MANAGING PATIENTS
WITH CHRONIC PAIN
Dr Lorraine de Gray
Lead Consultant in Pain Medicine, QEH
Chair, UK Regional Advisors in Pain Medicine,
Faculty of Pain medicine, Royal College of
Anaesthetists
BACK PAIN - A SLIPPERY
SLOPE

CASE SCENARIO 1
IE is a 55 year old male who presents with a four
month history of intractable low lumbar back
pain.
 He is struggling to work (accounts clerk)
 He has tried over the counter analgesics
 His wife has made him come and see you
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What questions would you ask?
USEFUL TO KNOW:
Type of pain
 Radiation?
 Referral?
 Weight loss?
 What makes it better?
 Sitting, standing, walking?
 Any bladder symptoms
 Any other relevant clinical symptoms?
 Any relevant past medical history
 Any relevant past medical history
 Smoker?

INFLUENCES ON THE PAIN EXPERIENCE
Age
Fear
s
Education
and
understandin
g
Gende
r
Pai
n
Previous
pain
experience
(self/family)
Culture
EXAMINATION
Paraspinal spasm low lumbar bilaterally
 Pain worse on extending the spine
 Lower limbs normal power, sensation, reflexes
 Positive straight leg raise at 60 degrees
bilaterally
 Looks well otherwise

Outcome measures
 Oswestry
 Roland Morris
 PHQ 9
 HADS

WHAT DO YOU DO?
WHAT DO YOU DO?
Reassure
 Simple analgesics, NSAIDS +/- muscle relaxant
 Heat
 Physiotherapy/Manual therapy via back pain
pathway


Review in four weeks
FOUR WEEKS LATER
No better
 Off work
 “Physiotherapy made me worse”
 His wife comes with him and says you have to
sort him out.
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
What do you do?
RED FLAGS
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Gross neurology
Sphincter disturbance
Saddle anaesthesia
Up going planters
Weight loss
History of malignancy
Recent significant trauma
Severe thoracic back pain
Severe bilateral leg pain
Spinal deformity
Severe constant night pain
Gait disturbance
Fever or night sweats
YELLOW FLAGS
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Personal
Fear avoidance
Pessimism depression, expressed stress, anger and
sometimes sleeplessness
Illness behaviour and adoption of the sick role
Passivity (external locus of control)
Helplessness
Tendency to see pain in a catastrophic light
Family: beliefs, expectations, reinforcement
Work: job satisfaction, difficulty working with pain,
flexibility of employer, work options
Non-health problems (financial, marriage?)
Mobility and function
Hobbies and pleasures. Restrictions
PAIN CLINIC
Undiagnosed back pain
 Likely mechanical
 Need to exclude sinister underlying cause
 Need to help patient understand why he has pain
 Take history
 Examine


What do I do?
BEST TOOL
Why Does
The
Patient
Hurt?
BLOOD TESTS
Full blood count
 Bone profile
 PSA
 Serum protein electrophoresis – Bence Jones
proteins
 CRP
 ESR

IMAGING??
MRI
Any
scan or REASSUROgram
point in doing a lumbar
spine X-ray?
Invalidism
Sick leave
Avoidance
Chronic
Depression
Helplessness
Failed treatment
Anger &blame
Catastrophising
Uncertainty & fear
Acut
e
OBJECTIVES OF CHRONIC PAIN
MANAGEMENT
Alleviate pain
 Alleviate psychological and behavioural
dysfunction
 Reduce disability and restore function
 Rationalize usage of medicines
 Reduction of utilization of health care
services
 Attention to social, family and occupational
issues

MANAGEMENT PLAN
Explain, explain and explain again
 Look at medication – is it nociceptive,
neuropathic or mixed pain
 Practical pain management advice
 ?Intervention – role of facet joint injections
 Back programme
 Support Back to work, ergonomics, employment
support

LUMBAR FACET JOINT INJECTIONS
TO INTERVENE OR NOT TO INTERVENE?
Spinal injections are simply a way of giving
patients a window of pain relief. They are not a
long term fix. Even a successful denervation will
not last more than eighteen months as a
procedure in its own right.
 Patients need multidisciplinary input aimed at
improving their pain management skills

Pain Management Advice seminars
 Back Programme
 Individual physiotherapy (including
hydrotherapy)
 Individual psychotherapy
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SUGGESTED READING
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Back Pain Revolution: Gordon Waddell 2004
2nd edition
British Medical Journal – EDITORIAL Red
flags for back pain BMJ 2013; 347 doi:
http://dx.doi.org/10.1136/bmj.f7432 (Published 12
December 2013)
NICE guidelines – CG 88 (2009)
WIDESPREAD BODY PAIN
CHRONIC FATIGUE SYNDROME
CASE PRESENTATION
33 year old woman
 Five year history of widespread body pain
 Chronic headaches, irritable bowel, irritable
bladder
 Low mood
 Constant fatigue, can’t do anything, can’t
concentrate, can’t sleep
 Joints feel swollen, non dermatomal upper and
lower limb pain
 Tried a variety of analgesics and antidepressants – none help
 Unable to cope at home, two small children,
partner unsympathetic

DIFFERENTIAL DIAGNOSIS
Inflammatory arthropathy
 Polymyalgia rheumatica
 Somatiform disorder/primary mental health
problem
 Hypothyroidism
 Lyme’s disease
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MAJOR CHALLENGES
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Lack of trust in the medical system
Multitude of symptoms
Yellow flags
Keep an open mind
Manage in a holistic way
Engage multidisciplinary pain management
Neuropathic medication
Physiotherapy to improve level of function
Psychology: group, individual
Occupational therapy
Complementary therapy – TENS, acupuncture
Where appropriate involve mental health services
Fibromyalgia Support groups
SUGGESTED READING
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Arnold LM, Sarzi-Puttini P, Arsenault P, et al. Efficacy and safety of Pregabalin in patients with
fibromyalgia and co-morbid depression receiving concurrent antidepressant therapy: a randomized,
2-way crossover, double-blind, placebo-controlled study [abstract L6]. Presented at: American
College of Rheumatology (ACR) 2013 Annual Meeting; October 29, 2013; San Diego, California.
Available at https://ww2.rheumatology.org/apps/MyAnnualMeeting/Abstract/39039. Accessed
November 11, 2013
Yunus MB. Fibromyalgia and overlapping disorders: the unifying concept of central sensitivity
syndromes. Semin Arthritis Rheum. Jun 2007;36(6):339-56. [Medline].
Gracely RH, Petzke F, Wolf JM, Clauw DJ. Functional magnetic resonance imaging evidence of
augmented pain processing in fibromyalgia. Arthritis Rheum. May 2002;46(5):1333-43. [Medline].
Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary
diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res
(Hoboken). May 2010;62(5):600-10. [Medline].
Crombez G, Eccleston C, Van den Broeck A, et al. Hypervigilance to pain in fibromyalgia: the
mediating role of pain intensity and catastrophic thinking about pain. Clin J Pain. Mar-Apr
2004;20(2):98-102. [Medline].
NEUROPATHIC PAIN ?CAUSE
SPEED IS OF THE ESSENCE
CLINICAL PRESENTATION
35 year old female otherwise healthy
 Trapped her left index finger in a door a two
weeks ago. At the time, finger bruised, treated
with cold compress, and simple analgesics
 She comes to see you, complaining of severe pain
in her left finger and hand. The pain is burning
in nature and keeping her awake
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What do you ask?
CLINICAL SCENARIO
COMPLEX REGIONAL PAIN SYNDROME
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CRPS type I requirements feature causation by
an initiating noxious event, such as a crush or
soft tissue injury; or by immobilization, such as a
tight cast or frozen shoulder.
CRPS type II is characterized by the presence of
a defined nerve injury.
Both types demonstrate continuing pain,
allodynia, or hyperalgesia that is usually
disproportionate to the inciting event.
IASP REVISED CRITERIA FOR CRPS
 Continuing
pain that is disproportionate
to any inciting event
 At least 1 symptom reported in at least 3
of the following categories:
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Sensory: Hyperesthesia or allodynia
Vasomotor: Temperature asymmetry, skin colour
changes, skin colour asymmetry
Sudomotor/oedema: Oedema, sweating changes, or
sweating asymmetry
Motor/trophic: Decreased range of motion, motor
dysfunction (eg, weakness, tremor, dystonia), or
trophic changes (eg, hair, nail, skin)
IASP REVISED CRITERIA FOR CRPS

At least 1 sign at time of evaluation in at least 2 of
the following categories:
Sensory: Evidence of hyperalgesia (to pinprick), allodynia (to
light touch, temperature sensation, deep somatic pressure, or
joint movement)
 Vasomotor: Evidence of temperature asymmetry (>1°C), skin
colour changes or asymmetry
 Sudomotor/oedema: Evidence of oedema, sweating changes, or
sweating asymmetry
 Motor/trophic: Evidence of decreased range of motion, motor
dysfunction (eg, weakness, tremor, dystonia), or trophic
changes (eg, hair, nail, skin)
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No other diagnosis better explaining the signs
and symptoms
COURSE OF CRPS
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The severity rather than the aetiology seems to determine the disease
course.
Age, sex and affected side are not associated with the outcome .
Fractures may be associated with a higher resolution rate (91%) than
sprain (78%) or other inciting event (55%) .
A low skin temperature at the onset of the disease may predict an
unfavourable course and outcome
A retrospective analysis of 1006 CRPS cases, mostly female, and
younger patients with CRPS of the lower limb showed an incidence of
severe complications in about 7%, such as infection, ulceration, chronic
oedema, dystonia and/or myoclonus
RECURRENCE OF CRPS
In 1183 patients (Veldman et al) the incidence of
recurrence was 1.8% per year.
 The patients with a recurrent CRPS were
significantly younger but did not differ in gender
or primary localization. The recurrence of CRPS
presents more often with few symptoms and
signs and spontaneous onset.
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SPEED IS OF THE ESSENCE WITH CRPS
Urgent referral to pain clinic
 Physiotherapy:
 Desensitization, graded motor imagery
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Medication
 Sympathetic nerve block: Stellate ganglion block
 Occupational therapy
 Neuromodulation
 Ongoing trials with immunoglobulin
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GRADED MOTOR IMAGERY
Step 1 - Laterality Reconstruction
Quite often, people with painful limb problems lose the
ability to recognise left or right images which can
obstruct a successful recovery. The good news is the brain
is plastic, and changeable, if given the right stimuli for
long enough. So with a little bit of work, patience and
persistence it is possible to reconstruct the brain’s
feature of laterality, which would have existed prior to
the limb problem.
Step 2 - Motor Imagery
Around 25 percent of the neurons in your brain are called
‘Mirror Neurons’ and are activated when you watch
someone else moving or think of performing an action.
Motor Imagery is the process where you observe others’
actions or positions and copy them in your head without
actually moving. The brain is being exercised and retrained with no motion required.
Part 3: Mirror therapy
This is the use of a mirror to present the reverse image
of a body part limb to the brain. It is also the final stage
of Graded Motor Imagery because there is evidence that
mirror therapy will be more effective if your sense of
laterality is intact
By using a mirror, you can trick the
brain into believing that an injured part
is actually okay, providing a powerful
synaptic exercise. For example, if the left
hand was a problem, it could be hidden
behind the mirror. And by using the
mirror image of the right hand and
concentrating on the mirror image, the
brain would construct that the left hand
was now somehow okay. It is a way of
signalling to the brain that ‘the hand is
fine, it’s now time to represent it
properly and look after it.’
http://www.rcplondon.ac.uk/sites/default/files/documents/complex-regional-painfull-guideline.pdf
FUNCTIONAL ABDOMINAL PAIN
HEART SINK PAR EXCELLENCE
CLINICAL SCENARIO
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23 year old university graduate presents with
unexplained abdominal and pelvic pain.
She has had extensive gastrointestinal,
gynaecological and urological investigations.
Pain is unremitting associated with nausea,
pallor, and intermittent diarrhoea or
constipation.
She is jobless, unable to seek work because she is
in too much pain. She is low in mood and
accompanied by her mother who is very
concerned about her.
How do you manage her?
HOW DO YOU MANAGE HER?
Take a history
 Ensure patient feels she is believed
 Think outside the box
 Take a good psychosocial history
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Useful outcome measures
Brief pain inventory
 Pain catastrophizing scale
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THINK
MULTIDISCIPLINARY
Hyper vigilant gut
 Think neuropathic
 Think desensitisation
 Think complementary
 Think psychology
 Think Hypnotherapy
 Think occupational therapy
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VISCERAL PAIN
Visceral pain is the most frequent form of pain,
felt by most people at one time or another
 the number one reason for patients to seek
medical attention.
 it is insufficiently treated as it is considered just
a symptom of an underlying disease
 many forms of visceral pain are diseases in their
own right and require focused and specific
therapies
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IASP
CLASSIFICATION OF VISCERAL PAIN
Visceral and other chest pain
 Chest pain of psychological origin
 Chest pain referred from the abdomen or gut
 Abdominal wall pain
 Abdominal pain of visceral origin
 Abdominal pain of generalised diseases
 Chronic pelvic pain syndromes
 Diseases of the pelvic organs
 Pain in the rectum, perineum and external
genitalia
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SIMPLER CLASSIFICATION OF
VISCERAL PAIN
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Organic abdominal pain
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Functional gastrointestinal disorders
Defined as a ‘variable combination of chronic or
recurrent gastrointestinal symptoms which are
not explained by structural or biochemical
abnormalities’
HYPNOTHERAPY IN IRRITABLE BOWEL
SYNDROME
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J Psychosom Res. 2008 Jun;64(6):621-3. doi:
10.1016/j.jpsychores.2008.02.022. Epub 2008 Apr 28.
Hypnotherapy for irritable bowel syndrome: the
response of colonic and noncolonic symptoms.
Whorwell PJ.
CG61 Irritable bowel syndrome: NICE guideline
08 October 2012 1.2.3.1
Referral for psychological interventions (cognitive
behavioural therapy [CBT], hypnotherapy and/or
psychological therapy) should be considered for people
with IBS who do not respond to pharmacological
treatments after 12 months and who develop a
continuing symptom profile (described as refractory
IBS).
SUGGESTED READING LIST
IASP clinical updates – Visceral Pain, Vol XIII,
No 6, December 2005
 Visceral Pain, Cervero et al, THE LANCET •
Vol 353 • June 19, 1999
 Gut pain & visceral hypersensitivity
published online 21 March 2013 British Journal
of Pain Adam D Farmer and Qasim Aziz
http://bjp.sagepub.com/content/early/2013/03/19/2
049463713479229
 Central sensitisation in visceral pain disorders,
Moshiree et al, GUT, 2006 July; 55(7): 905–908
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CLINICAL SCENARIO
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Mr XX is a 65 year old gentleman scheduled to
undergo a left below knee amputation. Two years
ago, he was involved in a work related incident when
his left foot was mangled in machinery.
Despite five attempts at surgical reconstruction of the
foot, the patient remains in severe pain with a foot
that is structurally unsound. In the interim he has
also undergone a right total knee replacement which
remains rather painful to date.
Clinically he has signs and symptoms of uncontrolled
neuropathic pain and he has pleaded with the
surgeon to amputate his foot.
CLINICAL SCENARIO: PAST MEDICAL HISTORY
He has an aortic abdominal aneurysm (40mm)
under annual surveillance
 He has a history of chronic lumbar back pain for
which he had attended the pain clinic in the past
(prior to the accident)
 He had one episode of dvt many years previously
after undergoing a knee arthroscopy
 He has an ongoing personal injury claim
 He is also awaiting trial at the high court for
unrelated offences

CLINICAL SCENARIO
Medication/other
treatment:
Fentanyl 87 micrograms per hour patch
Oramorph up to 120mg per day
Duloxetine 60mg am, 30mg pm
Pregabalin 300mg bd
Paracetamol
Clexane 40mg daily (ever since the accident)
Ramipril, Bendrofluazide, Simvastatin
Graded motor imagery
Beckham boot
Desensitisation therapy
FENTANYL MORPHINE EQUIVALENT
Fentanyl 12 = Morphine 45mg per day
Fentanyl 25 = Morphine 90mg per day
Fentanyl 50 = Morphine 180mg per day
Fentanyl 75 = Morphine 270mg per day
Fentanyl 100 = Morphine 360mg per day
HOW WOULD YOU MANAGE THIS PATIENT
POINTS TO CONSIDER
Preventive analgesia
 Regional anaesthesia
 Polypharmacy – significant amount of opiates
 Management of pain post-operatively
 Stump pain
 Phantom pain
 Likely recurrence of back pain
 Ongoing psychological stresses
 Need for Clexane
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ANY QUESTIONS?
THANK YOU FOR LISTENING