Recognising Common Pain Patterns
There are some common pain patterns that are worth learning to recognise and differentiate clinically. There are:
- Visceral Pain
- Bone Pain
- Nerve Pain
- Cutaneous Pain
Recognising these common pain patterns allows the appropriate use not only of strong opioids, but also of co-analgesics. It allows early identification of situations where other treatment modalities such as radiotherapy have a major role. It also allows explanation to patient and family and establishes confidence that the symptom is being addressed skilfully and professionally. This is an important first step in engaging patient and family in a jointly agreed management plan.
- Visceral Pain is poorly localised, diffuse and often aching in quality.
- Bone Pain is well localised and there may be localised bony tenderness. Movement and weight bearing classically exacerbate bone pain. If this feature is pronounced it may suggest impending pathological fracture and the affected area should be rested until an X-ray can be arranged. Have a high index of suspicion with cancers that commonly metastasise to bone (cancers of the breast, bronchus, prostate, kidney, and myeloma).
- Nerve Pain follows a dermatonal distribution (see dermatome map in annex). This is pathognomic. It is often described as burning, tingling, jabbing or stabbing and may be associated with disordered sensation or motor weakness. Patients find nerve pain very unpleasant. It can be difficult to manage with the usual painkillers and early liaison with a specialist palliative care or pain team is recommended.
- Colic comes and goes in spasms that last seconds to minutes. Bowel colic is often described as windy or griping pain by patients. It is poorly relieved by opioids but well relieved by anti-spasmodics.
- Cutaneous Pain is a well localised superficial pain. The commonest aetiology is pressure damage to skin.
Managing Some Common Pain Patterns
The first step is always to follow the WHO analgesic ladder , rapidly moving if needed to a strong opiod. However in bone pain, nerve pain, colic and cutaneous pain, additional interventions are almost always necessary. Don't delay initiating these additional measures (such as radiotherapy for bone pain). Again it comes back to the importance of a clear diagnosis of the pain and good anticipatory care.
Interventions for the different pain patterns:
|Pain Pattern||Morphine Responsiveness||Useful Co-Analgesics||Other Interventions|
|Visceral Pain||Usually completely responsive*||Not usually required||Not usually required|
|Bone Pain||Often good response||
|Nerve Pain||Partial response||
Early referral for specialist advice
|Colic||Partial response||Hyoscine butylbromide (buscopan)||(Rarely) Surgical relief of obstruction|
|Cutaneous Pain||Often little response (Case reports of topical use being helpful)||
Topical local anaesthetics
For pressure sores prevention is better than cure
*Pancreatic pain is the exception, probably because of early involvement of retroperitoneal tissue. As well as morphine, try NSAID’S, steroids and consider early referral to a pain anaesthetic service for coeliac plexus or splanchnic nerve block.
© Dr. Eileen Palmer, Dr John Howarth Palliative Care for the
Primary Health Care Team (2005) Quay Books ISBN 1856422291
Palliative Care Pain Pack 2. Dr Eileen Palmer 2008