Spr1&2 Chronic Pain Attachment

SpR1&2 Chronic Pain Attachment

Please read thoroughly as it is your responsibility to get signed up for this attachment

Content

1. Introduction and objectives

2. Pre-requisite knowledge

3. Organisation of the pain clinic

4. Assessment of the chronic pain patient

5. Treatment of the chronic pain patient

6. Appendix

(A) Patient pain scores audit

(B) Record of discussion topics

(D) Record of chronic pain problems seen

(E) Record of procedures

(F) Self assessment exercises

(G) Glossary

(H) Literature selection and web sites

(I) SHO and SpR1/2 competencies

(J) Feedback form for appraisal

(K) Workplace Assessment Record

Section I.

Introduction

During your SpR 1/2 training you will spend six weeks WTE undergoing training in pain management. You will be attached to a chronic pain clinic, with one day per week attached to the acute pain service. For many of you this will be your first contact with a chronic pain clinic and to ensure that you make the most of your attachment we have put together a short teaching guide. It is by no means a comprehensive overview but should enable you to satisfy most of the competencies relevant to chronic pain listed in Appendix (I)

Try to complete the section on pre-requisite knowledge (Section 2) before starting your attachment, as this will refresh the pain competencies achieved as an SHO.

On arrival in the pain clinic firstly familiarise yourself with the organisation of the pain clinic (Section 3) before moving on to assessment and treatment of the chronic pain patient (Sections 4&5). You should approach one of the consultants to be your clinical supervisor. They will be required to sign you off at the end of your block; it is very helpful for them to know this in advance of you presenting them with your form.

During your attachment complete the record sheets Appendix B-E; this will help you to see a wide variety of patient problems and procedures. Pick three interesting cases that you have seen (preferably with different aetiology e.g. nociceptive, neuropathic and cancer pain) and write them up as short case histories. There are also some MCQ’s and SAQ’s for those of you who are preparing for the FRCA.

At the end of your attachment you will be appraised by your pain clinic clinical supervisor. You will need to present your logbook and feedback will be obtained from the team members. On the basis of this information your clinical supervisor will sign off your workplace assessment record if he/she considers that you have met the required training objectives. You will also need to be appraised by your acute pain clinical supervisor to obtain the other signature on your workplace assessment record(s) indicating satisfactory completion of the whole pain management training module. This record will be inspected at your RITA.

Objectives

1. You will have a good basic understanding of chronic pain management allowing you to fulfil the knowledge, skills, attitudes and workplace training objectives laid out in the document from the Royal College of Anaesthetists.

2. You will have had sufficient exposure to chronic pain management to decide if you wish to continue further with training in this subspecialty.

Section 2

Pre-requisite Knowledge

1. Read Appendix G to familiarise yourself with pain management terminology.

2. Revise the anatomy relevant to the procedures listed in Appendix E.

3. Read through the SHO competencies in Appendix I and look up any sections where your knowledge is a little hazy. Some of the acute pain competencies will be relevant but concentrate on the chronic pain aspects.

4. Revise your history taking skills; asking open questions, using appropriate body language, developing empathy etc. Sit back and really listen to what the patient is telling you, and what their expectations are. There will be specific questions that you will want answers to but it is advisable not to try and close the questioning too soon. Think about descriptions of pain and how having chronic pain might interfere with the patient’s life: read through the pain clinic audit questionnaire (Appendix A). Some consultants use a proforma for documentation of the history and examination of a new patient; you may find this helps but you do need to be familiar with its content before trying to use it.

5. Revise your neurological examination technique.

Section 3

Organisation of the Pain Clinic

The pain clinic is made up of a multidisciplinary team including doctors (mostly anaesthetists although they may include other specialities such as palliative care, neurology, orthopaedics, rheumatology, rehabilitation medicine and psychiatry), nurses trained in pain management, psychologists, physiotherapists, occupational therapists, social workers and radiographers. Not all pain clinics will have the full range of personnel mentioned above but they will probably have access to them. Palliative care and the management of cancer pain form an essential part of your pain management training: you should aim to spend a day visiting the local hospice (arrange this through your educational supervisor).

If you look at the treatment options listed in Section 5 you will see that nerve blocks make up a very small part of the work that goes on in the pain clinic. We suggest that you do not get side-tracked into trying to become an expert in cervical epidurals etc. but try to see the full range of pain clinic treatments. There is a list in Appendix C to guide you towards some of the less obvious activities that are going on in the pain clinic.

Section 4 Assessment of the Chronic Pain Patient

Patients seen in the chronic pain clinic do not simply have an acute pain that is longstanding. Once a condition becomes chronic, secondary changes make for a complex situation, the management of which involves treating complications of the condition as well as the condition itself. Chronic pain is not just a symptom; it is an illness. It has its own symptoms, signs and complications and thus the assessment of the chronic pain patient does not follow the same pattern as the assessment of a patient with an acute problem.

The assessment can be broken down into:

(a) Background information. By the very nature of their problem patients may not be referred from the GP directly to the pain clinic as their first port of call. Many patients will have been passed from specialist to specialist in an attempt to diagnose and treat their symptoms. A clear record of whom they have seen in the past together with the outcome of any investigations and treatment are important parts of the history. This may well affect their attitudes and expectations of their visit. Are they expecting a diagnosis together with a miracle cure or do they just want somebody to listen and take their problem seriously? The initial assessment of the patient often forms the start of the treatment process and is thus vital that it is performed well.

(b) History. The pain must be assessed from a multidimensional perspective, determining not only physical aspects, but also behavioural, psychological and social contributing factors and the disruption that pain causes to normal function. To achieve this the history taking may involve the patient, their relatives, questionnaires, body drawings, and pain diaries. It is also important to remember that pathologies, which may be better treated in other clinics, still need to be excluded.

(c) Examination. This is not performed solely to form a diagnosis but has many other functions. It may exclude other conditions, reassure the patient that their pain warrants no further investigation or surgery, find physical signs associated with their pain, define baseline signs and monitor changes, and assess non-physiological responses.

Spend time observing patient assessment before taking the history yourself. Initially you may find it difficult to combine allowing the patients to talk freely in their own time about their pain, whilst remembering that you have not got all morning to see one patient!

Section 5 Treatment Modalities for the Chronic Pain Patient

· Drugs

1. Analgesics

2. Antidepressants

3. Anticonvulsants

4. Miscellaneous e.g. antiarrhythmics, capsaicin, baclofen

· Nerve blocks

1. Temporary – single shot or infusion of LA +/- steroid

2. Permanent – using ethanol, phenol, radiofrequency ablation, cryotherapy,

· TENS

· Implantable devices

1. Pumps

2. Dorsal column stimulation

· Psychological therapies

1. Education

2. Relaxation

3. Diversion

4. Operant behavioural techniques

5. Cognitive behavioural techniques

6. Stress management

7. Pain management programs

· Physiotherapy

1. Exercises

2. Electrical stimulation (e.g. interferential therapy)

3. Ultrasound

4. Pulsed shortwave Heat

5. Massage

6. Manipulation

· Complementary therapies

1. Acupuncture

2. Hypnotherapy

3. Reflexology

4. Homoeopathy

5. Aromatherapy

6. Shiatsu

Nick Campkin / Heather Knight 2006

Appendix A

PAIN CLINIC

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PATIENT TREATMENT ASSESSMENT FORM

PATIENT'S NAME: CLINIC DATE:

Please circle your response or ask for help if you are having problems.

1. How much Relief have pain treatments or medications FROM THIS CLINIC provided? Please circle the one percentage that most shows how much relief you have received.

No 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Complete

Relief relief

2. Please rate your pain by circling the one number that best describes your pain at its WORST in the past week.

No 0 1 2 3 4 5 6 7 8 9 10 Pain as bad

Pain as you can imagine.

3. Please rate your pain by circling the one number that best describes your pain at its LEAST in the past week.

No 0 1 2 3 4 5 6 7 8 9 10 Pain as bad

Pain as you can imagine.

4. Please rate your pain by circling the one number that best describes your pain on the AVERAGE.

No 0 1 2 3 4 5 6 7 8 9 10 Pain as bad

Pain as you can imagine.

5. Please rate your pain by circling the one number that tells how much pain you have RIGHT NOW.

No 0 1 2 3 4 5 6 7 8 9 10 Pain as bad

Pain as you can imagine.

6. Circle the one number that best describes how, during the past week, PAIN HAS INTERFERED with your:

a. GENERAL ACTIVITY