Wessex Deanery
Unit of Training: Pain Medicine
Clinical Lead: Nick Campkin (Chronic) nick.campkin@porthosp.nhs.uk &
Jeremy Nightingale (Acute) Jeremy.nightingale@porthosp.nhs.uk
Regular Consultants:
Chronic Pain- Mike Williams, Rob Baylis, Derek Pounder, Alison Allan
Acute Pain - Nick Barnes, Maya Kai, Ian Taylor
Intermediate Level (ST3/4) Pain Management
Module
Content
1.
2.
3.
4.
5.
6.
Introduction and objectives
Pre-requisite knowledge
Organisation of the pain clinic
Assessment of the chronic pain patient
Treatment of the chronic pain patient
Acute Pain Attachment
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Section I.
Introduction
During your time in Portsmouth you will undertake a 8 week module training in pain
management. You will be allocated a minimum of twenty sessions on your rota: 12
attached to the chronic pain clinic, 6-8 to the acute pain service, and 2 sessions
attached to the Rowans Hospice palliative care team. 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: you should refer to the RCoA website for 2010 curriculum for
intermediate training in pain management and to download workplace based
assessment forms, competency sign-off etc.
Try to complete the section on pre-requisite knowledge (Section 2) before starting your
attachment, as this will refresh the pain competencies achieved as a core trainee.
Prior to / on arrival in the pain clinic
Check with Elisabeth King which day you will be attending the Rowans. This should be
for one full Thursday. Contact Dr P-J Morey (or in her absence Dr Huw Jones), your
clinical supervisor at the Rowans, and let her know when you will be attending. You will
need to obtain a signed record of attendance for completion of the module.
Contact (email or telephone) one of the chronic pain consultants (normally Dr Allan or
Dr Campkin), and one of the acute pain consultants to be your main clinical supervisors.
They will be required to sign you off at the end of your block (two consultant signatures
required), and you therefore need to maintain close contact so that they can assess you
throughout the module and appraise you at the end. Advanced / higher trainees and
other staff e.g. nursing are not authorised to sign off your module.
Familiarise yourself with the organisation of the pain clinic (Section 3) and acute pain
team and introduce yourself to the nursing and administrative staff in both areas before
moving on to clinical assessment and treatment. (Sections 4&5).
During your attachment
Keep a written record of sessions attended and get this signed off by your clinical
supervisor prior to your end-of-module appraisal. You must complete a minimum of the
twenty sessions including at least 12 chronic pain and 2 palliative care to be signed off.
Keep a logbook of patients seen. You may wish to use the logbook available at the
Faculty of Pain Medicine webpages (RCoA website).
You are required to undertake at least one CEX, one DOPS and one CBD in each of
acute and chronic pain (6 WBA in total).
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You may wish to complete the record sheets Appendix B-E; this will help you to see a
wide variety of patient problems and procedures. 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 both your acute pain and chronic pain clinical supervisors. You
will need to present your logbook, signed session diary, palliative care attendance
record, and workplace bases assessments (at least one CEX in acute pain, one CEX in
chronic pain, one DOPS in acute pain, one DOPS in chronic pain, one CBD in acute
pain and one CBD in chronic pain). Feedback will be obtained from the pain team
members. On the basis of this information your clinical supervisors will sign off your
workplace assessment record if they consider that you have met the required training
objectives. You will need to be appraised by both your acute and chronic pain clinical
supervisors to obtain the two signatures on your workplace assessment record(s)
indicating satisfactory completion of the whole pain management training module. Only
consultants may sign off this record: this record will be inspected at your RITA / ARCP.
Generic sign-off form: http://www.rcoa.ac.uk/docs/EndofUnitofTrgSioff.pdf
Objectives
1. You will have a good basic understanding of pain management allowing you to fulfil
the learning outcomes laid out in the Royal College of Anaesthetists 2010 pain
medicine intermediate training curriculum.
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 basic training competencies (RCoA 2010 curriculum) and look up
any sections where your knowledge is lacking.
4. Revise your history taking skills; asking open questions, using appropriate body
language, developing empathy etc. 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 interferes with the patient’s life
(work, sleep, activities, mood etc).
5. Read about assessment tools / questionaires that you may encounter (e.g. Magill
Pain Scale, Oswestry Disability Index, Roland Morris Disability Quotient, SF-36,
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Leeds Assessment of Neuropathic Symptoms and Signs, Hospital Anxiety and
Depression Scale etc).
6. Read about red flags (risk factors for serious pathology) and yellow flags (risk factors
for chronicity) in spinal pain.
7. Read about neuropathic pain (peripheral and central) diagnosis and treatment
options.
8. Revise your neurological examination technique.
Section 3
Organisation of the Pain Clinic
A chronic pain clinic is usually 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.
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 other service that may be available 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:
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(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 cure or do they just want somebody to listen and take their
problem seriously? The initial assessment of the patient forms the start of the
treatment process and is thus vital that it is performed well to build an
effective therapeutic alliance. Often clear and confident explanation and
clarification of misconceptions can lead to acceptance and improved selfmanagement of chronic pain.
(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 treatable pathology may 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
Analgesics
Antidepressants
Anticonvulsants
Miscellaneous e.g. antiarrhythmics, capsaicin, baclofen
Nerve blocks
Temporary – single shot or infusion of LA +/- steroid
Permanent – using ethanol, phenol, radiofrequency (RF), cryoanalgesia
Neuromodulation
TENS
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


PENS
Pulsed RF
SCS
ITDD
Psychological therapies
Education
Relaxation
Diversion
Operant behavioural techniques
Cognitive behavioural techniques
Stress management
Pain management / functional restoration programmes
Physiotherapy
Exercises
Electrical stimulation (e.g. interferential therapy)
Ultrasound
Pulsed shortwave Heat
Massage
Manipulation
Complementary therapies
Acupuncture
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Section 6
Acute Pain
Acute Pain Attachment
It is expected that during your 8-week pain module approximately 1 day per week will be
attached to Acute Pain. During this time you will attend Consultant ward rounds,
accompany the pain nurses on their rounds and if possible participate in an Acute Pain
Study Day. At the end of this period there will be an ALMAT when you will be expected
to run the round with one of the Acute Pain Consultants in attendance.
The aim of the attachment is two-fold: firstly to improve skills in the management of
acute pain and secondly to introduce you to the workings and processes of an Acute
Pain Service.
Organisation of Acute Pain Services
The Acute Pain Service covers all surgical wards and the maternity unit is covered by
the service, although we do see patients on the medical unit if requested.
Four Consultant Anaesthetists & 7 Acute Pain Nurses staff the service, with the majority
of direct assessment and care being provided by the nursing team. Consultant rounds
occur 4 times per week.
Out-of-hours the 2nd on-call anaesthetist becomes the first point of call for Acute Pain
issues.
Pre-requisite knowledge/Assessments
Please ensure you are familiar with the curriculum relevant to your grade. For each unit
of training you need a minimum of one ACEX, one DOPs and one CBD. Consult the
Blueprint at the end of the curriculum document to check the specific needs.
http://www.rcoa.ac.uk/index.asp?PageID=1479
Basic: http://www.rcoa.ac.uk/docs/CCTAnnex%20B.doc#PM
Intermediate: http://www.rcoa.ac.uk/docs/CCTAnnex%20C.doc#PM
Higher (optional): http://www.rcoa.ac.uk/docs/CCTAnnex%20D.doc#PM
Advanced:
http://www.rcoa.ac.uk/docs/CCT%20in%20Anaesthetics%20Annex%20E.doc#PM
Record of patients
You should keep a record of patients you see on Acute Pain Ward rounds.
Particular attention should be paid to Type and Cause of pain, drug combinations and
any unusual techniques observed.
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Key Discussion Topics
Listed below are some areas of Acute Pain practice that you should discuss and
consider during your attachment. As you will see not all are directly clinical, but all are
current points of debate in the service and literature. You may wish to sign these off as
you progress as a reminder – they do relate to much of the Basic and Intermediate
Curriculum.
Topic
Methods of pain assessment
Drugs used in pain management
Nerve blocks for pain management
Discuss relationship between acute & chronic pain
Familiarity with WHO analgesia ladder + multimodal analgesia
Familiarity with techniques for PCA, PCEA and epidural infusions
Management of central and peripheral regional block complications
Central regional blocks and “anticoagulants” (LMWH, clopidogrel )
Principles of acute pain management for opioid dependent patients
Recommendations for the Appropriate Use of Opioids in Persistent
Non-cancer Pain. British Pain Society, RCA, RCGP RCPych
Publication.
Recognition & treatment of acute post-operative neuropathic pain
Pre-emptive treatment for the prevention of neuropathic pain
Acute pain treatment and reduction in chronic pain states
Organisation & objectives of an Acute Pain Service
Criteria for referral to the Chronic Pain Clinic
Nurse prescribing
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Signature Date
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Sign Off:
Once you have completed the unit of training please consult one of the regular
consultants named above, with your logbook, WPBAs and proof of minimum session
completion (see below)
Generic sign-off form: http://www.rcoa.ac.uk/docs/EndofUnitofTrgSioff.pdf
Sessions:
Date
Signature Date
Signature Date
Signature Date
Signature
Useful sources of Information
Books
1. Acute Pain Management: Scientific Evidence. 2nd Edition 2005. Australian & New
Zealand College of Anaesthetists and Faculty of Pain Medicine.
2. Textbook of Pain. 4th Edition 1999. Eds Wall PD, Melzack M.
3. Clinical Pain Management – Acute Pain. 2003.Eds Rowbotham DJ, Macintyre
PE.
4. Clinical Pain Management – Practical Application and Procedures. 2003.Eds
Breivik H, Campbell W, Eccleston C.
Websites
www.iasp-pain.org
www.postoppain.org
www.britishpainsociety.org
www.youranaesthetic.info
www.painnetwork.co.uk
www.anaesthesiauk.com
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www.rcoa.ac.uk
www.aagbi.org
www.pain-talk.co.uk
www.jr2.ox.ac.uk/bandolier/painpag/
http://pompi/acute-pain/links.htm
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Short Answer Questions
Previous exam chronic pain SAQs:
1
a) Define pain. (15%)
b) Distinguish between acute and chronic pain. (15%)
c) What symptoms and signs suggest a diagnosis of neuropathic pain? (40%)
d) What are the possible mechanisms of action of amitriptyline in treating
neuropathic pain? (30%)
2
Describe two assessment tools used for the measurement of acute pain in adults.
(30%)
Describe the McGill pain questionnaire used to assess chronic pain. (20%)
Include the strengths and weaknesses of each of the above. (30%)
Why do assessment tools used in acute and chronic pain differ? (20%)
3
A patient presents to the pain clinic with low back pain. List the indicators (‘red
flags’) that would alert you to the possibility of serious pathology? In their absence
what is the early management of simple mechanical low back pain?
4
What aims and strategies are emphasised in a "Pain Management Programme"?
5
Describe the features and management of phantom limb pain.
6
List, (with examples) the causes of neurogenic pain. What symptoms are
produced? What
treatments are available?
7
a) Describe the symptoms and signs of Complex Regional Pain Syndrome. (50%)
b) How many symptoms and signs are required to make the diagnosis? (20%)
c) What are the other pre-requisites for the diagnosis? (20%)
These can be used for practice or as points of discussion during your acute pain
attachment.
1. Describe an analgesic regime for a 28-year old asthmatic with four fractured ribs.
Discuss the pros and cons of each technique.
2. What are the advantages and disadvantages of Patient Controlled Analgesia
(PCA) for postoperative pain control?
3. What risks would you discuss with a patient having an epidural for perioperative
analgesia for revision hip surgery?
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4. Discuss pain management options for post amputation phantom pain.
5. Compare and contrast the use of systemic opioids and thoracic epidural
bupivacaine administration for postoperative analgesia following elective
abdominal aortic aneurysm repair.
6. Describe the pharmacology of NSAIDS. What adverse effects are associated with
their use?
7. Compare and contrast Pethidine and codeine.
8. What are the analgesic options for pain relief following a day case circumcision of
a 2-year old?
9. What are the characteristics of neuropathic pain? Discuss drugs that would be
appropriately used for this in the postoperative setting.
MCQs
1. With regard to postoperative pain relief:
a) Postoperative pain is more severe following a craniotomy than after
decompression laminectomy
b) Intercostal nerve blocks are more effective in relieving postoperative pain
than paravertebral blocks
c) Adequate postoperative pain relief reduces the incidence of respiratory
complications and thrombosis
d) Patient-controlled analgesia is safer than continuous opiate infusion
e) For relieving post-thoracotomy pain, epidural/intrathecal fentanyl inserted
at the lumbar level is more effective than morphine injected at the same
site
2. With regard to the NSAIDs:
a) They are very effective even in the absence if inflammation
b) They inhibit cyclo-oxygenase
c) Ibuprofen causes less gastric irritation than most NSAIDs
d) Ketorolac as marked anti-inflammatory
e) 50% of asthmatic patients are allergic to aspirin
3. Drugs that produce elevated levels of the following cause analgesia:
a) 5- hydroxytryptamine
b) Substance P
c) Noradrenaline
d) Gamma-aminobutyric acid
e) Prostaglandins
4. Regarding epidurals:
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a) A sensory block to T10 should be adequate for a Caesarean section done
under epidural anaesthesia
b) Segmental spread of local anaesthesia through an epidural increases in
the elderly
c) Excluding caudals in adults, the L2/L3 and L3/L4 interspaces are usually
the easiest places to enter the epidural space
d) The incidence of post-surgical thromboembolic phenomena is reduced with
epidurals
e) Epidurals are contraindicated in patients on prolonged NSAIDs
5. When compared with fentanyl, alfentanil
a) Has a greater volume of distribution
b) Is more potent
c) Causes more bradycardia
d) Is more protein bound
e) Has a longer elimination half-life
6. Alfentanil
a) Is less lipid soluble than fentanyl
b) Is more potent than fentanyl
c) Has a longer half-life than fentanyl
d) Is shorter acting than fentanyl
e) Has several active metabolites
7. Ropivacaine
a) Has an identical pKa to bupivacaine
b) Is less cardiotoxic than bupivacaine
c) Is more potent than bupivacaine
d) Produces greater motor block than bupivacaine
e) Is a pure enantiomer
8. Bupivacaine
a) Is an amide
b) Is highly protein bound
c) Is contraindicated in malignant hyperpyrexia
d) May cause refractory arrhythmias
e) Is the drug of choice for intravenous regional anaesthesia
9. NSAIDs
a) Are useful postoperative analgesia
b) May cause thrombocytopenia
c) Can be given intrathecally
d) Inhibit cyclo-oxygenase
e) Can precipitate renal failure
10. Intrathecal opioids
a) May cause urinary retention
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b)
c)
d)
e)
May cause shivering
May produce total spinal anaesthesia
May produce pruritus, relieved by Propofol
Are unlikely to produce significant respiratory depression
11. Opioid receptors
a) Are currently classified as MOP, DOP, KOP and NOP
b) All share a 6-transmembrane receptor structure
c) When activated cause an increase in neurotransmitter release
d) Are found in the knee joint
e) Possess their own endogenous ligands
12. Tricylic antidepressants
a) Have a rapid onset of action
b) May cause dry mouth and blurred vision
c) May cause tachycardia
d) Do not produce hypotension
e) Inhibit neuronal reuptake of noradrenaline
13. Peripheral nerve
a) A-alpha fibres have a conduction velocity of 70-120m/s
b) B fibres are unmyelinated
c) A-beta fibres convey afferent touch stimuli
d) Unmyelinated fibres can transmit at only 20m/s
e) Conduction velocity is dependent upon nerve fibre diameter
14. The following are excitatory transmitters in the CNS
a) Glycine
b) Aspartate
c) Glutamate
d) GABA
e) 5-hydroxytryptamine
15. Pharmacological effects of morphine include
a) Constipation
b) Biliary spasm
c) Histamine release
d) Cough
e) Release of antidiuretic hormone
16. Fentanyl
a) Has potency 10 times that of morphine
b) Is water-soluble
c) Has a large volume of distribution
d) Does not accumulate even after repeated doses
e) Is metabolized to norfentanyl
17. Diclofenac
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a)
b)
c)
d)
e)
Works by inhibiting lipo-oxygenase
May increase renal blood flow
Has anti-pyretic activity
Reversibly promotes platelet aggregation
May be used in the last trimester of pregnancy
18. Tramadol
a) Is a controlled drug
b) Can be administered IV
c) Has affinity for binding at the mu opioid receptor comparable to that of
morphine
d) Acts predominantly by inhibiting the reuptake of noradrenaline + serotonin
e) May be used concurrently with a MAOI
19. The following are capable of directly causing pain when applied to nerve endings
a) Prostaglandins
b) Bradykinins
c) Histamine
d) Serotonin
e) Potassium
20. Factors influencing the perception of pain include
a) Anxiety
b) Depression
c) Muscle tension
d) Fatigue
e) Age
21. The metabolism of morphine includes
a) Acetylation
b) Demethylation
c) Oxidation
d) Methylation
e) Conjugation with glucuronide
22. Gabapentin
a) Inhibits GABA receptors
b) Binds to voltage-gated calcium channels
c) Is useful in the management of neuropathic pain
d) Main side effect is euphoria
e) Is administered once daily
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MCQ Answers
1. FFTTF
2. FTTFF
3. TFTTF
4. FTTTF
5. FFFTF
6. TFFTF
7. TTFFT
8. TTFTF
9. TFFTT
10. TTFTF
11. TFFTT
12. FTTFT
13. TFTFT
14. FTTFF
15. TTTFT
16. FFTFT
17. FFTFF
18. FTFTF
19. FFTTT
20. TTTTT
21. FTTTT
22. FTTFF
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