue scale with red and green terminals 2- Numerical rating scale – pain thermometer 3- Simplified form of MPQ for children using different words familiar to the child

31. Discordance in Pain measurement in children 1- Child who reports high pain intensity and observed to be unaffected or playing (try to move a ball in front) 2- Child who exhibits a very low pain score where one may expect severe pain score e.g. postoperative pain 3- Child who may deny pain in front of strangers (Supposed to be brave or anticipates needle after reporting pain)

32. General Assessment - Patient’s general health : • Circulatory parameters • Kidney and liver function - Current drug therapy Look for enzyme inducers and enzyme inhibitors - Laboratory requirements Anaemia: correct severe forms with Hb below 70% Albumin: below 3 mg/dl is not favorable Coagulation profiles: Patients with prothrombin time of 16 seconds (control 12) and 60% or less concentration should be excluded from intervention -Correct dehydration

33. Breakthrough pain Acute episode of pain in a controlled patient with adequate analgesic cover Causes • Vertebral collapse of fracture • Acute obstruction of a hollow viscus • Raised intracranial tension, headache • Hemorrhage in a tumor • Arthralgia associated with sepsis • Other causes, exposure to cold, psychological state, sudden movement, lifting of heavy objects

34. Psychological and social assessment The purpose of psychological assessment is to frame the pain experience in the context of the patient’s life The response of the patient is highly dependent on his attitude to the situation (Coping). A very common situation is to give the patient a false report about the condition and this put on the treating physician a stress of false explanation

35. Purpose of psychological assessment of patient in pain It’s needed when : 1- The patient’s pain symptoms are greater than would be expected from physical examination 2- Patient demonstrate excessive use of the health care system (doctor shopping) 3- tendency toward drug abuse or dependence 4-When the patient’s pain and related symptoms are functional more than organic

36. Pure psychological pain or psychological disease is very rare, but the mild psychological imapct of chronic pain should be termed as “ Abnormal illness behaviors” It is the group of cognitive, affective and behavioral disturbances associated with chronic pain

37. Abnormal illness behavior It includes : • Reliance on non medical health care • Secondary gain behavior • Frequent persistent complaints • Behavioral symptoms as withdrawal and isolation • Depression is a common component of chronic pain syndrome • Patient has a poor response to treatment • Loss of faith in treatment recommendations • Poor compliance Note: it’s not accepted in cancer patient to make a diagnosis of malingering

38. MMPI (Minnesota multiphasic personality inventory) • The MMPI -2 is used in patients with chronic cancer pain • It contains 567 true and false questions tabulated in 10 scales • Types of scales: hypochondriasis, hysteria, depression, hypomania, psychopathic deviation, job dissatisfaction etc • Elevation of scale 1,2 and 3 means that the pain does not have organic basis (abnormal illness behavior) • Elevation of scale 1 and 3 with low scale 2 means that somatic distress is more with low level of emotional concern

39. Elevation of most of the scales means that the patient will be resistant to treatment • Patients with chronic cancer pain will have a high scale elevation in various scales than other chronic pain conditions • Patients engaged in idealism will have a good response to management • Elevation of job dissatisfaction scale means that return of patient to his work is difficult • Confusion of the patient may be due to sensory disturbance or drugs

40. Concerns affecting treatment • Belief that pain is inevitable with cancer • Belief that increased pain means cancer become worse • Fear of serious opioid side effects, respiratory depression • Fear of addiction to pain medications • Belief that patients are overmedicated • Fear of opioid tolerance and tendency to give the lowest doses in order to save large doses in the future • Tendency to give medication only on as needed basis rather than on routine schedule • Belief that opioid are used only in severe pain • Belief that interventions are ineffective in cancer pain • Fear that pain will be worse in the future

41. Comment on the following pain case Male patient aged 55 ys, transferred to pain clinic with diagnosis of carcinoma of the upper lobe of Rt lung. Right thoracotomy approach on Rt 6th rib was performed since 7 months in an attempt of surgical removal and ended by biopsy. Radiotherapy was then performed. He started to complain of severe aching pain in the Rt thoracic wall with paroxysms of burning pain especially by night. On examination, there was sensory hypothesia and allodynia in the distribution of the Rt 6th thoracic nerve . Laboratory finding pointing to hyponatrimia with dehydration • What are the possible causes of pain? What are radiological investigations needed? • What primary drug therapy would you like to start with? • What would be your interventional plan? • If investigations proved that patient has a mass in upper posterior mediastinum • If there are intraspinal extension • If investigation pointing to thoracic vertebral metastasis with partial collapse

42. Model Answer: Findings in the case:- • Aged patient with bronchogenic carcinoma of the Rt upper lobe • Rt thoracotomy incision • Severe aching chest pain plus paroxysmal burning pain by night • Sensory loss and allodynia along 6th thoracic nerve • Metastasis in the thoracic vertebrae • Presence of hypnatrimia and dehydration

43. Cause of pain: 1- Post thoracotomy pain, may be fibrosis, infection or recurrence either due to injury of the 6th thoracic nerve or neuroma formation at the side of the thoracotomy wound 2- Burning and paroxysmal pain denotes 6th nerve neuropathy caused by the thoracotomy maneuver, inercostal neuropathy (rib deposit), or deposit in the 4th thoracic vertebra (radicular rest pain) 3- Post radiation plexopathy, condition starts by heaviness of the arm, followed by weakness and then pain. (note, brachial plexopathy of the tumor infilteration in which pain occur first and then weakness) 4- Costopleural syndrome that affects the lateral cheat wall and pleura i.e nociceptive pain 5- intraspinal extension

44. Investigations needed 1-Renal functions (presence of hyponatrimia and dehydration) 2- PT and PC for interventional treatment 3- Albumin level (for spinal implant) 4- serum Ca+2 (for vertebral metastasis) 5- Hb (for correction of anemia if present)

45. The primary drug therapy This is a case of severe agonizing cancer pain, so I should start with giving WHO ladder step II which contains non opioid + strong opioid + adjuvant Give patient 400 mg Ibuprofen 3 times daily + TTs fentanyl patch (better than morphine for fear of bad renal functions). You can give tramal 50mg 3 times daily Give antidepressant 25 mg tryptizole by night You can give drugs of bone pain, neuropathic pain and corticosteroids

46. If there is a mass in the upper posterior thoracic cavity with mediastinal lymph node do either stellate block or epidural block (for thoracic sympathetic innervation) or do thoracic sympathetic chain ablation at T2 , T3 level by radiofrequency (RF) • If there is intraspinal extension give dexamethasone 100 mg then 20 mg for 2 days then tablets • If there vertebral metastasis with partial collapse do either vertebroplasty or kyphoplasty • You can do dorsal rhizotomy at level of 4th thoracic vertebra because the root pain is present along the 6th thoracic nerve (2 above) • You can perform spinal implant (albumin 4gm/dl or more) • In case of neuroma: is treated by injection, freezing or excision

47. Thank You