Summer 2010 - The British Pain Society

CHANGING PRACTICE
A Personal Reflection
on the British Pain
Management Programme
Society (SIG) Conference
2009
Dr Paul Wilkinson
Consultant in Pain Management,
Newcastle upon Tyne
The Pain Management Programme
held its 12th National SIG
conference at Northumbria
University in Newcastle upon Tyne.
The title "Clearing the Fog on the
Tyne” reflected not only the aims
of the conference but also some
nostalgia for the famous folk song
from Lindisfarne, the band which,
for many years, held Christmas
concerts in Newcastle.
As the Chair of the organising
committee, I offer here a personal
reflection of the conference.
Although this meeting was many
months ago the issues discussed
continue to be both pertinent and
topical. The aim is to provide a
summary for the benefit of those
who were unable to attend and
serve as a reminder for some of
those who did. Please note these
are personal reflections and may
reflect my own bias and memory!
As well as focusing on core issues
of pain management programmes,
the conference attempted to
consider issues allied to pain
management programmes. In
order to facilitate this, specialists in
other fields were amongst those
who were invited to help our
understanding.
Early Interventions in the
Management for Chronic
Pain
The conference began with
Professor Chris Main of Keele
University talking about designing
and implementing early
psychosocial interventions. What
was made clear during his talk is
that there is now a high level of
consensus about those factors
which predict chronicity. High
risk groups such as depression,
anxiety, high levels of early
disability, catastrophisation,
fear avoidance and other pain
morbidity predicted prognosis
and can be screened for early. It
is clear that properly tailoring and
targeting early interventions within
clinical trials is not trivial, especially
ensuring that interventions have
appropriately been carried out.
Despite these problems there
is now clear evidence for the
benefit of early psychosocial
interventions. There is a large,
flourishing contemporary field of
implementation science. This was
probably news to many including
myself.
NICE Guidelines for Early
Management of Persistent
Low Back Pain
We asked Professor Martin
Underwood, Professor for
Research at Warwick University
to help us understand better
the procedural elements of
undertaking NICE guidelines.
He was Chair of guidance
published in 2009. Clearly these
guidelines have been highly
controversial. The guidelines are
very procedurally driven and
have to rigorously adhere to
these procedures. Those involved
expose themselves to considerable
media and professional interest.
Professor Underwood defined
the scope of the guidelines which
had initially been between 6
weeks to 6 months and not to 1
year. He outlined that referring to
spinal surgeons but not referral
to pain clinics was considered as
part of the scope. He discussed
the procedures and how the
workings of the reference group
operated. In order to illustrate
the link between the conclusions
and the evidence, he focused
on the most controversial areas
namely acupuncture and injection
of therapeutic substances into
the back. As we now know these
issues are still the subject of
much controversy and discussion
at both NICE and the BPS ( see
the joint letter published by
NICE and the BPS in this issue).
For interventional procedures
this had only led to one low
powered admissible study and in
contrast, according to Professor
Underwood, there were several
recognised controlled studies
for acupuncture. Another area
which is the subject of much
debate. Further discussions were
undertaken about the nature and
the validity of all the evidence
presented in the document.
Complex arguments about the
nature of any evidence will no
doubt continue. All at the meeting
(including many from the BPS)
will be proactive in ensuring
the best care for all patients. Dr.
David Walsh, Associate Professor
in Rheumatology at Nottingham
and Chair of the SIG highlighted
that the NICE guidelines had
recognised the benefits of
physical and psychological
treatment in people who display
high disability or significant
psychological distress early. This
was obviously of great interest to
all PMP SIG members. The CPP
programme (combined physical
and psychological programme)
is recommended before the
pain becomes permanent and
before all treatment options have
been exhausted. Successful CPP
programmes require specialist
multi-disciplinary input helped
by CBT within group settings.
Healthcare providers have an
obligation to put NICE guidelines
into practice but there was anxiety
as to whether money for these
interventions would come from
existing funding or otherwise.
Update on catastrophisation
Professor Michael O'Sullivan
from McGill University in Canada
updated us on catastrophisation.
A tour de force again! One
particularly interesting fact out of
many is that catastrophisation can
carry a considerable amount of
the variance in treatment during
a trial. It has been shown in some
trials that if the castastrophisers
are included in the trials then
the treatment appears not to
work but if they are taken out
the treatment does! Treatment
resistance of catastrophisers
needs to be considered
carefully in the planning of care
and specific interventions to
minimise the consequences of
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PAI N N E W S S U M M E R 2010