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Physical Medicine Approaches To Pain Relief
Francine Manuel, RPT, Isadora Rosenbaum, MA, Ernest H. Rosenbaum, MD
Decubitus and Contractures
Pain relief for bedridden cancer patients can be facilitated by various nursing and physical therapy procedures. These range from simple ways to position the body to more complex techniques that require special equipment and trained personnel. Some of the simple procedures can be taught to family members.
The first step in reducing pain is to evaluate the cause and source of pain. Once it has been established through appropriate diagnostics that surgical intervention, radiation therapy or other treatments will not help, one needs to know if the pain comes from movement, lack of movement, position of limbs, position of entire body or such sources as muscle tension.
Pain experienced by the mastectomy patient can be minimized by immediate initiation of Range Of Motion of the shoulder, massage in the direction of the heart, use of the compression pump with edema and fitting with elastic garment before the problem becomes chronic.
Positioning or placing the body or a body part in a certain way can be effective for pain relief.
Back pain is relieved by several positions. The first is to place the head and trunk at 20° to 30° angle. Wedge pillows are used to accomplish this. Then place one or two pillows under the knees, If you have a hospital bed, this is done easily without pillows. The patient can usually do it himselfusing the bed controls.
A second positioning is used to relieve back pain specifically. Roll up two towels and tie them with string or rubber bands at either end. This keeps the roll tight and firm. Place the roll in the lumbar lordosis (the round of the back at the waist). If you put a long tie in the middle, the roll can be held around the waist. It helps to put the roll at the waist during side lying also. This same roll can be used in a chair when the patient is sitting up.
Patients who are not moving much on their own need to be positioned in various ways for pain and also to prevent decubiti (bedsores) and contractures (tight joints). If the patient is comfortable with knees bent, for at least one hour every four, they need to be positioned with theknees extended. If the arm is always held against the body, shoulder range of motion will decrease and washing under the arm becomes painful. The arm should be positioned at a 60° angle from thebody for half an hour three times a day. If possible, you should try to externally rotate the shoulderand place the elbow at 90° angle also. Gravity wants to pull the arm down, sometimes the wrist can be secured to the sheets with soft restraint. The hips want to roll into external rotation. Sand bags can be used at the greater trochanters and knees to help prevent external rotation contractures.
Any place that a bone protrudes must be protected from pressure sores, malleoli (bony bumps), kyphosis (rounded back), ischial tuberosities (sitting bones), sacrurn (flat area just above the buttocks). Any patients who are not moving and turning on their own must be positioned from side to side with pillows secured behind them every two hours. The bony areas should be massaged for two to three minutes after they are relieved.
The skin should be protected. It must be dried carefully after washing so that friction when moving is decreased. The use of draw sheets not only prevents friction, but also the pain of pulling on the patient's body parts.
If sores start to form, pads can be made to relieve them, i.e.: rolls around the ankles will keep heels and malleoli clear of the bed. Pads on elbows can protect them. Circular pads with holes in the center can relieve sores over vertebrae. If the patient can be turned on his stomach, this is the best relief for the buttocks and back area. Placing a pillow under the chest, stomach, and hips sometimes helps to tolerate this position better. It keeps the face from being pressed into the mattress and helps with breathing also.
Corsets and rib belts can be used to reduce pain. It is important that they be of a rigid type to be effective. They must have at least two staves in back or either side of the spine and one on both sides. The two in front can be omitted for bedridden patients. A plastic body jacket can be made to fit patients that have vertebral instability. They control pain and make it easier to move from bed to chair or while ambulating.
Pain from fractured ribs can be helped by a rigid belt over the thoracic area. This, plus holding a pillow tightly against the chest wall will make coughing less painful.
Cervical collars can help with neck pain from widespread metastatic disease. The collars need to be rigid enough to stop movement. Neck extension is usually the major offender and should be prevented. The Philadelphia collar or four poster will effectively stop cervical movement. A round,long pillow roll about 8 inches in diameter placed on top of the patient's pillow in the cervical lordosis will help support the head in proper position. There are many types of cervical pillows to try for controlling neck pain..
For neurological problems, a splint can be used to support a weakened or paralyzed joint. This not only relieves pain but also prevents deformity from occurring.
Splints can be made of plastics, plaster or simply from cardboard or wadded newspaper. They must be properly padded so they don't cause pressure sores on the area to which they are applied. They cannot just be put on and left there. A time schedule needs to be set up for their use, i.e.: two hours on and two hours off. The skin should be checked for breakdown, redness, or particular points of pressure, which must then be relieved in the splint.
Subluxed shoulders, painful arms and legs can be relieved by slings. The triangle bandage is the easiest to make. They can be made from torn sheets. A long belt with a loop at both ends can be used for an arm sling. These should be secured around the back, not around the neck. The neck gets tired and painful much quicker.
Simple slings can be rigged up for legs. One only needs a wide (about 6 inches) strap at the thigh and another at the ankle. Pressure must be monitored in these also and a time schedule setup for use.
Painful, swollen limbs can be supported by pillows of various shapes. These can also be used to elevate the limb to reduce edema.
Ace wraps or taping of joints can also relieve pain. Family members should be taught to use spiral, not circular, turns when using the Ace wraps. If the patient feels coolness or numbness in the extremity of the wrapped limb, it is wrapped too tightly. Taping requires special training and skill, but may also be taught to family members.
Limbs that need to be permanently immobilized like in non-union fractures should be handled with metal or plastic braces. The joints should lock to enable positioning of the limb in both a flexed and extended position. If braces are not available, casts can be made and bivalved and Aced or strapped on for periods of time. This can be used when moving patients.
Taping joints with adhesive tape can be used for temporary immobilization. The most important consideration should be the integrity of the skin. Malnourishment syndromes and open areas of any kind should not ever be taped over. Tape should not be left on the skin any longer than 8 hours. Johnson & Johnson has published a free booklet that demonstrates the correct taping procedure for each joint. Longitudinal strips are first placed to oppose the instability of the joint. These are secured at the top and bottom with circular turns. A figure 8 is done over the whole area. Tape size varies with the size of the joint. One inch can be used on a finger, 4 inch tape is needed over a hip. The areas should be shaved first and treated with a skin prep. There should not be any creases in the tape. When removing tape, always try to push the skin away from the tape rather than just pulling the tape off. Taping will not help well in humid conditions.
If available, a whirlpool bath can be helpful. It provides the benefits of both heat and massage to the entire body. The patient must be helped into and out of the tub carefully. Get someone to assist you if possible and have your helper watch to make sure limbs are bent as they should be. The patient must be placed in a comfortable position in the tub. If the patient is not comfortable, the whirlpool will do no good.
The water is kept between 103° to 105° Fahrenheit. The patient may stay in for 20 to 30minutes. For a patient with ischemic disease, the water should not exceed 96° Fahrenheit. Because this feels too cold for a full-body whirlpool; such a patient may not want to have this treatment.
Care must be taken with anyone that has cardiac disease, an infection or some kind of compromised circulation or mental status. Warm water over the entire body increase the cardiac output. Patients can faint or lose consciousness. All patients in a water bath should be closely supervised, but those with compromised mental status should never be left alone.
In cases of infections, the bath must be sterile. Clean the empty tub with a strong betadine(iodine solution) product or other disinfectant. You should add betadine or another disinfectant to the bath as well, unless the patient is allergic to this product. The turbulent water will also debride(cleanse) the wound.
There are several techniques that can be used for localized pain. Heat has been used successfully to relieve pain and increase relaxation in a specific joint or musculoskeletal area. Two types of heat treatment can be use: superficial and deep. The dividing point between superficial and deep is the superficial treatment only extends to a depth of I cm.
The traditional medical literature on cancer contraindicated the use of deep heat modalities for patients. This has changed. Recent studies using microwave and ultrasound have shown that they can shrink tumors rather then spreading them. This means that a cancer patient with any painful musculoskeletal condition can be treated in the conventional way.
Relief produced by heat probably comes from its primary effects on the body's physiology. Heat works to increase metabolism where it is applied. This leads to the faster removal of waste products, including lactic acid. Heat also opens up blood vessels and increase arteriolar dilation. This results in more delivery of oxygen nutrients, antibodies and leukocytes to the area of application.
There are many sources of superficial heat: moist hot towels, hot water bottles, steam packs(hydrocollators), infrared lamps, electric heating pads and ultraviolet lights. Deep heat techniques include ultrasound, diathermy and microwave.
Caution: Care should be taken whenever heat is used with patients who have decreased sensation. Also, patients should not be allowed to fall asleep on a hot water bottle or heating pad. Because they are asleep, they may not feel if they are getting burned.
Cold or ice has the opposite effect of heat. Cold is particularly effective in muscle spasm or spasticity. An application of 10- 15 minutes will achieve maximum effect. Anything longer is not necessary as it starts producing the same effect as heat.
The Jobst compression pump is a unit that has been used successfully in controlling lymphedema. It is recommended that 30mm. be used on the arm and 60mm. on the leg. The limb should be elevated while using the pump. To be effective, 2-4 hours of pumping must be done daily if edema is severe. An elastic garment or Ace wrap should be applied after pumping for best results.The patient's blood pressure should always be taken. The systolic pressure should never be exceeded with the pump.
In summary, there are several effective techniques for pain control which do not require advanced technology. Exercise, relaxation and massage will not alleviate pain totally, but are tools which help patients cope with complicated pain problems. We have presented a step-by-step approach so that you can teach your patients these techniques. The patients can then carry them onto their own home environments. These techniques are applicable to any socio-economic sphere.
The more technological approaches discussed for pain control are best supervised in hospital or office situations where the physician can more closely observe reactions and progressions.
These techniques are the most widely used and accepted in present day oncological practice. In our opinion, anything that is available should be tried in an attempt to improve the quality of life of cancer patients including those that are terminal.
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