Pain management (also called pain medicine) is the discipline concerned with the relief of pain.
Acute pain, such as occurs with trauma, often has a reversible cause and may require only transient measures and correction of the underlying problem.
In contrast, chronic pain often results from conditions that are difficult to diagnose and treat, and that may take a long time to reverse. Some examples include cancer, neuropathy, and referred pain.
Often, pain pathways are set up that continue to transmit the sensation of pain even though the underlying condition or injury that originally caused pain has been healed.
In such situations, the pain itself is frequently managed separately from the underlying condition of which it is a symptom, or the goal of treatment is to manage the pain with no treatment of any underlying condition (e.g. if the underlying condition has resolved or if no identifiable source of the pain can be found).
Pain management generally benefits from a multidisciplinary approach that includes pharmacologic measures (analgesics such as narcotics or NSAIDs and pain modifiers such as tricyclic antidepressants or anticonvulsants), non-pharmacologic measures (such as interventional procedures, physical therapy and physical exercise, application of ice and/or heat), and psychological measures (such as biofeedback and cognitive therapy).
Pain management practitioners come from all fields of medicine.
Most often, pain fellowship trained physicians are anesthesiologists, neurologists, physiatrists or psychiatrists.
Some practitioners focus more on the pharmacologic management of the patient, while others are very proficient at the interventional management of pain.
Interventional procedures - typically used for chronic back pain - include: epidural steroid injections, facet joint injections, neurolytic blocks, Spinal Cord Stimulators and intrathecal drug delivery system implants, etc.
Over the last several years the number of interventional procedures done for pain has grown to a very large number.
As well as medical practitioners, the area of pain management may often benefit from the input of Specialist Nurses, Physiotherapists, Clinical Psychologists & Occupational therapists, amongst others.
Together the multidisciplinary team can help create a package of care suitable to the patient.
In 1994 The Royal National Hospital For Rheumatic Diseases set up The Pain Management Unit to provide intensive programmes for adults with Chronic Pain.
In 1999 the first Pain Management Programme for adolescents in Europe began.
The Bath Pain Management Unit was established in 1994 to provide intensive rehabilitation programmes for adults with chronic pain, and to research and develop effective chronic pain treatments.
The unit has both a national and an international reputation for its clinical services and research.
Our programmes aim to enhance daily functioning; allowing individual’s to return to activities that are important to them.
We are an interdisciplinary team made up of Clinical Psychologists, Physiotherapists, Occupational Therapists, Nurse Specialists and Consultant / Specialist Registrars.
Our treatments are group based and we run both residential and outpatient programmes.
Residential programmes range from 3 to 4 weeks in length, while outpatient groups run twice a week for 6 weeks.
The service is diagnostically non-specific.
Accordingly, our assessment criteria are only that an individual’s pain should be persistent, disabling and unresponsive to other therapies.
The unit is a national service, and accepts referrals from throughout the UK.
Referrals generally come from general practitioners (GPs) or other NHS / private medical consultants.
This multi-disciplinary inpatient and outpatient service accepts national referrals from medical personnel for those adults suffering with Complex Regional Pain Syndrome.
The emphasis is on physical rehabilitation and all patients will initially be assessed as an outpatient by the multi-disciplinary team (MDT) prior to consideration for inpatient care.
Inpatient care involves a two week stay which will include a full MDT assessment, patient centred goal setting, concentrated physical rehabilitation and information on the condition.
Where relevant and available ongoing care will be discussed with the patient’s local MDT with expert support from the RNHRD CRPS team.
Research is integrally involved in this programme and patients will be invited to complete questionnaires to assess various aspects of their condition and how it affects their lives and the impact of treatments.
Novel therapeutic techniques are also used including mirror visual feedback.
The CRPS integrated care pathway maps the journey of the patient and provides a detailed overview of all clinical processes.
The ICP ensure that high quality, evidenced based care is delivered in a consistent manner by all members of the multi-disciplinary team from referral to either ongoing care in the patient’s local communities or to discharge.
Who to contact for information Dr Candy McCabe: Candy.mccabe@rnhrd-tr.swest.nhs.uk Phone number: 01225 787047
We are a multi-disciplinary research active group. Our specialist areas of interest are the mechanisms behind CRPS, the patient’s experience of living with the condition and novel therapeutic interventions.
We are supported by an ‘in-house’ clinical measurement laboratory which enables assessment of autonomic responses to interventions and altered condition states.
We collaborate with national and international experts in the field and communicate via research and clinical networks with other specialist centres across the UK.
Established over 16 years ago, INPUT is the UK's pre-eminent cognitive behavioural pain management programme.
The unit offers a number of different treatment programmes for sufferers with severe intractable pain where distress and disability is prominent and symptoms have not resolved through medical or surgical treatment.
Referral criteria:
Referral criteria for INPUT Pain Management:
Programmes are:
*Pain longer than one year
*No further pain interventions planned
*Pain having a significant impact on patient’s quality of life
*Ability to function within a group setting
*A basic standard of reading and writing
Exclusion factors are:
*Active psychosis
*Actively suicidal
*No alcohol or illicit drug misuse
*Cognitive impairment
*High physical care needs that require nursing care (Work up will be available for patients who are less confident in their abilities to self-care)
*Inability to speak English
Referral has to be made either by a General Practitioner (GP) or Consultant attached to an NHS Hospital.
Please send all Referrals to:
Pain Management St Thomas' Hospital Lambeth Palace Road London SE1 7EH
Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
Acute pain is associated with acute injury or disease.
Chronic pain is defined as pain that has persisted for longer than three months or past the expected time of healing following injury or disease.
Patients with cancer may suffer from both acute and chronic pain.
Epidemiological studies have revealed widespread unrelieved pain throughout society.
A Pain Management Programme (PMP) is a psychologically-based rehabilitative treatment for people with chronic pain which remains unresolved by other treatments currently available.
It is delivered in a group setting by an interdisciplinary team of experienced health care professionals working closely with patients.
Some Pain Centres may run Pain Management Programmes that aim to teach a group of patients with similar problems about pain, how best to cope with it and how to live a more active life, others may offer acupuncture and other complementary therapies.
For the majority of people, attending a Pain Management Programme reduces the disability and distress caused by chronic pain by teaching physical, psychological and practical techniques to improve quality of life.
It differs from other treatments provided in Pain Clinics in that pain relief is not the primary goal, although improvements in pain following participation in a Pain Management Programme have been demonstrated.
Referral to a Pain Management Programme is usually via your local pain clinic.
People with chronic pain may be able to attend a specialist Pain Clinic for assessment and possible pain management, together with advice on living a fuller life in spite of pain.
Pain Clinics vary in the treatments offered and not all hospitals may have a specific pain clinic.
Sometimes a Consultant with an interest in pain will prescribe drugs or give injections to try to control pain.
Other clinics have teams of doctors, psychologists, nurses, physiotherapists, occupational therapists and others.
For more information on pain clinics in your area, please send us an email at: clinic@britishpainsociety.org with your full address, including post code and we will send you a list of your ten nearest pain clinics; you may also contact us by telephone on 020 7269 7840.
Please note that you will need to be referred to a pain clinic by your GP or hospital consultant.
Mindfulness-Based Cognitive Therapy (MBCT) is a method of therapy which blends features of two disciplines:
Cognitive therapy aims to identify and alter cognitive distortions (warped or inaccurate thoughts);
Mindfulness is a meditative practice from Buddhism, which aims to help people identify their thoughts, moment by moment, but without passing judgement on the thoughts.
In MBCT, the patient is invited to recognize and accept feelings as they come and go instead of trying to push them away.
Traditional cognitive therapy, or cognitive behavioral therapy (CBT), focuses on changing negative content of thoughts while MBCT emphasizes the process of paying attention to thoughts and feelings moment by moment and without judgment.
Changing the patient's relationship to the suffering caused by negative thoughts is the key because there is no possible way to alleviate all suffering.
No therapy or meditation will prevent unpleasant things from happening in our daily lives but the two practices combined may provide more objectivity from which to view these unpleasant things.
MBCT's main technique is based on the Mindfulness-Based Stress Reduction (MBSR) eight week program, developed by Jon Kabat-Zinn in 1979 at the University of Massachusetts Medical Center.
Research shows that MBSR is enormously empowering for patients with chronic pain, hypertension, heart disease, cancer, and gastrointestinal disorders, as well as for psychological problems such as anxiety and panic.
People often misunderstand the goal of therapy and especially mindfulness.
Relaxation and happiness are not the aim, but rather a "freedom from the tendency to get drawn into automatic reactions to thoughts, feelings, and events" .[1]
Patients change the relationship to chronic pain so the pain becomes more manageable.
Mindfulness-Based Cognitive Therapy grew largely from Jon Kabat-Zinn's work. Zindel V. Segal, J. Mark G. Williams and John D. Teasdale helped adapt the MBSR program so it could be used with people who had suffered repeated bouts of depression in their lives. Currently, MBCT programs usually consist of eight-weekly two hour classes with weekly assignments to be done outside of session.
The aim of this program is to enhance awareness so we are able to respond to things instead of react to them.
"We can respond to situations with choice rather than reacting automatically.
We do that by practicing to become more aware of where our attention is, and deliberately changing the focus of attention, over and over again".[2]
The structure of MBCT requires strong commitment and work on the clients' part but the rewards can be lasting.
Patients participating in the program meet as a group on a weekly basis.
The Mindful Way Through Depression is used as the patient manual for the program and contains guided Mindfulness practices on CD that are assigned as homework.[3]
Research is now showing the effectiveness of mindfulness in the prevention of relapse.
The UK National Institute for Health and Clinical Excellence (NICE) has recently endorsed MBCT as an effective treatment for prevention of relapse.
Research has shown that people who have been clinically depressed three or more times (sometimes for twenty years or more) find that taking the program and learning these skills helps to reduce considerably their chances that depression will return.
In a study conducted with 145 participants, all the patients had previously recovered from depression and then relapsed.
These sufferers were split randomly into groups providing different methods of treatment.
Within a year, patients who were undergoing MBCT "reduced relapse from 66% (control group) to 37% (treatment group)".[4]
"Whereas most people might be able to ignore sad mood, in previously depressed persons a slight lowering of mood might bring about a potentially devastating change in thought patterns".[5]
The core skill of MBCT is to teach the ideas of recognizing these thought patterns in order to break away from the false constructs of our mind.
Relapse is avoided because the onset of depression is recognized before it has fully developed.
The vicious cycle is stopped before it even gets started.
study into three different physiotherapy treatments for chronic low back pain has found that physiotherapist-led pain management works as well as other methods and could lead to savings for the NHS in fewer referrals for further treatment.
The research, funded by arc, has just been published in the journal Spine.
In the study, carried out at King’s College London and Guy’s and St. Thomas’ NHS Foundation Trust, 212 patients with chronic low back pain were randomly allocated to one of three kinds of physiotherapy: *1) Individual (one-to-one) physiotherapy, and two new group treatments *2) spinal stabilisation exercise and *3) pain management.
Participants were assessed at six, 12 and 18 months.
All three treatments worked and people showed good improvements in disability, pain and quality of life after their respective therapies.
However, people who followed the pain management programme were four times less likely to visit a consultant and had fewer investigations (x-rays, blood tests, MRI scans) or procedures (injections, surgery).
One of the lead investigators, Duncan Critchley, from the Academic Department of Physiotherapy at King’s College London, said: “Above all we’ve shown that all three physiotherapy regimens improved people’s quality of life.
But the most cost-effective is pain management and ultimately, fewer referrals for further tests and treatment could save the NHS more than £126 million a year.”
Sandra Noonan, Superintendent Physiotherapist at Guy’s and St. Thomas’ NHS Foundation Trust added: “Chronic low back pain is a very distressing condition for a large number of people in this country so we were delighted that the study showed that all three treatments worked.
Comparing them in this way has given us some extremely helpful findings.”
Around 17 million people in the UK suffer from back pain every year and 1.6 million of these people are referred to NHS physiotherapy every year.
More than 110 million days sick-leave are taken a year because of low back pain per year, costing the economy approximately £9 billion.
*1. Individual physiotherapy is the current most usual kind of physiotherapy for low back pain. This consists of a combination of exercises, manipulation and advice specific to the individual’s problems. The exercises are taught in the clinic but usually performed at home.
*2. ‘Spinal stabilisation’ exercises are for specific stomach and back muscles that protect the spine but sometimes work incorrectly in people with back problems.
*3. In pain management, exercises are aimed at improving general fitness and flexibility and also at increasing people’s confidence so they can move without damaging or re-injuring their back.
This is allied with a structured programme of education and advice about coping with back pain.
The Physiotherapy Pain Association (PPA) was set up in 1994 for Chartered Physiotherapists with an interest in pain.
It was recognised as a Clinical Interest Group of the Chartered Society of Physiotherapy (CSP) in 1996.
Its objectives include the promotion of relevant research, effective treatments and education and training in pain and its management.
These standards appertain to physiotherapy practice within interdisciplinary Pain Management Programmes (PMPs).
This is a rapidly developing area of clinical practice.
The background knowledge and practical skills required for this speciality are not taught systematically at undergraduate level in physiotherapy education, neither is there a recognised route to gaining these competencies either during pre-qualifying or post-qualifying education.
It was therefore necessary to develop standards of practice for physiotherapists working in this speciality in order to ensure best practice and to assist in the identification of training needs to achieve this.
Due to the rapid proliferation of PMPs and the fact that treatment is based on a psychological rather than a medical model it was felt that it would be helpful to have unidisciplinary standards whilst continuing to recognise the importance of interdisciplinary team standards.
The physiotherapist is a core member of the interdisciplinary team (Pain Society, 1996), having competencies key to this type of rehabilitation.
This specific role in pain management and within the pain management team has continued to develop.
These standards should be read in conjunction with the CSP Standards of Physiotherapy Practice (CSP, 1993) and other relevant speciality standards and Directives. They will be reviewed in 1999.
The standards have been developed by a working party of the Physiotherapy Pain Association, who are grateful for the help and support of Judy Mead MCSP, Senior Professional Advisor, CSP.
The physician faced with a patient in chronic pain has several important tasks.
The first is obviously the assessment of the pain and its various causes, including physical and psychological components.
Realising that pain is a bio-psycho-social phenomenon, all of these aspects have to be addressed in the history and evaluation of the patient.
Only when a proper evaluation has been made can appropriate treatment be carried out.
Only the most naive of clinicians would take a simplistic mechanistic approach, or indeed go the other way and dismiss pain as "all in the mind".
Such assessment is complex and beyond the scope of this short presentation.
However, I make it clear that this has to be undertaken, and undertaken well.
Not only does the pain have to be evaluated, but so does the distress that it causes the sufferer and whether this feeds back to have a major part of the pain itself.
Finally disability has to be considered; is it appropriate for the known nociceptive disease, or inappropriate? Is the disability that has developed a major factor in the chronicity?
Once this assessment has been made, management can be developed along appropriate lines.
The distress should be minimised and disability should be reduced. Sometimes this can be done with great effect (eg, through Pain Management Programmes) without altering the actual amount of pain.
On the other hand, sometimes relief of the pain (for instance appropriate intervention) will alleviate distress and reverse the disability.
In most cases it is impossible to completely alleviate pain and thus a management plan has to be agreed with the patient.
This may involve a rehabilitation approach, including increased mobility, perhaps in conjunction with a physiotherapy team, or the patient's own exercise programme.
These will be facilitated by appropriate analgesic techniques.
These various techniques will now be considered.
The different types of strategies that can be applied are as follows:
The Pain Management Programme consists of a combination of modern concepts of chronic pain (hurt does not equate to harm); the use of positive coping strategies; group general strengthening, stretching and light aerobic exercises progressed according to pacing principles; and the encouragement of a graded return to usual activities with goal-setting.
A cognitive-behavioural approach is used.
Physiotherapist-led general exercise and brief education in small groups has been shown to reduce disability and health-care costs compared with best primary care.
(UK BEAM Trial Team 2004) and is just as clinically effective, results in fewer repeat visits to doctors and is more cost-effective than usual individual physiotherapy (Critchley et al 2007).
