Year : 2017 | Volume
: 31 | Issue : 2 | Page : 77--79
Holistic care in chronic pain
Geeta M Joshi
Department of Pain and Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
Geeta M Joshi
Department of Pain and Palliative Medicine, Gujarat Cancer and Research Institute, CHA Campus, Asarwa, Ahmedabad - 380 016, Gujarat
|How to cite this article:|
Joshi GM. Holistic care in chronic pain.Indian J Pain 2017;31:77-79
|How to cite this URL:|
Joshi GM. Holistic care in chronic pain. Indian J Pain [serial online] 2017 [cited 2018 Nov 13 ];31:77-79
Available from: http://www.indianjpain.org/text.asp?2017/31/2/77/214126
A holistic care means treating the whole person, and not only pain, symptom or other specific ailment. It is the concept that the human being is multidimensional, and mind and body are not separate. Holistic medicine attempts to treat both the mind and the body.
Why should a pain physician have “holistic approach” while treating a chronic pain patient? There are number of reasons and evidence which emphasizes this theory. When one is treating a patient with holistic approach, he/she addresses the symptom of a person with different levels, physical, emotional, mental, and spiritual. A pain physician should address all aspects of a person's life using a variety of health-care practices.
Human Beings are Multi-Dimensional
All human beings are different and their pain as well is different!! We have conscious and unconscious aspects, rational, and irrational aspects. Hence, one cannot treat chronic pain with single, conventional, and biomedical modality. It needs a system of comprehensive or total patient care that considers the physical, emotional, social, economic, and spiritual needs of the person; his or her response to illness; and the effect of the illness on the ability to meet self-care needs.
Chronic Pain is a Disease
Most critical is the understanding that chronic pain is a disease of the person and that a traditional biomedical approach cannot adequately address all of the pain-related problems of this patient population. A multidisciplinary approach is needed to treat chronic pain patients. A systematic review of randomized controlled trials found strong evidence that multidisciplinary treatments for chronic pain are superior to standard medical treatments. There was moderate evidence that multidisciplinary treatments were more effective than various single strategies. Strategies included cognitive behavioral therapy, physiotherapy, exercise, relaxation and patient education, among others. Overall, intensive inpatient programs were most effective.
Chronic Pain and Life-Limiting Illnesses
Most of the patients suffering from life-limiting illnesses have chronic pain at one time or other, during their disease trajectory. Pain in HIV/AIDS and cancer pain are few examples. It is not only pain but also the prolonged illness, loss of identity, loss of body image, social rejection, and understanding of incurable nature of disease, etc., produces lots of distress, which contributes to worsening of pain. Dame Cicely Saunders defined the concept of total pain as the suffering that encompasses all of a person's physical, psychological, social, spiritual, and practical struggles.
Palliative care physicians have “holistic approach” to treat this pain. In cancer pain, physical aspect of pain cannot be treated in isolation. A biopsychosocial approach to assessment and management is needed that takes into account all these areas of the pain experience. It is treated by multidisciplinary team including pain physicians, oncologist, psychologist, psychiatrists, physiotherapist, and religious gurus. It is important that patient and caregivers be part of this team! Spiritual pain should be always evaluated by in-depth discussion on beliefs, religion and spirituality. The term “opioid-irrelevant pain” is sometimes used to describe components of pain that are not amenable to analgesics, such as fear or financial distress, which need different management strategies.
Goebel et al. have described total pain theory and applied it to research and practice in advanced heart failure. The theory of total pain, as articulated by Saunders, is especially salient for the investigation and management of pain in advanced heart failure because of its ability to holistically assess and manage suffering.
Disability and Comorbidity in Chronic Pain
New statistics released by International Association for the Study of Pain and European Pain Federation on October 11, 2004, the first Global Day Against Pain indicates that one in five people suffer from moderate to severe chronic pain and that one in three is unable or less able to maintain an independent lifestyle due to their pain.
Most of the chronic pain conditions are related to noncommunicable diseases or life style diseases, old age, posttraumatic conditions, etc. These conditions may be associated with disability, which in turn has psychosocial impact. A holistic care of these patients involves not only treatment of pain but involves rehabilitation. Holistic care toward promoting active self-management and making them independent is part of pain management team. In these patients, pain is often not the only problem!!! They have socioeconomic disadvantage and high levels of psychological distress. Depression, anxiety, posttraumatic stress disorder, and substance misuse are associated with chronic pain.
Chronic pain is independently associated with suicide. New Zealand research found that about 30% of people with chronic pain also reported a mental health condition, compared with 14% of people without chronic pain.
Comprehensive multidisciplinary management based on the biopsychosocial model of pain has been shown to be clinically effective and cost-efficient but is not widely available. Busy pain physicians usually rush the patients without giving attention to details. Services of nurse, pharmacists, and physiotherapists are underutilized. Psychological therapy is employed infrequently and often too late. Doctors are more concerned with treating underlying conditions, managing pain with medicines, interventions, and paying less attention to coping strategies. The problem of poor physician/patient communication is more evident with chronic pain patients.
Pain clinics may address specific pain problems, and they do not offer the complete package needed to help a person regain control of their lives. It is important that a pain treatment should include more active self-management strategies to improve outcomes for pain, distress, and disability. It should provide with the physical, emotional, and psychological components as per patient's need.
Nowadays, there are many practicing pain physicians in India, but still pain has low priority within health-care system. In Europe, only 2% of patients with chronic pain report being managed by a pain specialist.
A lack of resources, policy, and evidence-based practical guidelines and lack of awareness and education in fellow practitioner are few of the obstacles in pain practice.
Components of Multidisciplinary Pain Program
An effective pain program should have a multidisciplinary team on its panel. Patients should assume the role of primary caregiver. Pain physician and team should help patients and their families to develop skills and confidence to manage their chronic pain.
Nurses should be involved in pain practice to very great extent. Improving their knowledge of pain therapy would enable them to give more comprehensive advice to patients on the importance of adequate medication and encourage treatment adherence.
Pharmacists' skills are often not fully utilized in pain practice in India. Their one particular responsibility is to provide advice and guidance on the use of over-the-counter analgesic agents. They have a very important role in maintaining opioids record.
Physiotherapists typically receive many more hours of pain-relevant training than medical students, yet few patients with chronic pain are referred for physiotherapy. In addition to their primary role of restoring physical functioning, physiotherapists are ideally placed to provide reassuring advice, explanation, and education, as well as encouraging an early return to normal activity.
Psychologist needs to be involved right from beginning as integrating psychological therapy is recognized as being effective, but they are involved only when the pharmacological treatment fails. Psychologists are helpful in dealing with fear, anxiety, preoccupation, catastrophization, and depression and disability, reduced function, more days of work lost which is more frequent pain behavior in chronic pain patients.
Nutrition and correction of micronutrient deficiencies are crucial in treating chronic pain. For example, a Mayo Clinic study discovered that pain patients with insufficient levels of Vitamin D were taking twice the amount of opioids for twice as long as patients without a deficiency.
Mind body medicine and alternate medicine can be part of multidisciplinary pain program. Mind body interventions are useful as adjunctive therapy to ameliorate pain, enhance treatment response, and reduce the use of more costly and risky interventions. A trial at a Ford Motor plant found a 58% reduction in prescription pain medication use when acupuncture and mind-body practices were used to treat low back pain. Compliance is a factor in achieving sustained benefits.
Indian Society for the study of pain also supports the multidisciplinary approach to chronic pain. Hence, the constitution allows membership from various specialties. It has 25 specialists as life member. Recently, nurses are added to this list. However, do all pain physician practice Holistic approach or multidisciplinary approach for chronic pain patients? Excluding few medical colleges or teaching institutions, do we have such team to treat our patient as whole?
Palliative care specialty does practice “holistic care” and patient-centered approach. Neighborhood Network of Kerala Model of palliative care is a community-led initiative to prove home-based palliative care in South India. Through this holistic care is given to patients with the help of volunteers. The role of nurses, physiotherapist, and counselor/social worker is emphasized in palliative care. Can chronic pain patients been approached in similar way?
Apart from involving multiple specialties, structured education and training on pain are utmost desired not only for medical professionals but also for nurses, physical medicine specialists, pharmacists, and psychologists. The education of patient, caregivers, and volunteers is equally important.
Are we heading in the direction of the United States, adopting sophisticated interventions and medicines, without addressing other aspects of patient's life? Do we involve our colleagues from psychology, physiotherapy, occupational therapy, nursing, and psychiatry for treating our patients of low back pain and arthritis? We need to do introspection on how much holistic care we are providing to our chronic pain patients.
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