Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Holistic Management Of Cancer Pain


Published on

Talk given at Topeka Cancer Pain Conference April 8th 2010

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Holistic Management Of Cancer Pain

  1. 1. Holistic Managementof Cancer Pain:Beyond Opioids<br />Christian Sinclair, MD, FAAHPM<br />Kansas City Hospice & Palliative Care<br />April 8th, 2010<br />
  2. 2. Objectives<br />Clarify the broad umbrella of holistic health<br />Discuss the major elements of a holistic assessment of cancer pain<br />Apply proven holistic therapies for cancer pain<br />
  3. 3. The Impact of Pain<br />Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage<br />
  4. 4. Endocrine<br />Increased<br />ACTH<br />Cortisol<br />ADH<br />Epinephrine<br />Norepinephrine<br />GH<br />Catecholamines<br />Renin<br />Angiotensisin II<br />Aldosterone<br />Glucagon<br />IL-1<br />Decreased<br />Insulin<br />Testoterone<br />
  5. 5. Metabolic<br />Gluconeogenesis<br />Hyperglycemia<br />Glucose intolerance<br />Insulin resistance<br />Muscle protein catabolism<br />Increased lipolyis<br />
  6. 6. Cardiovascular<br />Increased <br />HR<br />Cardiac output<br />Myocardial oxygen consumption<br />Hypertension<br />Hypercoagulation<br />DVT<br />
  7. 7. Pulmonary<br />Decreased<br /> Airflow<br />Volumes<br />Atalectasis<br />Shunting<br />Hypoxemia<br />Cough<br />Sputum retention<br />Infection<br />
  8. 8. GU/GI<br />Decreased<br />Urinary output<br />Retention,<br />Hypokalemia<br />
  9. 9. MSK<br />Fatigue<br />Immobility<br />Muscle spasm<br />
  10. 10. Developmental/Psych<br />Reduced cognitive function<br />Altered mood<br />Increased anxiety<br />Depression<br />Addictive behaviors<br />Future pain disorders<br />Insomnia<br />Suicidal ideation<br />Fear<br />Hopelessness<br />
  11. 11. Holistic?<br />Taking into account all the needs of a patient<br />Physical<br />Social<br />Psychological<br />Spiritual<br />Essential element of palliative medicine<br />
  12. 12. Holistic Can Also Mean<br />‘New Age’<br />Complimentary and Alternative Medicine<br />Herbal medicines or botanical supplements<br />Exotic rituals<br />A natural approach<br />Art and music therapy<br />Hypnosis<br />Imagery<br />Meditation<br />Psychotherapy<br />Spirituality and prayer<br />Yoga<br />
  13. 13. Cancer Pain Assessment<br />Biomedical model<br />Pain scale<br />VAS<br />Are you hurting? Do you have pain?<br />Location, intensity, quality<br />Onset, duration, variations<br />Therapeutic effectiveness<br />Physiologic signs<br />
  14. 14. Cancer Pain Assessment<br />Holistic Model<br />How are you feeling today?<br />Do you have any pain?<br />Include elements of biomedical model<br />Observe patient at rest and with function/movement<br />Cultural considerations<br />Family input<br />Temporal/Contextual considerations<br />
  15. 15. Who is the expert on pain?<br />No objective measures exist<br />Patient report is the gold standard<br />But open to many alterations<br />Interpretation bias from staff/family<br />Important distinction between accepting and believing a patient<br />
  16. 16. Cancer Pain Treatment<br />Education of patient and family<br />Administration<br />Indications<br />Addiction concerns<br />Diversion concerns<br />Tolerance concerns<br />Cultural concerns<br />
  17. 17. Attitudes<br />Patient/Family/Staff exaggerated fears about ‘narcotics’ and addiction<br />Skeptical of health care professionals to relieve pain<br />Lack of access to effective pain control<br />
  18. 18. Non-Drug Approaches to Pain<br />Method can be direct pain reduction<br />Or indirect<br />Making pain more bearable (changing pain threshold)<br />Improved mood<br />Reduced distress and fatigue<br />Increasing control<br />Increasing sleep effectiveness<br />
  19. 19. Non-Drug Therapies<br />Usually inexpensive<br />Low risk<br />Easy to do<br />Readily available<br />Not uniformly effective (intra or interpersonal differences)<br />Usually in addition not substitution of medications<br />Lack strong scientific evidence<br />
  20. 20. Cutaneous Stimulation<br />Heat, cold and vibration have been shown to be effective in various pain types<br />Increase pain tolerance <br />Reduce pain<br />Doesn’t always have to be at site of pain<br />Direct<br />Proximal (between the pain and the brain)<br />Distal (beyond the pain)<br />Contralateral (consensual response v. distraction)<br />
  21. 21. Cold v. Heat<br />Thought to be related to increase or decrease of blood flow<br />Underlying mechanism not clear<br />Both cause decreased sensitivity to pain, decrease muscle spasm<br />Cold – numbness/anesthesia<br />Limited in hospital by physician’s order<br />
  22. 22. Heat<br />Typically 104 to 113F<br />Warms only superficial skin (restinsulated by subcut fat) <br />Can be applied indefinately<br />Avoid immersion<br />Avoid burns<br />Layer between heat source and skin<br />Avoid in irradiated skin – possible increased tissue damage<br />
  23. 23. Cooling<br />Usually around 60F<br />Can cool the muscles in sites with decreased subcut fat<br />10 minutes in slender people<br />30 minutes in obese people<br />Can be applied indefinitely at low level<br />Cold usually relieves pain better longer and faster than heat<br />Alternating probably more effective than either<br />
  24. 24. Vibration<br />Can cause numbness, paresthesia/anesthesia<br />Can change quality of pain (sharp ->dull)<br />Avoid in <br />Patients with easy bruising<br />Thrombophlebitis/clots<br />Injured skin<br />
  25. 25. Distraction<br />A type of sensory shielding<br />Focused attention on other areas decreases pain<br />Can be internal or external<br />Increase pain tolerance and self-control<br />Decrease in intensity<br />Changes in quality of pain<br />Limitations<br />May increase pain<br />More useful in acute pain than chronic pain<br />
  26. 26. Successful Distraction Techniques<br />Interesting to the patient<br />Consistent with patient’s energy level<br />Ability to concentrate<br />Rhythm is emphasized (keeping time)<br />Stimulate all senses<br />Hearing, vision, touch, movement<br />
  27. 27. Visual Distraction Techniques<br />Picture<br />Look at pictures and describe them<br />Hide picture and recall<br />Count or name items or colors<br />Tell a story<br />Mix known vs. new photos<br />Photographs versus art/paintings<br />
  28. 28. Musical Distraction Techniques<br />Pick a song you know the lyrics to<br />Sing (out loud or just mouth the words)<br />Mark time to the song (tap finger/toes)<br />Sing faster/louder if the pain increases<br />
  29. 29. Music Therapy<br />Controlled trials demonstrate<br />Reduced anxiety, stress, depression and pain<br />Decreased HR, RR<br />Trials have demonstrated decreased pain med needs<br />Trials have often been small and exact cause of responses unclear<br />From music or relaxation?<br />
  30. 30. Humor<br />Of questionable impact<br />Studies conflicting<br />But if it helps your patient then use it<br />
  31. 31. Relaxation<br />Alternating tensing and relaxation<br />Progressive relaxation<br />May be combined with imagery/music<br />Tend to have a narrow focus<br />May require practice and motivation<br />Deep breathing<br />Time involved may be a limiting factor<br />Rarely selected non-drug approach<br />
  32. 32. Art Therapy<br />Behavioral modality<br />Enhances coping skills<br />Well studied in children<br />And can be effective outlet for adults<br />Limited evidence, limited availability<br />Often seen in self-motivated individuals<br />
  33. 33. Acupuncture<br />Availability limited by provider availability<br />Evidence is mixed<br />Current Cochrane Collaboration is underway<br />More evidence with nausea/vomiting associated with chemo<br />
  34. 34. Therapeutic Touch/Reiki<br />Often has ties to ‘ancient healing methods’<br />AKA distance healing / energy field manipulation<br />Not connected with faith healing<br />Debunked in JAMA 1998 by an 11 year old<br />Cochrane Review<br />Lack of sufficient data means results are inconclusive, the evidence that does exist supports the use of touch therapies<br />
  35. 35. TENS for Cancer Pain<br />Electrical stimulation via battery<br />Limited use in chronic back pain per Neurology review<br />Not widely used secondary to lack of availability<br />See your local PMR doc<br />Cochrane Collaboration Review<br />‘Insufficient Evidence’<br />
  36. 36. Opioids and Cancer Growth<br />Highlighted in the media end of 2009<br />Based on speculative connections with methylnatlrexone and opioids given at time of surgery<br />In very early stages of research<br />See for review of the evidence<br />
  37. 37. Summary<br />Medical analgesia should be the main therapy<br />Consider physical, social, psychological, spiritual aspects of patient and family in assessment<br />Get access to experts in these holistic modalities – amateur efforts of minimal help<br />May need to try multiple approaches to non-drug management of cancer pain<br />
  38. 38. Contact Info<br />Christian Sinclair, MD, FAAHPM<br />Kansas City Hospice & Palliative Care<br />Cell: 816-786-8895<br /><br />Twitter: @ctsinclair<br />Blog:<br />
  39. 39. References<br />Oxford Textbook of Palliative Medicine 4thed<br />Pain Clinical Manual 2nded –McCaffery & Pasero<br />Malone MD, Strube MJ, Scogin FR. Meta-analysis of non-medical treatments for chronic pain. Pain. 1988 Sep;34(3):231-44.<br />The Cochrane Review – Pain, Palliative and Supportive Care Group<br />
  40. 40. References<br />Cold and Heat studies: Bini1984,Shere 1986, Collins 1985, Creamer 1996, Lehman 1985, Melzack 1965, Yarnitsky 1997<br />Dubinsky, Miyaski. Assessment: efficacy of TENS in treatment of pain in neurologic disorders. Neurology 74(2) 173-176<br />Rosa, Rosa, Sarner, Barrett. A Close Look at Therapeutic Touc. JAMA 1998; 1005-10.<br />Ward SE et al. Patient-related barriers to management of cancer pain. Pain. 1993 Mar;52(3):319-24.<br />