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Recent Ideas Relating to ‘Total Pain’ Dr Peter Nightingale FRCGP Hon Senior Lecturer in Palliative Care UCLAN Macmillan GP Lancaster.

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Presentation on theme: "Recent Ideas Relating to ‘Total Pain’ Dr Peter Nightingale FRCGP Hon Senior Lecturer in Palliative Care UCLAN Macmillan GP Lancaster."— Presentation transcript:

1 Recent Ideas Relating to ‘Total Pain’ Dr Peter Nightingale FRCGP Hon Senior Lecturer in Palliative Care UCLAN Macmillan GP Lancaster

2 Objectives By the end of this session I hope that you will have refreshed your ideas about ‘Total Pain’, and reflected on recent evidence that informs practice

3 Body – mind split Descartes explained pain through the bodily mechanisms called nociceptors Human pain is not a only a sensation but a perception dependent upon the mind ’ s active power to make sense of experience Functional MRI (fMRI) confirms ‘pain matrix’ involving insula thalamus, prefontal cortex etc. The mind ’ s power to alter nociception makes pain far more complex than a Cartesian alarm bell

4 ‘Total Pain’ development A far more sophisticated model of pain was needed one which locates individuals within their social and cultural contexts, which allows for the inclusion of feelings and emotions (Bendelow & Williams 1995)

5 Total Pain Dame Cicely Saunders

6 Total Pain This concept expands the medical definition of pain into the emotional, spiritual, social as well as physical aspects of pain

7 “ Total Pain ” – Cicely Saunders More than physical pain and related symptoms Psychological distress with grief over loss and change Social disruption with financial, residential, family and role strains Spiritual and existential distress Addressing these issues is part of comprehensive palliative care – a team approach is needed


9 Pain story Narrative is basic to any account of pain These narratives may not separate the physical and psychosocial aspects of the pain experience

10 Types of physical pain Acute Chronic Acute superimposed on chronic pain Breakthrough pain Pain may also be described as Nociceptive (visceral, somatic) Neuropathic (nerve damage or irritation)

11 How we perceive pain Physical Pain is an almost universal experience (Except for 3 families in Northern Pakistan with SCN9A channelopathy) Designed as an “ alert ” system in the body that something is wrong and/or needs attention We give pain meaning – the meaning can affect the way we respond to the pain stimulus Chronic pain serves no useful purpose and needs to be controlled Chronic pain serves no useful purpose and needs to be controlled

12 Mannix K et al Palliative Medicine 2006; 20:579-584 Cognitive Behaviour Therapy (CBT) can be used by palliative care staff to help patients. Training may become more widely available

13 CBT Cognitive Behaviour Therapy Physical Pain

14 CBT Techniques for Palliative Care Professionals Demonstrating the Thoughts/Moods/ Behaviours Link

15 Demonstrate the Thoughts/Moods/Behaviours Link

16 ABC of CBT! A is the activating event B is your beliefs and thoughts C is the consequences, such as emotions you feel

17 Balloon challenge!


19 Neuro-imaging and Pain Functional MRI studies show 1. Prefontal cortex activated in chronic pain states 2. Imagined pain is difficult to distinguish from experienced pain 3. Placebo induced analgesia and opioid induced analgesia engage similar brain regions

20 The anterolateral prefontal cortex (al PFC) People with a strong belief that they have control over their own life don’t activate alPFC when pain is externally controlled Belief’s are important. Religious v non religious groups studied. Images helped people cope with pain

21 Mindfulness Associated with Zen Buddism Evidence for reducing stress and chronic pain Increased awareness ‘the present moment with an uncluttered mind’

22 The Mercedes Model THINKINGEMOTIONS PHYSIOLOGY Our ever present internal states consist of:

23 NLP is … N euro our mind-body system and how it works; how the 5 senses form the basis of our thinking and behaviour L inguistic how we use language to make sense of our experience; how we communicate our experience to ourselves and others P rogramming patterns of thoughts and behaviours that help or hinder us

24 Evidence for NLP British Journal of Nursing 1999 Jacquie Turnbull, Intuition in Nursing Relationships, the result of skills or qualities ? An Evaluation of the Living with cancer project using NLP in Ellesmere Port 2004-Centre for Public Health Research,University College Chester

25 The Communication of Meaning Source: Mehrabian & Ferris Journal of Counselling Psychology, 1967 55% 7% 38% dance music words

26 Useful NLP techniques 1. Well-formed Outcomes 2. Anchoring



29 Now ‘Anchor’ that feeling with a movement or gesture

30 Brain Basics Flight or Fight Reptilian Brain Limbic Brain Immune system Hormone system Memory Emotions Neo-Cortex L R Logic Reason Sequence Word Analysis Detail Emotion Creativity Flow Tone Pattern Big picture

31 Why talk with patients about other things apart from pain? The conscious mind can only pay attention to chunks of information at any one time. ~ George Miller 7 + -2

32 Factors Affecting Pain Threshold Threshold  Threshold  DiscomfortRelief of other symptoms InsomniaSleep FatigueSympathy AnxietyUnderstanding FearCompanionship AngerCreative Activity SadnessRelaxation Depression  Anxiety Boredom  Mood Mental IsolationAnalgesics Social abandonmentAnxiolytics Antidepressants

33 Psychological Pain This is where listening to the patients story is critical if we are to help

34 Two ways to discover Patients perspective 1. Picking up verbal and non verbal cues 2. Asking about:- Ideas Concerns Expectations Effects Feelings

35 Ways to pick up verbal and non- verbal cues Repetition of cues ‘ upset? ’ ‘ something could be done? ’ Picking up and checking out verbal cues ‘ you said you were worried it may be something serious-what did you have in mind? ’ Picking up and checking out non-verbal cues ‘ Am I right in thinking you are quite upset about the explanation you have had in the past? ’

36 Ideas ‘ what you think may have started this pain? ’ ‘ is there anything you think that may have made this problem worse?

37 Concerns Is there anything in particular about this disease that is worrying or frightening you? ‘ Some people with cancer find that they get worries or fears about certain things-has that happened to you?

38 Fear of dying is very widespread and deep Fear of the dying process "what will it be like?" Will it be painful? Fear of loss of control "will I be dependant on others? Will I be unable to care for myself? Fear of loss of loved ones "How will they manage without me? Fear of others reaction to them "How will people cope with seeing me like this? Fear of isolation "Will people stop coming to see me? Fear of the unknown "what happens after you die? Fear that life will have been meaningless Naming and recognising the fear can reduce it.

39 Expectations ‘You ’ ve clearly given this some thought, what were the most important things you were hoping I may be able to do to help you with these problems? ’ ‘ How do you see things developing from here? ’

40 Effects ‘ How are these symptoms effecting your life at present? ’ ‘ What do you find most helpful to support you when you have all this to deal with? ’

41 Feelings ‘ I sense you are upset/angry/tense, would you like to talk about it? ’ ‘ Some people with cancer get depressed, or anxious-has that happened to you? ’ ‘ Do you find there is anything you can still look forward to?’ ‘Are you depressed?’ (Chochinov)

42 Use of a Summary  One of the most important information gathering skills  It is the key method of ensuring accuracy because:- 1)It demonstrates you are interested and have listened 2) It invites the patient to confirm or correct your interpretation 3)We can pause and formulate our thinking in both disease and illness frameworks

43 Palliative Care Professionals and Spiritual Pain Marie Curie state health care workers could be regarded as providing spiritual care. Palliative Care Professionals at Level 3 of 4.

44 Core Spiritual Needs Love and Meaning

45 Identifying Spiritual Pain ‘What are the things that keep you going?’ ‘What is important to you?’

46 Identifying Spiritual Pain

47 Helping with Love/Positive Regard 1. Being genuine 2. Respecting the patients individuality 3. Deep listening Attentive silence, To listen with the whole of our being. We should avoid giving "answers" Expressing empathy, warmth and positive regard.

48 EMPATHY Empathy can be learned It overcomes the patients isolation in their illness It is therapeutic in its own right Communicated by linking the ‘I’ and the ‘you’ ‘I can see how difficult this pain is for you’

49 Helping with finding Meaning "He who has a why to live for can bear almost any how" (Nietzsche). A useful working framework is The "4 R's", described in "A Handbook for Mortals“ by Dr Joanne Lynn and Dr. Joan Harrold. 1. Remembering 2. Reassessing 3. Reconciling 4. Reuniting


51 To die healed We need to be allowed to express I love you Forgive me I forgive you Thank you Goodbye

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