The treatment of persistent pain - Australian Pain Society

Thank you for your many comments regarding the changes we have
initiated in the newsletter. The editorial committee appreciates feedback
and has been working hard to commission new articles. I particularly
thank John Quintner, Lorimer Moseley, Sue Inglis and Philip Siddall.
We have over 700 members in our society but only 25% have given
us their correct email address. From time to time our secretariat
sends out a group email message to notify members of upcoming
events or updates on the website. If you have changed your email
address please notify the Secretariat
Amal Helou
Editorial 1
President’s Report 1
Attachment style II: The treatment of persistent pain 2 - 4
Evidence for persisting pain as a disease entity 5
Physio Spot 6
IASP News 7
New Members 7
APS Board News 8
Spotlight on members 8
Upcoming Meetings/Announcements/Pigni Report 9
By the time this Newsletter reaches you many of us will have returned
from the 10th World Congress on Pain held by the IASP in San Diego.
These truly multidisciplinary congresses are at the cutting edge of pain
research and therapy, and ideal places to network with like-minded
colleagues from around the world. The 11th World Congress of the
IASP will be held in Sydney in 2005, and plans are well advanced
for an exciting meeting. Geoff Gourlay is the Chair of the local
arrangements committee, and discusses this further in his IASP report.
If members of the Society have ideas for an Australian Pain Society
Meeting in 2005, perhaps in association with a satellite meeting of the
World Congress, please let either Geoff or myself know.
1
AUGUST 2002
Towards the end of August a teleconference will be held to further
nursing issues within the Society. All nurses are urged to contact their
State PIGNI representative if they want input.
The Society was represented recently at a National Institute of Clinical
Studies (NICS) planning day to examine national initiatives relating to
pain management. Issues discussed were; making pain more visible in a
hospital setting, reviewing appropriate global pain assessment tools,
and mechanisms for implementing clinical guidelines. It is heartening
that the Board of NICS has seen pain as a focus area.
The Australian Pain Society/Australian Council and Healthcare Standards
guidelines for Multidisciplinary Pain Clinics are due for review, and
Robyn Quinn will Chair a working party to do this. If members have
suggestions or amendments they think should be considered, please
contact Robyn, e-mail robynquinn@msn.com.au.
The APS facility directory is also due for a review, and members will be
circulated with an information sheet shortly.
The APS/APRA PhD scholarship will be awarded again prior to the start
of the 2003 academic year. (See advert in this Newsletter) Those of you
who have followed the progress of this project must have been
impressed with the presentations of the awardees at recent Annual
Scientific Meetings. The Chairman of the PhD Scholarship Committee,
and the person who developed and launched the project, Geoff
Gourlay, wishes to step down because of his IASP work. This is an
important continuing role for the Society, and I would welcome
expressions of interest for Chairing this committee from members.
This is a rewarding, interesting, and not very demanding role.
At the Strategic Planning Committee meeting the Society held last
August, "pain in the elderly" was identified as an area for the Society
to focus on. It has been decided to explore the possibility of developing
clinical practice guidelines for pain management in nursing homes and
other aged care facilities. Approaches will be made to other interested
bodies, such as the RACGP, Society for Geriatric Medicine, Royal
College of Nursing, and all the allied health groups. A direct approach
for involvement will also be made to the Federal Government.
Plans are well advanced for the combined Australian & New Zealand
Pain Societies’ Scientific meeting to be held in March 2003 in Christchurch.
This meeting will see the introduction of online abstract submissions.
The closing date is 1st November 2002, so hopefully planning is well
ahead for your own submissions - and don't forget whilst you are at
your computer, send us your latest e-mail address. C.Roger Goucke

Suzanne Scott
Multidisciplinary Pain Centre, Royal Brisbane Hospital
Robin Murray
Pain Management and Research Centre, Royal North Shore Hospital
Health professionals who work with
individuals who have persistent pain have
difficulty at times in accounting for differences
in outcome when those with similar complaints
respond in ways that are unpredictable.
(Pearce, Cramond, Creed, (2001). Bowlby’s attachment theory fits
within the biopsychosocial model of persistent pain and may explain
the sometimes puzzling behaviour of these individuals. This article relates
differences in treatment outcome to differences in early developmental
histories and examines the influence of secure and insecure attachment
styles on the response of persistent pain sufferers to treatment.
Attachment theory is a robust concept that is useful for health
professionals when assessing and treating persistent pain. It may
explain the origins of help-seeking and self-caring behaviours of these
individuals and help us to understand why certain behaviours are
directed toward professionals who are caring for them. At a time of
need individuals approach a carer in a particular manner and display
certain behaviours that they learned within their family of origin.
Children internalise experiences with caretakers and these attachment
experiences become the prototype for their relationships in adult life.
A child who grows up in a caring and nurturing family environment
has the best chance of growing to maturity as a self confident adult
with strong self respect, respect for others, and high self efficacy.
In contrast, a child who has to survive in a dysfunctional family
environment, has less chance of developing such strong personal
resources. The quality and the type of the developmental influences
on children determine their manner of attachment.
Attachment behaviours become prominent when individuals are
afraid or ill. They approach or avoid their carers according to their
internalised model of "self" and "other" at these times.
2
The treatment of persistent pain
The key constructs of this model are:
1Whether or not the attachment figure is judged to be the
sort of person who in general responds to calls for support
and protection, &
2Whether or not the self is judged to be the sort of person
anyone, and in particular the person from whom care is
sought, is likely to respond to in a helpful way.
A "carer" is defined here as one with whom the person has a close
emotional bond, or a health professional. When individuals have
persistent pain these carers become the source and the focus of help
and support. The relationship an individual sets up with any of these
carers reflects their model of interpersonal relationships. In times of
need, they are likely to approach a carer with the same behaviours
and intensity that they brought to the relationship with an original
carer such as the mother. It is suggested that this model of self and
other is stable throughout life. (Ainsworth, 1982; Bowlby, 1944;
George, Kaplan & Main, 1987).
Attachment theory is relevant to health research and to clinicians because
it has been shown that the particular behaviours that are the outcome
of attachment learning determine in part, the ability of the individual
to effectively manage and recover from illnesses, traumas or disabilities.
Each of the models of attachment behaviour favours certain problem
solving strategies. Clinicians generally consider the resources of the
patient when considering ways in which information is presented or
in attempting to remedy a problem. Cognitive abilities are usually
taken into account, but it is less likely that the influence of emotional
factors related to the individual’s attachment style will be considered.
Our experiences as children influence our subsequent years at least
until we are mature enough to make judgements less coloured by
emotion. Bowlby made his first reports about the detrimental influences
of dysfunctional families on children living within these families in
1958. He reported that attachment behaviour is organised, learned
and reinforced or extinguished by social interactions within the family
(Bowlby, 1958). His theories are supported by Ferster and Perrott (1968).
Ainsworth, Blehar, Waters and Wall (1978) classified the attachment
styles of children according to their ability to recover from separation
anxiety. Because children are vulnerable when sick or afraid, these
researchers suggested that a strong supportive family environment
not only gives the best possible chance for a child to recover from

illness or injury, it also gives the child a view of itself that it is worth
helping. This model of the self as worthwhile influences the view of
other people as being helpful, dependable and trustworthy. Their
sense of "felt security" then becomes stable and resilient.
In contrast to secure children, children who are neglected, abused,
or abandoned do not view themselves in the same manner as the
secure group. These insecure children have varying views of the self
and diminished confidence in others. Their model of attachment
underlies a negative model of the world where they must strive to
overcome difficulties in an unstable environment. The two
fundamental styles of attachment are secure and insecure. The factor
which is thought to be common to all insecure individuals is chronic
depression. Children who are unwanted or neglected from birth are
vulnerable to early onset depression, while those who are traumatised
or bereaved, abused or ill are thought to become depressed as a
result of the particular problem. (Bowlby, 1944).
Bowlby described two sub-styles of insecure adjustment. A child
who had suffered loss such as abandonment or neglect is likely to
become obsessively self-reliant and dismissive of others. He labelled
this group "avoidant." Avoidant or dismissive attachment style is
characterised by a strong sense of self and a low opinion of the ability
of others to be dependable or trustworthy. These individuals avoid
being rejected by others by never allowing them to get close enough
to provide care or attention.
Those who have been forced to survive traumas such as prolonged
illness, abuse or bereavement were posited by Bowlby to exhibit an
"anxious" attachment style that is characterised by a low sense of self
and a distorted view of the importance of others. However, despite
this distorted sense of other’s importance, they may harbour a strong
sense of resentment even though they are care-seeking (Bowlby, 1977).
These individuals are typically anxious when they are confronted by
health problems and find it hard to sustain involvement in treatment.
Occasionally health workers come into contact with individuals who
are very anxious, very wary of contact with others and ambivalent
about their own care. So strongly do these individuals reject others
that a fourth attachment style has been suggested (Bartholemew and
Horowitz, 1991; Hazan and Shaver, 1987). This group of avoidant
individuals has been labelled "fearful." The fearful group are thought
to consider themselves unworthy and unlovable and expect that
3
The treatment of persistent pain
others will be rejecting, untrustworthy and unavailable. By avoiding
close contact with others they protect themselves from anticipated
rejection (Bartholomew and Horowitz, 1991; Hazan & Shaver, 1987).
It is suggested that these fearful-avoidant individuals are low in
self-respect, while dismissive-avoidant individuals are higher in self
respect but also regard others with suspicion (Bartholomew &
Horowitz, 1991).
The fundamental differences between
secure and insecure attachment remain the
most important aspects of this research.
A secure individual seeks help when in difficulty and can make
appropriate choices, consistently apply beneficial strategies to
overcoming problems, remain involved in treatment and aware of
their own needs. These health behaviours are very different to those
of an insecure individual who may select inappropriate, ineffective or
dangerous strategies to deal with health problems.
Bringing together the constructs of attachment style, the role of trauma
in childhood, and issues in health care, papers by Schofferman,
Anderson, Hines Smith and White (1992) and Schofferman,
Anderson, Hines Smith and Keene (1993) highlighted the issue of
prejudicial environmental influences on the development of somatic
pain. In these studies on unsuccessful outcomes of back surgery, they
demonstrated a clear and significant correlation between unsuccessful
lumbar spine surgery and a history of childhood traumas. This
correlation was seen in single-level, multilevel, primary and repeat
surgeries (Schofferman et al., 1992; Schofferman et al., 1993). These
researchers maintain that recognition of predictors for
unsuccessful outcome can be useful in avoiding surgery in patients
whose indications for surgery are borderline. The greater challenge is
to help the patient who, despite being at high psychological risk for
negative outcome, has severe spinal pathology that will require
surgery. Their conclusions are that preoperative psychological
assessments to assess the influence of childhood traumas are critical
in defining patients for whom surgery should be avoided unless
overwhelming spinal pathology is present, or for those patients who
have failed to improve despite previous surgery that has been
technically successful.

Attachment style in health research
Secure attachment style
The higher self esteem of the secure person with their confidence
that others will support them suggests that secure individuals are
able to seek out and communicate with carers, assess the
appropriateness of the services offered and comply with recommended
self-help strategies. Their stability, ability to care for themselves and
strong personal resources enable them to cope and to find support
even when long-term physical problems are present.
Insecure attachment: Anxious style
These individuals who view themselves negatively and others as
positive have a tone of communication which idealises health
professionals coupled with self-blame and self-depreciating stances
(Mikhail & Henderson, 1994). Initially they are said to be compliant
with self-care strategies but become disillusioned easily and move on
to the next consultant and the next "cure." These individuals are
suggested to be the "doctor shoppers" who accumulate many pills
and procedures and many disappointments about the "failure" of
the carer and the "failure" of the self to be cured.
Insecure attachment : Avoidant style
Those individuals exhibiting an avoidant attachment style respond to
threat by avoiding caretaking figures (Simpson, Rholes & Nelligan,
1992). Approaches to health professionals occur only when they
eventually decide they can no longer cope with pain. This presentation
as an "emergency" can result in frustration to both carer and cared-for
as the real issues are not obvious and the presentation is highly
emotional. The carer may feel pressured to provide immediate relief
that may not be appropriate for the long term. The positive view of
self and negative view of others displayed by these individuals helps
them to feel self-sufficient and to view others as unresponsive and
unavailable (Bartholemew, 1990).
4
Avoidance
The treatment of persistent pain
Insecure attachment: Fearful style
The negative global view of these individuals suggests that they
experience considerable anxiety and hostility in interpersonal matters,
stemming from a history of abuse, neglect and / or trauma
(Bartholemew & Horowitz, 1991). When anxiety increases they
retreat and avoid seeking help (Simpson et al., 1992). When help is
finally sought they present as hopeless and helpless and their distress
may encourage health professionals to recommend psychiatric care
for their perceived suicidal intentions. Mikhail (1994) suggested that
this situation serves to intensify the feelings of rejection experienced
by these people and increases their punitive view of self.
Summary
Health professionals generally seek to understand differences in pain
presentation through a multidisciplinary assessment of the individual.
They also educate individuals in positive coping strategies in order
to help them develop the self-efficacy needed to manage chronic
pain. Psychological assessment includes an assessment of the
individual’s developmental history as well as an appraisal of their
cognitive skills, and psychological treatments may be essential when
pain-related behaviours associated with insecure attachment styles
are present. This may prevent such individuals needing long-term
involvement with pain clinicians.
Attachment theory provides a sound evidence based approach that
gives an insight into the patient’s world and philosophy of life.
1. secure
Value of the self = high
Value of others = high
• stable / autonomous
• organised • active copers
• problem solvers
3. insecure-avoidant/dismissive
Value of the self = low
Value of others = low
• dismissing of intimacy
• obsessively self-reliant
• relationship stressed
• distrusting & aggressive
• chronic depression - early onset
Anxiety
Attachment style: An explanatory model
2. insecure-preoccupied
Value of the self = low
Value of others = high
• dysfunctional • disorganised
• compulsive caregivers
• ambivalent & anxious
• chronic depression
2. insecure-preoccupied
Value of the self = low
Value of others = low
• anxious & avoidant
• helpless & distressed
• disoriented • passive aggressive
• chronic depression

� References
1 AINSWORTH, M.D. (1982).
Attachment: Retrospect and prospect, in C.M. Parkes and J.
Stevenson- Hinde (eds.) The Place of attachment in Human
Behaviour (pp.3-30), London: Tavistock.
2. AINSWORTH, MD, BLEHAR, MC, WATERS, E, & WALL, S (1978).
Patterns of attachment: A psychological study of the strange
situation. Sydney: John Wiley & Sons.
3. BARTHOLOMEW, K. (1990).
Avoidance of intimacy: An attachment perspective.
Journal of Social and Personal Relationships, 7, 147-178.
4. BARTHOLOMEW, K., & HOROWITZ, L.M. (1991).
Attachment styles among young adults: A test of a four-category
model. Journal of Personality and social psychology, 61(2), 226-244.
5. BOWLBY, J. (1944). Forty-four juvenile thieves (ii).
International Journal of Psychoanalysis, 25, 107-128.
6. BOWLBY, J. (1958). The nature of the child’s tie to his mother.
International Journal of Psychoanalysis, 42, 317-340.
7. FERSTER, C.B., & PERROTT, M.C. (1968).
Behaviour Principles. New York: New Century. Pp 104-116.
8. GEORGE, C., KAPLAN, M., & MAIN, M. (1987).
The adult attachment interview, in M.Main (ed.) Behaviour and
the Development of Representational Models of Attachment:
Five Methods of Assessment.
9. HAZAN, C., & SHAVER, P. (1987).
Romantic love conceptualised as an attachment process.
Journal of Personality and Social Psychology, 52, 511-524.
10. MIKHAIL, S., HENDERSON, P., & TASCA, G. (1994).
An interpersonally based model of chronic pain: An application
of attachment theory. Clinical Psychology Review, 14(1), 1-16.
11. PEARCE, S., CRAMOND, T., & CREED, P. (2001).
Attachment style and chronic pain syndrome.
Australian Pain Society Newsletter, May, 2-4.
12. SCHOFFERMAN, J., ANDERSON, D., HINES, R., SMITH, G., &
WHITE, A. (1992). Childhood psychological trauma correlates with
unsuccessful lumbar spine surgery. Spine, 17(Suppl.), S138-144.
13. SCHOFFERMAN, J, ANDERSON, D, HINES, R, SMITH, G, KEANE, G.1993
Childhood psychological trauma & chronic refractory low-back pain.
Clinical Journal of Pain, 9, 260-265.
14. SIMPSON, J.A., RHOLES, W.S., & NELLIGAN, J.S. (1992).
Support seeking and support giving within couples in an anxietyprovoking
situation: The role of attachment styles.
Journal of Personality and Social Psychology, 62(3), 434-446.
5
Michael Cousins
Chair of Anaesthesia and Pain Management
Royal North Shore Hospital and The University of Sydney
I have deliberately used the term "persistent pain" as it is a
convenient way of describing how some patients who begin with
acute pain, pass into a transitional phase where the pain does indeed
"persist". This is a very important phase for us to study as it is clearly
not a normal situation, and poses the very significant risk that the
patient will develop "long term persisting pain". As a side issue, I
would like to propose that we consider adopting persistent pain rather
than chronic pain for the following two reasons:
1Chronic pain has developed some extremely unfortunate
connotations which will be difficult to change; and
If we focus our attention on the transitional phase, as
2
described above, the patient and public perception will
shift towards an appreciation that we are trying to prevent
patients from suffering pain on a permanent basis.
The evidence for persisting pain as a disease entity, falls under the
categories of: � basic science � clinical manifestations
� psychological changes � unhelpful environmental adaptations
With respect to the basic science of persisting pain, there is now
overwhelming evidence that there is a neurobiological process
associated with tissue and nerve injury which poses at least the
potential for a continuum from the acute to persistent phase.
Unfortunately, most animal models must be regarded as very much
representing only the acute phase, since they have neglected to
investigate the occurrence and persistence of behavioural changes
that have been well identified in humans. However, recent experiments
by Kevin Keay, Richard Bandler and Associates from our group, have
identified an exciting new avenue of studying the transitional phase in
animals. This may provide the opportunity for some clinically relevant
investigation of some of the changes that have been identified in
largely acute models such as:
� pathophysiology in the form of spontaneous firing of
damaged peripheral and nervous system neurons, including
"burst firing" in thalamus and associated brain areas;
� neuroanatomical reorganisation of dorsal horn apparently
under control of growth factors such as NT3 and BDNF;

� potential death of inhibitory neurons due to excessive release
of nitrous oxide, with associated interference with inhibitory
neuro-transmitters such as GABA;
� genetic changes associated with long term increase response
of neurons; neuroanatomical reorganisation at a brain level,
resulting in increased central representation of"painful areas".
Clinically detectable abnormalities associated with persisting pain can
sometimes be difficult to document. On the other hand, patients with
syndromes such as complex regional pain syndrome (CRPS) can
manifest striking changes including secondary hyperalgesia, allodynia,
hyperpathia, vasomotor changes, abnormalities in motor function
and trophic changes. It is possible that such clinical abnormalities
may be directly linked to the pathophysiology, which has been
identified in animal models, however, such a linkage has yet to be
made. An exciting opportunity to link abnormalities identified at a
basic level with clinical abnormalities may lie in the use of magnetic
resonance spectroscopy (MRS). Philip Siddall and Annie Woodhouse,
in collaboration with Professor Carolyn Mountford, have developed
capabilities to detect regional abnormalities in brain function which
seem to show specific patterns for different pain states.
Perhaps the strongest evidence currently available is from the clinical
psychology literature where a substantial number of abnormalities
have been documented in patients with persisting pain including;
high levels of anxiety, depression, feelings of hopelessness and
helplessness, fear avoidance behaviour, etc. Currently the only factors
that have been identified as being important in the progression from
an acute to a persistent phase are in the psychological domain, and
the only available studies relate to patients with low back pain. It
would thus seem important to study patients following surgery and
trauma to examine whether psychological factors may also be
important in these areas.
Despite the shortcomings in some of the currently available evidence,
there is increasing evidence from the basic and clinical sciences that
persisting pain does become a disease entity regardless of the
underlying causes of the pain. Clearly, the primary objective is to
treat any underlying causes. However, there is also a concern now
that such treatment of underlying causes should be carried out
expeditiously. Otherwise the processes associated with persisting pain
may move into a persistent phase, such that treatment of the
underlying condition may no longer result in a reversal of the pain
process.
6
This month, the physio spot is introducing
(not that they need introduction!)
Tina Souvlis and Bill Vincenzino
Tina and Bill are doing research at the Department of Physiotherapy,
University of Queensland, in the area of central analgesic and motor
effects associated with manual therapy. Obviously, this is an important
area for anyone doing manual therapy – the more we understand
about why and how these techniques work, the more we promote
targeted and effective intervention.
Comments invited: l.moseley@mailbox.uq.edu.au
Manual therapy and pain relief
What reasons spring to mind about the effectiveness of manual
therapy? To most people the thought of "putting something back
into place" or "getting things moving" ie the biomechanical effects
are paramount. However, musculoskeletal pain is one of the main
reasons for attendance at physiotherapy clinics. Physiotherapists
along with other medical and health practitioners have long used
manual therapy techniques in the relief of pain. These techniques
include both manipulation such as a high velocity thrust techniques,
passive oscillatory mobilisation and more recently mobilisation
techniques incorporating active movement.
Manual therapy has long been known anecdotally to be effective
in the management of pain and the treatment of musculoskeletal
conditions. In addition, meta-analyses carried out looking at spinal
manual therapy in the management of both cervical and lumbar spine
pain conditions have demonstrated positive short-term effects.
Although, there is a growing body of literature into the biomechanical
effects of manual therapy until relatively recently there has been little
research carried out into other potential neurophysiological mechanisms
by which these types of treatments may exert some of their effects.
The potential for spinal manual therapy to activate endogenous pain
reliving mechanisms was hypothesized by Wright (1995). Since then,
a number of studies have demonstrated that spinal and peripheral
manual therapy can produce analgesia which is significantly greater
than that produced by placebo or control techniques in a range of
conditions. The hypoalgesia produced by these treatments have
consistently been shown to be specific to mechanical pain thresholds.
Manual therapy treatments do not change thresholds to thermal
pain. This change in mechanical threshold is immediate in onset, it is
not reversible by naloxone and does not demonstrate tolerance to

epeated dosing. In short, the characteristics of this response seem to
suggest non-opioid mechanisms.
In addition to the hypoalgesic effects, many studies have postulated
a motor effect following spinal manual therapy. Depending on the
techniques used and muscles tested, studies have shown that there
may be facilitation of motor effects or perhaps inhibition of muscle spasm
associated with pain. An increase in both peripheral and central measures
of sympathetic nervous system activity have also been demonstrated
to occur in conjunction with these motor and pain relieving effects.
These effects have also been demonstrated over a number of studies.
This tripartite effect of hypoalgesia, activation of the sympathetic
system and motor facilitation may be regulated by a center such as
the periaqueductal gray area of the midbrain which has connections
to multiple systems through nuclei in the rostroventral medulla.
It is tempting to assume that the techniques described as manual
therapy are limited to producing biomechanical or perhaps even
psychological effects. The implications of such a widespread
response over a number of systems is that the afferent input via
manual therapy is a sufficient stimulus to also activate a coordinated
response including the descending pain inhibitory systems.
This research is progressing and more evidence as to the mechanisms
and effectiveness of manual therapy as well as other physiotherapeutic
tools will hopefully emerge. Please contact us if you would like to
enquire about these studies or to comment.
Tina Souvlis t.souvlis@shrs.uq.edu.au
Bill Vicenzino b.Vicenzino@shrs.uq.edu.au
Department of Physiotherapy, University of Queensland. Brisbane.
Reference WRIGHT, A., Hypoanalgesia post manipulative therapy,
Manual Therapy, 1 (1995) 11-16.
The Society would like to welcome new members to the APS
Steve Brimstone Psychology
Anne Burke Psychology
Louise Chapple Nursing
Janet Mosquera Psychology
Kerrie Noonan Psychology
Maryanne Sparrow Pain Management
Anne Ward Nursing
7
There is feverish
activity at the IASP
Secretariat in Seattle
preparing for the San Diego World Pain
Congress in a couple of weeks time.
At the time of writing this piece (late July), registration numbers
march steadily towards the 4000 mark which is very close to the
number predicted by the Secretariat about 6 months ago. Over the
last decade or so, an interesting trend in Congress registration
numbers has arisen in that Congresses sited in Europe have a larger
number of delegates compared to those in North America. Congress
sites have oscillated between UK / Europe and North America save
the 1990 World Congress in Adelaide. Delegate numbers in San Diego
has great implications for the 2005 Congress in Sydney which, as I
have said previously, is only the second time a World Pain Congress
has been sited in the Southern Hemisphere. The IASP Council, Local
Arrangements Committee for the 2005 Congress and the Australian
Pain Society Board of Directors wish all APS members to become
ambassadors for the 2005 Sydney meeting both here and abroad.
After 2005, it will be a considerable time period before the vast
number and diversity of pain experts, clinicians and researchers in all
pain disciplines will grace our shores at the one time. Thus, Sydney
2005 does represent a unique opportunity for all trainees and
practitioners to learn the latest developments and we must all make
every effort to promote the meeting to all, ie members and non-APS
members alike.
There is already great interest in arranging a number of Satellite
meetings to the main Sydney meeting. Various groups are already
assessing potential sites that will be in desirable geographical locations.
At the present time, I have been approached informally by at least 4
groups already with a view to arranging satellite meetings around
the Sydney World Congress.
The other important issue I wish to bring to your attention is possible
participation of APS members in the various IASP Taskforces and
Committees. These Taskforces and Committees serve a vital function
that essentially maps the current and future direction of the
International Association. Consequently, I believe it is most important
to have as wide as possible participation of APS members in the various
IASP activities and earnestly urge APS members to think about this

issue. It is a requirement that all members of IASP Committees and
Taskforces must be IASP members (Australian Pain Society membership
is insufficient) and this is not unreasonable if you think about it.
The current Directory of Members is the appropriate source to see
the options for your consideration. If you are interested, please
contact one of the APS Board members and they will arrange to
have your name considered. Clearly, we are not in a position to
guarantee that you will actually be offered a position of your choice.
What I can say is that historically, there has been regular and
frequent representation; past members have contributed significantly
and this has been appreciated by the IASP. So go to it!
Geoff Gourlay
Directors' Meeting 30th September 2002
� Planning commenced for the 2004 ASM in Canberra
Provisional dates 7-11 March 2004
Convenor Geoff Speldewinde
� Teleconference PIGNI – August 28
� Approval for refundable deposit for block booking of Qantas
flights to Christchurch for the 2003 ASM
� Abstracts online. Website engineering $1,000 approved
� Review of the ACHS/APS pain facility guidelines
Shared costs with ACHS $2,000 approved
� 2005 local organising committee financial support $6,000
approved
� Possibility of a Queensland satellite meeting for 2005 in
association with the World Congress.
� Elections due 2003: call for nominations to be sent by
November 2002
� APS / APRA PhD Scholarship applications to close Nov 2002
� NICS awaiting minutes of exploratory meeting held 29 July 2002
� Possibility of developing clinical practice guidelines on pain in
the elderly with other interested organisations
� Facility directory template to send to members to be developed
C. Roger Goucke
8
Julien P. de Jager FRACP
President, Australian Rheumatology Association
Interviewed by Dr Sue Inglis
Who was/is your most influential mentor? I ‘ve had many, but the
late Dr Brian Billington, gastroenterologist at Prince of Wales Hospital,
and Dr Milton Cohen at St Vincent's Hospital in Sydney (still very
much alive) would top the list.
Most challenging patient? A young lawyer with severe destructive
rheumatoid arthritis who was very poorly compliant with treatment,
requiring narcotics for pain relief, bilateral hip replacements, requiring
knee, metacarpal replacements and triple fusions of her feet. We
finally had a showdown where I requested she find another
rheumatologist and since then we have got along famously!
Most rewarding experience in medicine? Seeing a young lady with
severe juvenile arthritis and SLE go into remission on therapy, then
graduate from Uni, and marry a great young man. These rewards come
every week mixed with all the treatment failures and adverse reactions!
What would you advise those starting out in the field?
Never give up, whether it is passing exams or puzzling out a problem,
and do it all for the people we are committed to serve. There is good
in everyone, but make the most of those inspirational patients who
carry you through difficult times with the others.
How has medicine changed since you started out? We have
come full circle, I think. I am from a family of lawyers and was inspired
to do medicine by our family doctor, and family friends who were
doctors, with their incredible dedication. Then during training (70s and
early 80s) the world was all about satisfying the individual, and
technological advances. This isolated many doctors from the very thing
that makes medicine so worthwhile. It is pleasing to see the curricula
of medical schools, and the emphasis in general practice in the last
10 or more years redressing that. We are back to the situation where
our responsibility is first to the patients and their needs.
If you weren’t a doctor what would you like to be?
I have never wanted to do anything else.
What book are you reading at the moment?
Peter Carey's ‘True History of the Kelly Gang’.
Your favourite saying? "Send not to know for whom the bell tolls,
it tolls for thee", by John Donne who was vicar of St Paul's. The
preceding lines are usually omitted, but are even more inspirational
"Any man's death diminishes me, because I am involved in mankind".
Julien P de Jager, FRACP, President, Australian Rheumatology Association
dejager@ozemail.com.au

Pain Conference Canberra
7 -11 March 2004
The planning for this meeting is underway in a preliminary
sense with a local organising committee being grouped
(not yet finalised and will probably be a little fluid for a while).
DC Conferences, with usual efficiency, has arranged the dates
during our annual Canberra Week in sunny & warm March 2004.
We are actively considering the following 3 themes:
1. 'Musculoskeletal' issues, possibly in a conjoint effort with
Australasian Faculty of Musculoskeletal Medicine
2. Placebo in pain management.
3. Exploring psychological constructs 'beyond' CBT
ie what else is relevant?
However planning is still at the embryonic stage and we
welcome ideas from the membership. Please send these to
Geoffrey Speldewinde: email gspeld@capitalrehab.com.au
Please reply as soon as possible as the themes will be firmed up
over the next 2 months.
Geoffrey Speldewinde
for the Conference Organising Committee
AUSTRALIAN PAIN SOCIETY APS and
AUSTRALIAN PAIN RELIEF ASSOCIATION APRA
PhD Scholarship
The APS is a Multidisciplinary Society whose charter is to improve the education,
research and development, diagnosis and treatment of all forms of pain.
APRA is a registered charity with the Australian Taxation Office and
works closely with the APS to support educationl and research in pain.
The Australian Pain Society and the Australian Pain Relief Association have
funded three PhD Scholarships over the last 4 years (one in conjunction with CSL).
The stipend for this Scholarship is AUD20,000 per annum and the APS will
provide some financial support to allow the candidate to attend the
Annual Scientific Meeting of the Society.
The award is to enable full time research leading to a Doctor of Philosophy
or equivalent, at any recognised Australian University. The applicant must be
an Australian citizen and the applicant and his/her supervisor must be members
of the APS. The funded project can be related to any aspect of the mechanisms,
diagnosis or treatment of acute or chronic pain. Further information about the PhD
Scholarship, including the Conditions of Award, can be obtained from the Secretariat:
DEADLINE 15 NOVEMBER 2002
APS Secretariat: DC Conferences • PO Box 571 Crows Nest NSW 1585
Phone 02 9954 4400 • Fax 02 9954 0666
Email APS@dcconferences.com.au
9
Australasian Academy of Cerebral Palsy and
Developmental Medicine Inaugural Conference
20 - 21 September 2002 • Australian National Maritime Museum
Darling Harbour, Sydney, Australia
PIAA International Section Conference 2002
Physician Insurers Association of America International Section
in association with MDA, MDAV & UMP
‘Minimising Medical Error and Limiting Liability ... a work in progress’
10 - 12 October 2002 • The Regent Hotel • Sydney, Australia
A Combined Meeting: Australian Pain Society 24th ASM &
New Zealand Pain Society 10th ASM
9 - 13 March 2003 • Christchurch Convention Centre Christchurch,
New Zealand
ISPP 2003 • 6th International Symposium on Paediatric Pain.
Pain in Childhood: The Big Questions
15 - 19 June 2003 • Sydney Convention Centre
Darling Harbour, Sydney, Australia
Contact the APS Secretariat for further details:
Phone 02 9954 4400 • email aps@dcconferences.com.au
APS Secretariat Website www.dcconferences.com.au
APS Website www.apsoc.org.au
Report from Pain Interest Group – Nursing Issues
From Julieanne James on behalf of the PIG-NI organising committee
The half day seminar "Nurse Initiated Pain Management" was held on Sunday 24
March preceding the APS Annual Scientific Meeting. The speakers were well
received with enthusiastic positive feedback. There were just over 200 registrants
and information from the Responder Questions are outlined below. We would like
to thank the following companies for their generous and ongoing support of this
meeting. Abbott Australasia, AstraZeneca, Ansell International, Baxter Healthcare,
CSL Limited, Jansen Cilag, Medtronic, Mundipharma & the Royal College of Nursing.
Represented regions of registrants:
67% from NSW; 8% QLD; 6% VIC; WA, SA, ACT & TAS were all 4% and under.
Areas of practice
Acute 30%; Chronic16%; Palliative14%; Critical Care 13%;
Surgical Nursing 7%; Several other areas 20%

Website: www.apsoc.org.au • Password for members site: Placebo
President: Dr C. Roger Goucke
WA Pain Management Centre • Sir Charles Gairdner Hospital
QE2 Medical Centre, Hospital Ave Nedlands WA 6009
Tel 08 9346 3263 • Fax 08 9346 3481
Vice President: Dr Carolyn Arnold
Caulfield Pain Management Research Centre
260 Kooyong Rd, Caulfield VIC 3162
Tel 03 9276 6834 • Fax 03 9276 6675
Treasurer: Dr Paul J Graziotti
Sir Charles Gairdner Hospital 199 Cambridge St, Wembley WA 6014
Tel 08 9388 8289 • Fax 08 9386 5927
Secretary: Dr Bruce Rounsefell
Royal Adelaide Hospital Pain Clinic, North Terrace, SA 5000
Tel 08 8222 5403 • Fax 08 8222 5904
ACT State Councillor: Dr Geoffrey Speldewinde
15 Napier Close Deakin ACT 2600
Tel 02 6282 6240 • Fax 02 6282 5510
NSW State Councillor: Dr Raj Sundaraj
60 Derby Street, Kingswood NSW 2747
Tel 02 4722 8100 • Fax 02 4722 8388
Newsletter Editor: Ms Amal Helou
Pain Management Centre QE2, Royal Prince Alfred Hospital
59 Missenden Rd, Camperdown NSW 2050
Tel 02 9515 9739 • Fax 02 9515 9751
Email amalh@diab.rpa.cs.nsw.gov.au
Website Coordinator: Dr John Corry
Suite B6, 161 Strickland Crescent, Deakin ACT 2600
Tel 02 6285 1833 • Fax 02 6285 2280
Website www.apsoc.org.au • Email apsoc@org.au
10
QLD State Councillor: Dr James P O’Callaghan
Arnold Janssen Centre 259 Wickham Tce Brisbane QLD 4000
Tel 07 3831 0383 • Fax 07 3834 6481
SA State Councillor: Dr Timothy J Semple
Pain Clinic Royal Adelaide Hospital Adelaide SA
Tel 08 8222 5403 • Fax 08 8222 5163
TAS State Councillor: Ms Kerry Merse
Hobart Pain Clinic Calvary Hospital
49 Augusta Rd, Lenah Valley TAS 7008
Tel 03 6228 2700 • Fax 03 6278 9005
VIC State Councillor: Ms Lyn Boag
Multidisciplinary Pain Centre, Parkville
MECRS PO Box 7000, Carlton South 3053
Tel 03 8387 2258 • Fax 03 8387 2141
WA State Councillor: Ms Sally Greenway
St John of God Hospital
65 Rupert St, Subiaco, WA 6008
Tel 08 9382 6111 • Fax 08 9382 6115
Secretariat: DC Conferences P/L PO Box 571, Crows Nest NSW 1585
Tel 02 9954 4400 • Fax 02 9954 0666
Email aps@dcconferences.com.au
IASP 909 NE 43rd St, Suite 306, Seattle WA 98105-6020 USA
Tel 1.206-547-6409 • Fax 1. 206-547-1703
Email iaspdesk@ juno.com
New website www.iasp-pain.org
IASP LIAISON: Dr Geoff Gourlay
Pain Management Unit, Flinders Medical Centre, Bedford Park SA 5042
Tel 08 8204 5346 • Fax 08 8374 1758
Email Geoff.Gourlay@Flinders.edu.au