31 Mar, 14 | by Toby Hillman
A paper in the current issue of the Postgraduate Medical Journal tackles a relatively modern concern: chronic postsurgical pain.
With the advent of modern anaesthetics, and advances in surgical technique, the potential for surgical intervention to tackle disease exploded. Indeed, there is now a whole industry based on surgically changing the way people look, which in the early days of surgery would have been almost unthinkable. For example, Samuel Pepys put off an operation for his bladder stone (which caused great pain and many infections) for many years before submitting to be cut by Thomas Hollier. [The lithotomy is now a rare beast, having been superseded by less invasive means of removing stones from the urinary tract.]
So surgery is now a much more accessible, and much safer option for the management of disease than it once was. However, it is not without its problems, and one which may have been under-represented for many years is that of ongoing pain. The incidence of chronic pain is quite remarkable, with up to 35% of patients undergoing hernia repair reporting pain more than 3 months after their surgery, and higher percentages in patients undergoing cardiac or thoracic surgery, and even in cholecystectomy rates of CPSP of up to 50% have been reported.
The paper discusses the pathophysiology of pain, and strategies to reduce the likelihood of developing chronic pain. The concepts of central sensitisation, secondary hyperalgesia, wind-up potentiation and pre-emptive and preventative analgesia are of great interest.
However, as one progresses through the article, a change takes place. One is guided into the realm of the pain clinic. Here, it is recognised that pain is not simple, it cannot be neatly captured in a line diagram of the spinothalamic tracts, but that pain is a multi-faceted experience for each patient, that can be influenced by a whole range of factors. The physical risk factors identified for the development of chronic postsurgical pain are important to note, including surgical technique, repeat surgery, and radiation to the surgical site, but what struck me more was the number of risk factors which could be described as relating to mental wellbeing. Six of the listed risk factors relate to mental state.
This key component of chronic postsurgical pain is borne out by the authors as they discuss the importance of the fear-avoidance model, and how anticipation, and fear have measurable influences on pain perception – confirmed through neuro-imaging studies. These insights into the development of a chronic condition, and how patients respond to their pain is hugely important, and their application extends beyond chronic postsurgical pain.
One of the key interventions the authors highlight is the provision of information to patients who are undergoing surgery to enable them to understand what they were experiencing post-operatively. The paper refernced was the report of an experiment conducted about 50 years ago that examined the effect of an enthusiastic anaesthetist discussing the expected levels of post-operative pain, non-pharmacological methods of alleviating that pain, and a daily reinforcement of this message. The results are quite impressive, with a reduction in narcotics required, improved comfort, and a 2.7 day reduction in length of stay.
It is on similar techniques that the enhanced recovery programmes employed by many NHS trusts are founded. Essentially, patients are encouraged to take an active role in understanding their condition, the surgery they are undergoing, and are briefed as to what is normal with regards to pain and limitation post-operatively.
The key intervention for me here is that patients are fore-warned about what they are likely to experience, they are given ‘permission’ to be in pain – and to know that this is not a harbinger of doom, or that they are doing irreparable damage to their newly fashioned wounds. By being up-front about these experiences, fear is dissipated, patients are empowered, and outcomes tend to be better, even though the surgical technique, anaesthetic technique, post-operative pain regime and environment are all pretty much the same. The major difference is that the patient has been offered some psychological protection, even if it is not labelled as such.
The lessons learned through the experiences of surgical patients over the years can be translated across many spheres of medicine – the marriage of body and mind is not always perfect, and yet, if we only pay attention to one side of the equation, our patients may well pay the price in the longer term. It is a shame that the lessons published in 1964 are not more widely employed, although the tide is changin. I am convinced that psychological interventions can play a hugely important part in enabling patients to cope with their long-term conditions, of all sorts.
Despite being the calling card of politicians recently, it really is true that there is not such thing as health, without mental health.