Pain Managment - The pain clinic: Management of persistent pain

    McGonagle, Catherine, World of Irish Nursing 12 (5) pp 35-36, May 2004.

by Catherine McGonagle

 

Pain is the most common reason for seeking medical attention and in many cases of chronic pain, the challenge is how to manage it even if the underlying cause cannot be cured. Some 50% of people presenting with pain are suffering continuously; 46% experience above average pain; pain interferes with the daily life of 42% of sufferers and 40% say they cannot sleep properly.

However, there is an increasing number of therapeutic solutions available. Managing pain needs a multi-disciplinary approach and this module aims to promote the highest possible standards in the management of pain, through education, training and research in all fields of pain and by facilitating the exchange of information and experience.

This month we focus on the role of the multidisciplinary pain clinic in the management of chronic pain. Subsequent articles will focus on: chronic pain in old age; and cancer pain management.

The characteristics and structure of a pain clinic depend on the personnel and resources available as well as the patient population to be served.

The first clinic established solely to treat patients suffering from chronic pain was set up by an anaesthetist, Dr Rovenstine, in New York in 1936. This was followed shortly by several such clinics in the US, which essentially employed one method of treatment nerve blocks.1 In the 1940s, seeing the undertreatment of chronic pain during World War II and also recognising that pain is both a physical and psychological experience, Dr John Bonica, again an anaesthetist, saw the need for a multidisciplinary approach to chronic pain management. The first multidisciplinary pain clinic was subsequently established in Seattle. 2

Influenced by Bonica, the formation of multidisciplinary clinics throughout the world took off in the early 1970s when there were pain treatment facilities in most of the developed world.

In Ireland, the first outpatient pain clinic run on a regular basis was started in 1977 by Dr Raftery at St Laurences Hospital, Dublin. By the late 1980s, there were a number of pain clinics in Ireland, all run by anaesthetists, mostly single-handed.

The multidisciplinary pain clinic
The ideal multidisciplinary pain clinic should represent a balanced programme of patient care as well as a diverse collection of medical specialists and office support personnel. This multidisciplinary model provides extensive diagnostic, therapeutic and rehabilitative services3 (see Table 1).

Services provided by the pain clinic
Diagnostic
  • History questionnaire and verbal
  • Physical examination
  • Psychologic testing and interpretation
  • Psychologic interview (psychiatrist or psychologist)
    • with patient and with family members
  • Laboratory
    • Clinical laboratory
    • Radiographs, computed tomography, MRI, bone scan
Therapeutic
  • Pharmacologic analgesics, psychotropics, anti-inflammatory, muscle relaxants
  • Medical modalities nerve blocks, steroid injections, neurosurgical ablation, neural stimulation (acupuncture, TENS)
  • Physical modalities strengthening, range of motion exercises, heat, cold
  • Vocational retraining
  • Other support services dietary, social services

People experiencing chronic, non-malignant pain (CNMP) benefit most from having their problems managed through a multidisciplinary pain management clinic.4
Patients usually require referral by their GP or consultant, and some clinics now take referrals from physiotherapists and nurse specialists. The clinics consist of a variety of healthcare professionals who will assess the patient and offer expert help in the management of pain. These include:

Interdepartmental relationships should be encouraged, particularly with colleagues in areas such as neurology, rehabilitation medicine, rheumatology, dentistry, orthopaedic surgery and neurosurgery, where there are opportunities for mutual collaboration.

Client group
Back pain constitutes a significant proportion of chronic non-malignant pain 60% of the population experiences it at some time in their lives and one in five is referred to a pain specialist. Other common pain syndromes seen in the pain clinic include conditions such as complex regional pain syndrome (CRPS), and neuropathic pain associated with conditions such as postherpetic neuralgia, trigeminal neuralgia, chronic scar pain, phantom limb and stroke pain.

However, most referrals to multidisciplinary pain clinics concern patients with longstanding disability resulting from pain caused by non-malignant disease. They often have complex medical histories. A single pathophysiological explanation is not available for many chronic non-malignant pain states. Up to one third of chronic pain patients will have no objective findings of organic disease and conventional treatment solely aimed at relieving pain is unlikely to be appropriate for such patients.5

Treatments
To function optimally, the multidisciplinary pain clinic requires adequate space for patient assessment and the appropriate equipment for therapeutic interventions. Although some therapeutic interventions are carried out in the pain clinic, the majority are scheduled as day-stay cases primarily because of time constraints. Furthermore, access to a patient case conference room is essential to facilitate multidisciplinary team meetings, as well as patient and staff seminars and lectures.3

Table 2 lists the range of treatments generally available.

Range of treatments offered by pain clinic
  • Medications/drug therapy control and rationalisation of drug therapy
  • Nerve blocks, including peripheral nerve blocks, sympathetic blocks, facet injections and radiofrequency lesioning
  • Stimulation induced analgesia such as TENS and acupuncture
  • Physiotherapy with exercise-orientated programme
  • Psychological therapies for managing chronic pain
  • Spinal cord/dorsal column stimulation
  • Rehabilitation programmes
  • Education methods for patients and professional colleagues in prevention and early effective management of conditions which may lead to chronic pain

Adapted from Provision of pain services: The Association of Anaesthetists of Great Britain and Ireland, The Pain Society 1997

Drug therapy
Pharmacotherapy is an important element in the interdisciplinary approach to effective treatment of chronic pain. According to the severity of the pain and its response to analgesia, medication may be controlled in a stepwise fashion similar to those suggested by the World Health Organisation for cancer pain.6

The three-step WHO analgesic ladder begins with relatively low doses of low-potency analgesic medications and progresses systematically and incrementally to higher doses of more potent medications (specifically, opioids) as pain worsens. While use of opioids remains controversial, they show results where weak opioids at maximum do not. In conjunction with this ladder, anticonvulsants and tricyclic anti-depressants can be considered for their specific and appropriate actions on shooting and burning pain, usually of neurogenic origin, ie. trigeminal neuralgia, painful diabetic neuropathy.

Nerve blocks

Nerve blocks or regional anaesthesia can be used as a diagnostic, prognostic or therapeutic tool, or a combination of these.  Regional anaesthesia is effective in managing patients with pain because it interrupts nociceptive input at its source or transmission of nociceptive information in afferent nerves. (7)  Spinal nerves may be involved in transmitting nociceptive informatINO from all parts of the body and consequently are candidates for diagnostic/prognostic and therapeutic nerve blocs.  Examples of cervical nerve blocks include paravertebral block occuipital nerve block, brachial plexus block and phrenic nerve block. thoraciac spinal nerve blocks include intercostal nerve block, intrapleural block and rectus block.  Femoral nerve block, sciatic nerve block and pudendal nerve blocks are performed on the lumbar and sacral spinal nerves.  Other blocks include lumbar sympathetic, coeliac plexus and stellate ganglion blocks.

Stimulation techniques

Transcutaneous electrical nerve stimulation (TENS) and acupuncture are techniques which are said to inhibit pain pathways and stimulate endorphins.  Both modalities are relatively simple and safe in appropriate hands and seem to offer significant benefit to patients.  Dorsal column stimulation involves the insertion of electrodes onto the spinal cord where tiny variable-frequency electrical currents can then be delivered.

Physiotherapy

Physical therapy benefits the patient by improving their personal function ad fitness. Direct results of physical therapy include improved flexibility, increased strength and endurance, and correct use of assistive devices or body mechanics. (8)

Psychological al strategies

A major goal of psychological pain management strategies is to provide the patient with tools for controlling the effects of pain on their lives.  These include relaxation training, sleep management, patient education and cognitive/behavioural therapy (9).

The role of the pain nurse specialist

The specialist nurse performs a key coordinating role within the multidisciplinary pain clinic setting - collaborating, organizing, issues can be assessed and addressed, improving quality of life for this patient group and ensuring continuity of care.  In addition to the nursing aspects, the role includes patient data collection, patient education, assisting with nerve blocks, applying therapeutic modalities (TENS), relaxation, relaxation training and following up patients and their families on their treatment regimens.

The multidisciplinary/interdisciplinary team within the pain clinic setting offers the best available way to manage patients with persistent pain.  The biological, psychological and social issues  can be assessed and addressed, improving quality of life for this complex patient group.


Catherine McGonagle is Clinical Nurse Specialist (Pain Management) at Cork University Hospital

References:

  1. Swerdlow M. A History of the early years of pain relief clinics in the UK and Ireland. Painwise: Irish J of Pain Med 2002; 1: 19-20.
  2. Bonica JJ. Multidisciplinary/interdisciplinary pain programs. In Bonica JJ (ed): Management of Pain. Philadelphia: Lippincott Williams and Wilkins, 2001.
  3. Johnson WL, Abraam SE, Lunch NT, Pain Clinic Organisation and Staffing. In: Amran SE. Haddox JD (eds): the Pain Clinic Manual. Philadelphia: Lippincott Williams & Wilkins, 2000.
  4. Flor H et al. Efficacy of multidisciplinary pain treatment centres: a meta-analytic review. Pain 1992; 49: 221-230.
  5. Association of Anaesthetists of Great Britian and Ireland and the Pain Society. Provision of Pain Servies. London: Assoc Anaesthetists of Great Britain and Ireland and the Pan Society, 1997.
  6. US Department of health and Human Services, Agency for Health Care Policy and Research. Clinical Practice Guideline Number 9: Management of Cancer Pain 1994: 11-16.
  7. Buckley PF. Regional Anaesthesia with Local Anaesthetics. In Bonica JJ (ed): Management of Pain. Philadelphia: Lippincott williams & Wilkins, 2001.
  8. Schramm-Bloodworth Dm. Physical Pherapy in the Pain clinic. In: Amran SE. Haddox JD (eds): the Pain Clinic Manual. Philadelphia: Lippincott Williams & Wilkins, 2000.

 


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