Download Assessment of the Chronic Pain Patient

SpR1&2 Chronic Pain Attachment
Please read thoroughly as it is your responsibility to get
signed up for this attachment
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
Appendix
(A) Patient pain scores audit
(B) Record of discussion topics
(C) Record of activities
(D) Record of chronic pain problems seen
(E) Record of procedures
(F) Self assessment exercises
(G) Glossary
(H) Literature selection and web sites
(I) SHO and SpR1/2 competencies
(J) Feedback form for appraisal
(K) Workplace Assessment Record
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Section I.
Introduction
During your SpR 1/2 training you will spend six weeks WTE undergoing training in
pain management. You will be attached to a chronic pain clinic, with one day per
week attached to the acute pain service. 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 but should enable you to satisfy most of the competencies
relevant to chronic pain listed in Appendix (I)
Try to complete the section on pre-requisite knowledge (Section 2) before starting
your attachment, as this will refresh the pain competencies achieved as an SHO.
On arrival in the pain clinic firstly familiarise yourself with the organisation of the
pain clinic (Section 3) before moving on to assessment and treatment of the chronic
pain patient (Sections 4&5). You should approach one of the consultants to be your
clinical supervisor. They will be required to sign you off at the end of your block; it is
very helpful for them to know this in advance of you presenting them with your form.
During your attachment complete the record sheets Appendix B-E; this will help
you to see a wide variety of patient problems and procedures. Pick three interesting
cases that you have seen (preferably with different aetiology e.g. nociceptive,
neuropathic and cancer pain) and write them up as short case histories. 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 your pain clinic clinical
supervisor. You will need to present your logbook and feedback will be obtained
from the team members. On the basis of this information your clinical supervisor will
sign off your workplace assessment record if he/she considers that you have met
the required training objectives. You will also need to be appraised by your acute
pain clinical supervisor to obtain the other signature on your workplace assessment
record(s) indicating satisfactory completion of the whole pain management training
module. This record will be inspected at your RITA.
Objectives
1. You will have a good basic understanding of chronic pain management allowing
you to fulfil the knowledge, skills, attitudes and workplace training objectives laid
out in the document from the Royal College of Anaesthetists.
2. You will have had sufficient exposure to chronic pain management to decide if
you wish to continue further with training in this subspecialty.
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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 SHO competencies in Appendix I and look up any sections
where your knowledge is a little hazy. Some of the acute pain competencies will
be relevant but concentrate on the chronic pain aspects.
4. Revise your history taking skills; asking open questions, using appropriate body
language, developing empathy etc. Sit back and really 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 might interfere with the patient’s life: read through the pain clinic audit
questionnaire (Appendix A). Some consultants use a proforma for
documentation of the history and examination of a new patient; you may find this
helps but you do need to be familiar with its content before trying to use it.
5. Revise your neurological examination technique.
Section 3
Organisation of the Pain Clinic
The pain clinic is 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: you should aim to spend a day visiting the local hospice
(arrange this through your educational supervisor).
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 less obvious activities that are going on in the
pain clinic.
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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:
(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 miracle cure or do they just want
somebody to listen and take their problem seriously? The initial
assessment of the patient often forms the start of the treatment process
and is thus vital that it is performed well.
(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 pathologies, which may be
better treated in other clinics, 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!
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Section 5
Treatment Modalities for the Chronic Pain Patient







Drugs
1. Analgesics
2. Antidepressants
3. Anticonvulsants
4. Miscellaneous e.g. antiarrhythmics, capsaicin, baclofen
Nerve blocks
1. Temporary – single shot or infusion of LA +/- steroid
2. Permanent – using ethanol, phenol, radiofrequency ablation, cryotherapy,
TENS
Implantable devices
1. Pumps
2. Dorsal column stimulation
Psychological therapies
1. Education
2. Relaxation
3. Diversion
4. Operant behavioural techniques
5. Cognitive behavioural techniques
6. Stress management
7. Pain management programs
Physiotherapy
1. Exercises
2. Electrical stimulation (e.g. interferential therapy)
3. Ultrasound
4. Pulsed shortwave Heat
5. Massage
6. Manipulation
Complementary therapies
1. Acupuncture
2. Hypnotherapy
3. Reflexology
4. Homoeopathy
5. Aromatherapy
6. Shiatsu
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Appendix A
PAIN CLINIC
*************************************
PATIENT TREATMENT ASSESSMENT FORM
PATIENT'S NAME:
CLINIC DATE:
Please circle your response or ask for help if you are having problems.
1. How much Relief have pain treatments or medications FROM THIS CLINIC provided? Please circle the one percentage that
most shows how much relief you have received.
No
Relief
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Complete
relief
2. Please rate your pain by circling the one number that best describes your pain at its WORST in the past week.
No
Pain
0
1
2
3
4
5
6
7
8
9
10
Pain as bad
as you can imagine.
3. Please rate your pain by circling the one number that best describes your pain at its LEAST in the past week.
No
Pain
0
1
2
3
4
5
6
7
8
9
10
Pain as bad
as you can imagine.
4. Please rate your pain by circling the one number that best describes your pain on the AVERAGE.
No
Pain
0
1
2
3
4
5
6
7
8
9
10
Pain as bad
as you can imagine.
5. Please rate your pain by circling the one number that tells how much pain you have RIGHT NOW.
No
Pain
0
1
2
3
4
5
6
7
8
9
10
Pain as bad
as you can imagine.
6. Circle the one number that best describes how, during the past week, PAIN HAS INTERFERED with your:
a. GENERAL ACTIVITY
Does not
0
1
2
3
4
5
6
7
8
9
10
interfere
Completely
interferes.
b. MOOD
Does not
0
interfere
1
2
3
4
5
6
7
8
9
10
Completely
interferes.
2
3
4
5
6
7
8
9
10
Completely
interferes.
d. NORMAL WORK (includes both work outside the home, housework and hobbies)
Does not
0
1
2
3
4
5
6
7
8
interfere
9
10
Completely
interferes.
e. RELATIONSHIPS WITH OTHER PEOPLE
Does not
0
1
2
3
4
interfere
5
6
7
8
9
10
Completely
interferes.
f. SLEEP
Does not
0
interfere
c. WALKING ABILITY
Does not
0
1
interfere
1
2
3
4
5
6
7
8
9
10
Completely
interferes.
g. ENJOYMENT OF LIFE
Does not
0
1
2
interfere
3
4
5
6
7
8
9
10
Completely
interferes.
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Appendix B
Try to discuss as many of the following topics as you can during your attachment. Please get them
signed off as you complete them.
SIGN/DATE
TOPICS FOR DISCUSSION
Mechanisms of pain: somatic, visceral and neuropathic pain.
Consequences of peripheral nerve injury, spinal cord injury and
deafferentation.
Other medication used to manage chronic pain: antidepressants,
anticonvulsants, antiarrythmics and other adjuvant medication.
Principles of neural blockade for pain management: peripheral nerve,
plexus, epidural and subarachnoid blocks; sympathetic blocks
including stellate, coeliac plexus and lumbar sympathetic blocks;
neurolytic agents and procedures; implanted catheters and pumps for
drug delivery.
Non-pharmacological methods of pain control. The principles of
stimulation induced analgesia: transcutaneous electrical nerve
stimulation and acupuncture.
The role of other treatment modalities; physical therapy, surgery,
psychological approaches, rehabilitation approaches, pain
management programmes.
Understanding of the principles of chronic pain management in the
pain clinic setting. Importance of working as a part of a multiprofessional team.
Understanding of the importance of psychology and pain.
Basic assessment of patients with chronic pain.
Basic assessment and management of patients with cancer.
Management of severe pain and associated symptoms in palliative
care.
Able to diagnose and institute initial management for neuropathic pain.
Management of side effects of pain relieving medication and
procedures.
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Appendix C
Record of Activities
Try to see as many of the following list as you can during the attachment
SIGN / DATE
WHEN DONE
ACTIVITY
Acupuncture
TENS fitting
Assessment with the Psychologist
Pain Management Program
Relaxation
Research nurse – patient recruitment for
studies
Physiotherapy assessment
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Appendix D
Record of Pain Problems Seen
TYPE OF PAIN
CAUSE OF PROBLEM
NUMBER
SEEN
Headaches
Back Pain
Neck Pain
Somatic
Nociceptive Pain
Musculoskeletal Pain
Post surgical pain
Metastatic bone pain
Other
Pancreas
Heart
Visceral
Nociceptive Pain
Pelvic organs
Intraperitoneal metastasis
Other
Phantom Limb Pain
Post Herpetic Neuralgia
Trigeminal Neuralgia
Neuropathic Pain
Peripheral Neuropathies
Compression Neuropathies
Post Traumatic/Surgical
Psychogenic Pain
Other
No nociceptive or neuropathic
origin
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Appendix E
Record of Procedures
NUMBER
SEEN
PROCEDURE
NUMBER
DONE
Lumbar
Epidural
Thoracic
Cervical
Lumbar
Facet Joint
Injection
Thoracic
Cervical
Lumbar
R/F or Cryo
to Facet
Joint
Thoracic
Cervical
Nerve root
Injection
Trigger Point injection
Intercostal Block
Suprascapular nerve block
Stellate Ganglion block
Trigeminal Ganglion block
Coeliac Plexus block
Lumbar sympathectomy
Guanethidine block
Cordotomy
Other
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Appendix F
Short Answer Questions
1. Describe the anatomy of the 8th intercostal nerve. Discuss the indications and
methods for performing an intercostal nerve block. What complications may
occur?
2. Discuss the prevention and treatment of the main complications of epidural
analgesia using local anaesthetic drugs.
3. Describe a technique for stellate ganglion block. What are the indications and
complications of this block?
4. Discuss the mechanism of action and use of spinal opioids.
5. Write short notes on (a) complications of neurolytic block
(b) neurolytic agents
(c) TENS
(d) Cryo-analgesia
6. How would you perform a coeliac plexus block?
7. What are the toxic effects of Local Anaesthetics?
8. What preservatives are in a bottle of Local Anaesthetic?
9. Outline the peripheral pain pathways.
10. Outline the distinguishing features between nociceptive and neuropathic pain.
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Appendix G
Glossary
Pain
Allodynia
An unpleasant sensory or emotional experience associated
with actual or potential tissue damage, or described in terms
of such damage
Pain due to a stimulus that does not normally provoke pain
Dysaesthesia
An unpleasant abnormal sensation, whether spontaneous or
evoked
Hyperaesthesia
Increased sensitivity to stimulation
Hyperalgesia
An increased response to a stimulus that is normally painful
Neuralgia
Pain in the distribution of a nerve
Paraesthesia
An abnormal sensation, whether spontaneous or evoked
Anaesthesia
dolorosa
Pain felt in an area that is otherwise numb
Sensitization
Deafferentation
Peripheral receptor or central neuron responds to a stimulus
in a more intense fashion or it responds to a stimulus to
which it would normally be insensitive
Loss of normal input from primary sensory neurons
Referred pain
Pain felt in an area removed from the site of tissue injury
Nociceptive
pain
Pain resulting from activation of nociceptors by noxious
stimuli that may be mechanical, thermal, or chemical
Neuropathic
pain
Pain due to neural injury or irritation. Usually persists long
after the precipitating event
Psychogenic
pain
Pain where no nociceptive or neuropathic mechanism can
be identified
Phantom pain
Pain felt in a part of the body that has been surgically or
traumatically removed
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Appendix H
Literature Selection
General:
Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention.
Lancet. 2006 May 13;367(9522):1618-25. Review.
Siddall PJ, Cousins MJ. Persistent pain as a disease entity: implications for clinical management.
Anesth Analg. 2004 Aug;99(2):510-20. Review.
Ashburn MA, Staats PS. Management of chronic pain.
Lancet. 1999 May 29;353(9167):1865-9. Review.
Nurmikko TJ, Nash TP, Wiles JR. Recent advances: control of chronic pain.
BMJ. 1998 Nov 21;317(7170):1438-41. Review.
Willis WD et al. Neuroanatomy of the pain system and of the pathways that modulate pain. J Clin
Neurophysiol 1997;14:2-31.
Neuropathic pain:
Rowbotham MC. Mechanisms of neuropathic pain and their implications for the design of
clinical trials. Neurology. 2005 Dec 29;65(12 Suppl 4):S66-73.
Dworkin RH, Backonja M, Rowbotham MC, Allen RR, Argoff CR, Bennett GJ,
Bushnell MC, Farrar JT, Galer BS, Haythornthwaite JA, Hewitt DJ, Loeser JD, Max
MB, Saltarelli M, Schmader KE, Stein C, Thompson D, Turk DC, Wallace MS, Watkins
LR, Weinstein SM. Advances in neuropathic pain: diagnosis, mechanisms, and treatment
recommendations. Arch Neurol. 2003 Nov;60(11):1524-34. Review.
Woolf CJ et al. Neuropathic pain; aetiology, mechanisms and management. Lancet 1999;353:195964.
Backonja M et al. Gabapentin for the treatment of painful diabetic neuropathy in patients with
diabetes mellitus. JAMA 1999;280:1831-1836.
DiVadi PP et al. The use of lamotrigine in neuropathic pain. Anaesthesia 1998;53:808-809.
Ashburn MA et al. Management of chronic pain. Lancet 1999;353:1865-69.
Rowbottom M et al. Gabapentin for the treatment of postherpetic neuralgia. A randomised controlled
trial. JAMA 1999;280:1837-1842.
Kingery WS. A critical review of controlled trials for peripheral neuropathic pain and complex regional
pain syndromes. Pain 1997;73:123-139.
McQuay HJ et al. A systematic review of antidepressant drugs in neuropathic pain. Pain
1996;68:217-227.
McQuay HJ et al. Anticonvulsant drugs for management of pain: a systematic review. BMJ
1995;311:1047-1052.
Back Pain:
Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006 17;
332(7555):1430-4. Review.
Carragee EJ. Clinical practice. Persistent low back pain.
N Engl J Med. 2005 May 5;352(18):1891-8.
Nick Campkin / Heather Knight 2006
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Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain.
Ann Intern Med. 2005 Apr 19;142(8):651-63. Review.
Carragee EJ, Hannibal M. Diagnostic evaluation of low back pain.
Orthop Clin North Am. 2004 Jan;35(1):7-16. Review.
Samanta J, Kendall J, Samanta A. 10-minute consultation: chronic low back pain.
BMJ. 2003 Mar 8;326(7388):535. Review. Lang AM.
Opioids:
Portenoy RK et al. Opioid therapy for chronic non-malignant pain: a review of the critical issues. J
Pain Symptom Management 1996;11:203-217.
Savage SR et al. Opioid use in the management of chronic pain. Med Clin North Am 1999;83:761786.
Cancer pain:
Fallon M, Hanks G, Cherny N. Principles of control of cancer pain.
BMJ. 2006 Apr 29;332(7548):1022-4. Review.
GilmerHill HS et al. Intrathecal morphine delivered via subcutaneous pump for intractable cancer
pain: a review of the literature. Surg Neurol 1999;51:12-15.
Spinal cord stimulation:
Ubbink DT, Vermeulen H, Spincemaille GH, Gersbach PA, Berg P, Amann W. Systematic review
and meta-analysis of controlled trials assessing spinal cord stimulation for inoperable critical leg
ischaemia. Br J Surg. 2004 Aug;91(8):948-55. Review.
Cameron T. Safety and efficacy of spinal cord stimulation for the treatment of chronic
pain: a 20-year literature review. J Neurosurg. 2004 Mar;100(3 Suppl Spine):254-67. Review.
DeJongste MJ, Tio RA, Foreman RD. Chronic therapeutically refractory angina pectoris.
Heart. 2004 Feb;90(2):225-30. Review.
Facial pain:
Marbach JJ. Medically unexplained chronic orofacial pain. Temporomandibular pain and
dysfunction syndrome, orofacial phantom pain, burning mouth syndrome, and
trigeminal neuralgia. Med Clin North Am. 1999 May;83(3):691-710, vi-vii. Review.
Tekkok IH etal. The neurosurgical management of trigeminal neuralgia. Neurosurg Q 1996;6:89-107.
Miscellaneous:
Morley S et al. A systematic review and meta-analysis of randomised controlled trials of cognitive
behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain
1999;80:1-13.
Latthe P, Mignini L, Gray R, Hills R, Khan K. Factors predisposing women to chronic pelvic pain:
systematic review. BMJ. 2006 Apr 1;332(7544):749-55.
Viner R, Christie D. Fatigue and somatic symptoms.
BMJ. 2005 Apr 30;330(7498):1012-5. Review.
Hill A. Phantom limb pain: a review of the literature on attributes and potential mechanisms. J Pain
Symptom Management 1999;17:125-142.
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Hamer AJ. Pain in the hip and knee.
BMJ. 2004 May 1;328(7447):1067-9. Review.
Mason L, Moore RA, Derry S, Edwards JE, McQuay HJ. Systematic review of topical capsaicin for
the treatment of chronic pain. BMJ. 2004 Apr 24;328(7446):991. Epub 2004 Mar 19. Review.
Mason L, Moore RA, Edwards JE, McQuay HJ, Derry S, Wiffen PJ. Systematic review of efficacy of
topical rubefacients containing salicylates for the treatment of acute and chronic pain.
BMJ. 2004 Apr 24;328(7446):995. Epub 2004 Mar 19. Review.
Hocking G, Cousins MJ. Ketamine in chronic pain management: an evidence-based review.
Anesth Analg. 2003 Dec;97(6):1730-9. Review.
Botulinum toxin type A therapy in chronic pain disorders.
Arch Phys Med Rehabil. 2003 Mar;84(3 Suppl 1):S69-73; quiz S74-5. Review.
Wong GY, Sakorafas GH, Tsiotos GG, Sarr MG. Palliation of pain in chronic pancreatitis. Use of
neural blocks and neurotomy. Surg Clin North Am. 1999 Aug;79(4):873-93. Review.
Useful Websites
www.iasp-pain.org
www.postoppain.org
www.britishpainsociety.org
www.anaesthesiauk.com
www.painnetwork.co.uk
Nick Campkin / Heather Knight 2006
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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Appendix I
COMPETENCIES AND TRAINING OBJECTIVES from RCA
1. SHO TRAINING IN PAIN MANAGEMENT
Knowledge
1. Afferent nociceptive pathways, dorsal horn, peripheral and central mechanisms,
neuromodulatory systems, supraspinal mechanisms.
2. Nociceptive pain, visceral pain, neuropathic pain.
3. Influence of therapy on nociceptive mechanisms.
4. Opioids and other analgesics.
5. Non-steroidal anti-inflammatory drugs.
6. Local anaesthetic agents.
7. Other drugs: anticonvulsants, antidepressants.
8. Measurement of pain.
9. Basic principles of assessment and management of chronic pain.
10. Basic principles of assessment and management of cancer pain (including WHO ladder).
Skills
1. Assessment and management of postoperative pain.
2. Monitoring acute pain and pain relief.
3. Use of simple analgesics: NSAIDs, paracetamol.
4. Prescribing opioids by different routes: oral, intramuscular, intravenous infusion, intravenous
PCA, subcutaneous PCA, epidural, transdermal.
5. Programming PCA and epidural pumps.
6. Use of inhalational analgesia.
7. Regional techniques: lumbar epidural, caudal epidural, inguinal field block, peripheral nerve
blocks, intercostal blocks, intravenous regional blocks.
8. Management of complications of analgesic techniques.
9. Management of acute pain in special clinical groups: children, elderly, patients receiving
intensive care.
Attitudes
1. Appropriate communication with patients, relatives and staff.
2. Rapid response to unrelieved pain.
3. Management tempered by awareness of potential complications and side effects.
4. Awareness of personal limitations in pain management and of when to seek help.
Workplace training objectives
1. Able to prescribe pain management regimen for most patients after common types of surgery .
2. Able to institute appropriate action for patients with unrelieved pain in the immediate postoperative period.
3. Able to demonstrate technical proficiency with procedures from the skills list.
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2. BASIC TRAINING IN PAIN MANAGEMENT (SpR 1/2)
The recommendations for basic training are in addition to the knowledge, skills, attitudes and
workplace training objectives described for SHO training. Topics that are already included in the lists
for SHO training are treated in greater depth during the SpR 1/2 period.
Knowledge
1. Anatomy, physiology, pharmacology and basic psychology relevant to pain management.
2. Mechanisms of pain: somatic, visceral and neuropathic pain.
3. Consequences of peripheral nerve injury, spinal cord injury and deafferentation.
4. Assessment and measurement of acute pain.
5. Techniques for control of acute pain: postoperative and post-traumatic -including children and
neonates, the elderly, and patients who are handicapped, unconscious or receiving intensive
care.
6. Application of pharmacological principles to the pain control: conventional analgesics and
adjuvant analgesics; side effects; problems of drug dependency and addiction.
7. Opioid and non-opioid medication, opioid infusions, patient controlled analgesia.
8. Other medication used to manage chronic pain: antidepressants, anticonvulsants, antiarrythmics
and other adjuvant medication.
9. Pharmacology of local anaesthetics.
10. Principles of neural blockade for pain management: peripheral nerve, plexus, epidural and
subarachnoid blocks; sympathetic blocks including stellate, coeliac plexus and lumbar
sympathetic blocks; neurolytic agents and procedures; implanted catheters and pumps for drug
delivery.
11. Non-pharmacological methods of pain control. The principles of stimulation induced analgesia:
transcutaneous electrical nerve stimulation and acupuncture.
12. The role of other treatment modalities; physical therapy, surgery, psychological approaches,
rehabilitation approaches, pain management programmes.
13. Assessment of patients with chronic pain and of pain in patients with cancer.
14. Understanding of the principles of chronic pain management in the pain clinic setting.
15. Understanding of the importance of psychology and pain.
16. Management of severe pain and associated symptoms in palliative care.
17. Principles and ethics of pain research.
Skills
1. Assessment and management of acute pain: postoperative, post-traumatic and non-surgical
acute pain.
2. Management of acute pain including special clinical groups: infants, patients with opioid
dependence or tolerance, non-surgical acute pain (e.g. sickle cell disease crisis), patients who
are handicapped or with impaired consciousness.
3. Explanation of analgesic methods: oral; sublingual; subcutaneous, IM; IV; inhalational analgesia,
patient controlled analgesia, epidural; regional techniques and local blocks; possible side effects
and complications.
4. Neural blockade: brachial plexus blocks, paravertebral nerve block, intrathecal and epidural drug
administration for acute and cancer pain.
5. Management of side effects of pain relieving medication and procedures.
6. Basic assessment of patients with chronic pain.
7. Recognition of neuropathic pain.
8. Prescription of medication for chronic pain including antidepressants and anticonvulsants.
9. Use of stimulation induced analgesia: transcutaneous electrical nerve stimulation.
10. Basic assessment and management of patients with cancer
Nick Campkin / Heather Knight 2006
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Attitudes
1. Listens to patients and their relatives.
2. Provides explanations in a way that patients and relatives can understand.
3. Appropriate communication with staff.
4. Enlists help I advice from other professionals when appropriate.
5. Awareness of role in a multi-professional team.
6. Awareness of ethnic, cultural and spiritual issues in pain.
7. Keeps adequate records.
Workplace training objectives
1. Able to assess and manage acute pain for patients after most types of surgery including
cardiothoracic, neurosurgery and paediatric surgery.
2. Able to provide explanation of analgesic methods: oral, sublingual, subcutaneous, IM, IV drugs,
inhalational analgesia, patient controlled analgesia, epidural and regional techniques; possible
side effects and complications.
3. Able to institute appropriate action for patients with unrelieved pain in the immediate postoperative period and unrelieved non-surgical acute pain on the wards.
4. Able to establish priorities and formulate a treatment plan.
5. Able to diagnose and institute initial management for neuropathic pain.
6. Able to demonstrate technical proficiency with procedures from the skills list.
7. Able to work as a part of a multi-professional team.
Nick Campkin / Heather Knight 2006
18
Clinical Assessment
Chronic Pain Management
CONFIDENTIAL
Excellent
Good
Satisfactory
Poor
Atrocious
Not
Assessed
Overall
Assessment
Clinical
Judgement
Communication
with staff
Theoretical
Knowledge
Record
Keeping
Time Keeping
Number of Cases:
Comments:
This is a fair reflection of the pain clinic assessment. Any areas of concern have been discussed and
will be addressed as follows:
Trainee signature:
Trainer signature:
(Must be signed by chronic pain consultant))
Date:
Nick Campkin / Heather Knight 2006
19
Work Place Assessment Record
CHRONIC PAIN MANAGEMENT
Wessex School of Anaesthesia:
Trainee:
NTN:
RCOA number:
The above trainee has completed a period of training in Chronic Pain Management and attained the
necessary skills, attitudes and behaviour in this specialty. They have achieved the Work Place
Objectives as set out and required by the Royal College of Anaesthetists.
This assessment is based on:
Direct observation in outpatient clinics
YES / NO
Direct observation in procedure lists
YES / NO
Feedback from Pain Clinic staff
YES / NO
Inspection of logbook evidence of appropriate clinical cases
YES / NO
Formal assessment (clinic / procedures)
YES / NO
Trainee signature:
Trainer signature:
(Must be signed by chronic pain consultant)
Date:
Nick Campkin / Heather Knight 2006
20