*Anna M. Lotowska-Cwiklewska1, Piotr Jakubow2, Urszula Kosciuczuk1, 2
Behavioral aspect of pain in laryngological (ENT) patients
Behawioralne aspekty bólu u pacjentów laryngologicznych
1Department of Anaesthesiology and Intensive Care, Medical University of Bialystok, Poland
2Pain Treatment Clinic “Vitamed”, Bialystok, Poland
Streszczenie
Zagadnienia związane z leczeniem bólu coraz częściej stanowią przedmiot zainteresowania lekarzy wszystkich specjalności. W prawidłowym postępowaniu z pacjentem z bólem niezwykle istotna jest współpraca nie tylko w obrębie całego zespołu terapeutycznego, ale również bezpośrednio z chorym, a także znajomość patomechanizmów powstawania poszczególnych typów bólu, oceny ich natężenia, jak również stosowania leczenia multimodalnego.
Ból ostry stanowi szczególnie istotne zagadnienie, które powinno być dokładnie zgłębiane nie tylko przez specjalistów leczenia bólu, ale także lekarzy specjalności zabiegowych. Prawidłowe postępowanie przeciwbólowe umożliwia nie tylko szybkie opanowanie bólu, ale też zapobiega jego chronifikacji.
Pacjenci laryngologiczni stanowią wyjątkową grupę chorych. W ich przypadku istotne jest nie tylko skuteczne uśmierzenie bólu, ale również zapobieganie ewentualnym działaniom niepożądanym leków przeciwbólowych, które mogłyby wpłynąć negatywnie na oddychanie. Osiągnięcie takiego efektu wymaga posiadania niezbędnej wiedzy na temat patomechanizmów powstawania bólu oraz farmakoterapii.
Summary
Issues related to the treatment of pain are increasingly the subject of interest to doctors of all specialties. In proper management of the patient with pain, it is extremely important to cooperate not only within the entire therapeutic team, but also directly with the patient. Knowledge of the pathomechanisms of the formation of particular types of pain, their intensity assessment, as well as the use of multimodal treatment is vital.
Acute pain is a particularly important issue that should be thoroughly investigated not only by pain specialists, but also by surgical specialty doctors. The correct analgesia allows not only to quickly control the pain, but also prevents its persistence.
Laryngological patients are a unique group of patients. In their case, it is important not only to effectively relieve pain, but also to prevent possible side effects of analgesics that could adversely affect breathing. Achieving this effect requires having the necessary knowledge about the pathomechanisms of pain formation and pharmacotherapy.
INTRODUCTION
Pain is the most common sign found in medicine forcing patients to seek medical help. It triggers a cascade of defence and adaptive reactions in the central and peripheral nervous system as well as in the endocrine system which in the net result will lead to repair and recovery of the damaged tissue. According to the definition presented by The International Association for the Study of Pain, pain is a subjective, unpleasant sensory and emotional experience arising because of the stimulus damaging the tissue or threatening to damage it. It’s a serious health problem all over the world – provided that acute pain is usually a symptom of an illness or tissue damage, chronic pain can be a separate disease entity on its own.
The process responsible for feeling pain is nociception which consists of 4 consecutive stages: transduction (transforming chemical, mechanical, thermal stimulus into electrical impulse), transmission (transmitting pain stimulus), modulation (stimulating, inhibiting or summating of stimuli occurring in spinal cord) and finally perception of pain experience in the central nervous system. Serotoninergic and noradrenergic descending pathways which inhibit influx of impulses to spinothalamic tract (1, 2) have crucial meaning in the mechanism of the formation of pain.
Acute and chronic pain issues should be examined separately because of the different causes, mechanism of the formation and ways of treatment of these kinds of pain. The knowledge of these issues is crucial to successful treatment of pain. In the present dissertation we will discuss issues concerning acute pain that might happen to laryngological patients.
General rules of treating pain are described in WHO’s pain ladder (fig. 1). It is necessary to pay special attention to the use of co-analgesics for example antiepileptic drugs, antidepressants, local anaesthetics and glucocorticosteroids in the case of neuropathic pain. Furthermore, it is recommended to use small doses of strong opioids rather than maximum doses of drugs from the second step of an analgesic ladder (3, 4).
Fig. 1. WHO analogesic ladder
Acute pain is often a nociceptive pain. It lasts no longer than 3 months. It’s relatively easy to treat and by providing an effective therapy it subsides after a few or several days. Acute pain might develop either as a consequence of irritation of nociceptors (physiological pain) or because of the change in their properties (inflammatory and neuropathic pain). Physiological pain, when speaking about laryngological patients, is a pain associated with injuries and postoperative pain. Inflammatory pain is adaptive – it is formed due to tissue damage and subsequent inflammation (for example acute otitis media) but eventually it is supposed to lead to repair and regeneration.
Neuropathic pain is caused by direct damage of the somatosensory system structures, it is characterized by significant intensity, it is resistant to “normal” analgesic and is not adaptive (for example glossopharyngeal neuropathy). It is formed in the case of insufficient or improper treatment of acute pain.
REVIEW
Evaluation of pain intensity
Pain is a subjective symptom. It means that the same pain stimulus can trigger a pain of varied intensity depending on different people. We use the scale of pain evaluation to assess pain intensity (5, 6).
The most used in clinical practice and at the same time easy to use at the doctor’s is NRS (Numerical Rating Scale). It’s really sensitive and is characterised by strong repeatability of the results, that is why it is suitable for evaluation of acute pain as well as chronic pain, also as a way of monitoring effects of the treatment. It is used for the patients over 9 years old. The patient determines the intensity of felt pain using eleven – degree scale with 0 meaning no pain and 10 – the strongest imaginable pain. Analgesic treatment is adjusted accordingly to that number.
Another easy to use and often chosen is VAS (Visual Analogue Scale). To evaluate pain while using this scale a 10 cm ruler is needed, on which a patient points the intensity of the felt pain using the same rules as with NRS. Modified VAS assumes that the ruler used in the evaluation, has faces drawn on the far points of the scale – a happy face drawn next to the lack of pain end of the scale and a distorted face next to the point of the scale meaning the strongest felt pain. Unfortunately, this kind of scale is unintelligible and overly complicated for 10-25% of the patients.
The scale that enables descriptive evaluation of pain is VRS (Verbal Rating Scale) and the most commonly used one is a five-level Likert scale. The patient picks with its help the description of the pain intensity with the assigned number (1-5) that matches the symptoms felt by the mentioned patient. This type of scale is quite hard to use by the patients because of the ambiguity of pain intensity terms and because patients avoid inputting extreme values of the scale.
In children’s case it is necessary to use scales adapted to the age of the patient. Children over 3 years old can be successfully evaluated by using picture scales for example FPS (Faces Pain Scale for example Wong-Baker scale, Oucher scale) and FSM (Finger Span Measure), in which a child evaluates the intensity of pain by a distance between the index finger and the thumb – linked fingers mean lack of pain, parted fingers – the strongest imaginable pain for the child (7). If the patient is a child less than 3 years old, the most successful scales are behavioural ones (based on the evaluation of the facial expression, lower limbs arrangement, crying, possibility of consolation and general activity) and MIPS/NIPS (Modified Infant Pain Scale/Neonatal Infant Pain Scale).
Neuropathic pain, which is a particular kind of pain not only because of the different type of treatment, but also because of the distinctive mechanism of formation and accompanying symptoms, is evaluated with the use of separate scales and forms. The most common being DN4 (Douleur Neuropathique en 4 Questions), NPQ (Neuropathic Pain Questionnaire) and PainDetect Questionnaire Self-assessment Questionnaire (8). In the neuropathic pain evaluation, except for the intensity evaluation scales, equally relevant to a correct diagnosis is a physical examination verifying the extent of pain as well as negative symptoms (hypoesthesia, hypoalgesia) and positive symptoms (paresthesia).
Inflammatory pain
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