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Ovid: Oxford Handbook of Palliative Care

Editors: Watson, Max S.; Lucas, Caroline F.; Hoy, Andrew M.; Back, Ian N. Title: Oxford Handbook of Palliative Care, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Symptom Management > Chapter 6a – The management of pain > Pain and function Pain and function Surveys across different cultures show that the relationship between pain and physical performance is non-linear. Impairment in function becomes markedly worse above a pain severity rating of four on a ten point scale. This suggests that we have the capacity to deal with a certain amount of pain but once this capacity is exhausted, function quickly becomes impaired.4 This has important implications in the management of pain, as reducing some of the secondary effects of pain, such as anxiety or financial worries, may decrease the overall experience of pain to a point where function is markedly improved. Improvement of function can have a very positive effect reducing the experience of pain and restoring morale; some of the symptom control success achieved in inpatient palliative care units must be attributed to a reduction in secondary pain effects. The pain threshold will vary from person to person and within the individual. It also varies according to multiple physical and psychosocial factors which are constantly changing. Models that help us understand pain need to take account of this constantly changing nature of pain perception. Such a model understands pain perception as a ‘plastic phenomenon’ which is constantly in flux. This is supported by the growing understanding of the rapidly altering neurochemical environment of the central and peripheral nervous system. Changes in concentrations of neurotransmitters and of neuroreceptors impact on the transmission of painful stimuli. Tom had been admitted to the hospice for symptom control from his local area hospital. Despite receiving nearly 1000 mg of diamorphine subcutaneously per day he persisted in scoring his pain at 8 or above. Tom was a self made man of 55 who had built up a chain of shoe shops after leaving school at 16. When his oesophageal carcinoma was diagnosed he had a chain of shops all over the area. He was not expecting his diagnosis of cancer and the news that curative intervention was not possible came as a devastating blow to a man used to controlling his own life and business. Suddenly his life had been invaded and his inner resources for dealing with the situation overrun. One week later Tom went home from the hospice requiring MST 20 mg b.d. and diazepam 5mg nocte to control his symptoms. Tom achieved his improved pain control by having his underlying anxiety addressed and treated, and by gaining back some control over his life, the lack of which had caused him deep anguish. ‘The space and peace in the hospice gave me time to get my head around things’. Footnotes 4 Serlin R. C., Mendoza T. R., Nakamura Y., Edwards K. R., Cleeland C. S. (1995) When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain, 61, 2: 277–84.

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