NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - AUTUMN 2002
FROM THE EDITOR: you would like covered, please send them in the costs of research projects are available. An t o a d d r e s s b e l o w. A n y p h o t o g r a p h s , outline of the proposed study should be sent to: - We l c o m e t o t h e a u t u m n e d i t i o n o f embarrassing or otherwise, suitable for the Threshold. I would like to thank Janssen Cilag caption competition would be much Dr. Mick Serpell, for sponsoring this issue of Threshold. Many appreciated. Consultant Anaesthetist, thanks to A. Menarini for sponsoring the last Department of Anaesthesia, issue. Post them to: - Gartnavel General Hospital, Great Western Road, It seems a long time since Ruhy Parris Dr. Colin Rae Glasgow. casually dropped a small bombshell into our Department of Anaesthesia, conversation over a cup of coffee. “How do Stobhill Hospital, you fancy being the new Editor of Threshold, 133 Balornock Road, Glasgow. Colin? You’d be good.” Immediate panic. “No G21 3UW NBPA Competition 2003 I wouldn’t be.” I thought, desperately thinking Tel no: 0141 201 3005 - PRIZE £750 of an excuse. Seeing the determined look on Ruhy’s face, I quickly decided that even Fax no: 0141 201 4167 Email: The closing date for this years competition pretending I am dyslexic wuoldn’t be enuohg. Colin.Rae@NorthGlasgow.Scot.NHS.uk is March 31st 2003. This competition is open Could I really be an Editor? It sounded good. NBPA web-site: http://www.nbpa.org.uk to everyone. To enter, please submit one of the Editor of Threshold! Why shouldn’t I be able following to a maximum of 3,000 words. to do it? Well, English was my worst subject at school. I don’t suppose that will matter. 1. An essay on a pain related topic, OR There is that tendency I have to leave 2. The report of completed audit or research everything to the last minute. Mmmmm. It’s project, OR only twice a year though. It’s a challenge. Yes, 3. A case report I’ll do it!! Entries should be sent to: - Well, here we are, several months later. Dr Ruhy Parris, It’s nearly midnight and the pressure is Consultant in Anaesthesia and Pain beginning to tell. Ruhy is a hard act to follow. Management, I know you’ll go easy on me for the first NHS Dept. of Anaesthesia, couple of issues while I learn the ropes. By Walton Building, then, I’m sure I will have another excuse Glasgow Royal Infirmary. prepared……. G4 OSF Ruhy Parris and Colin Rae, outgoing and On a more serious note, we are all indebted incoming Editors of Threshold to Ruhy for her hard work over the last four years as Editor. I am sure that you will agree she has done an excellent job. Her journalistic MINUTES OF THE flair, style and red lipstick will be sorely EIGHTEENTH ANNUAL missed. She will, however, still grace the pages of Threshold in her new role as NEWS FROM GENERAL MEETING Secretary of the NBPA. NBPA COUNCIL OF THE NORTH BRITISH PAIN ASSOCIATION, It has been a busy year since the Spring Council would like to remind everyone that POLLOCK HALLS, UNIVERSITY Scientific Meeting with many developments membership of the NBPA is open to in the North British Pain Association. Many undergraduates of all specialties. Membership OF EDINBURGH of you (the lucky ones) have been on a long forms can be downloaded from the NBPA web- Friday 10th of May 2002. haul trip to San Diego to the IASP Congress. site. Dr. Lisa Manchanda, winner of the 2002 Chairman’s Report: Dr Murray NBPA Essay Competition, has sent in some Travel grants are available to attend Carmichael started by welcoming everyone to photographs from the congress, which will be meetings or work abroad and applications the meeting. He announced that since the used at a later date for caption competitions - should be sent to Dr. Alan Semple at Falkirk departure of Dr Dil Kapur for a sabbatical in so be warned! and District Royal Infirmary. Australia, the post of Secretary was in a transition phase and records were not entirely If there are any articles you would like to The research group of the NBPA would like available (in Dil Kapur ’s luggage). As a submit to Threshold, suggestions, or topics to publicise that grants of up to £1000 towards consequence, the minutes of the AGM of 11th May 2001 would be tabled at the next meeting. A list of the new NBPA council is given adenomyosis, chronic pelvic inflammatory Dr Serpell was acting temporary Secretary until below. disease, adhesions, pelvic congestion and the post could be filled. ovarian cysts. Non-gynaecological causes Council Membership of NBPA - May 2002 include pathology in the GI tract including He then summarised the past year. The AGM irritable bowel syndrome, interstitial cystitis, last May on the Economics of Pain and the Chairman musculo-skeletal conditions and psychological Dr Murray Carmichael Autumn meetings had both been well attended. disorders. East Scotland - Anaesthesia At the last AGM, MSP Dorothy Grace Elder Secretary had voiced her support for Chronic Pain services Dr Ruhy Paris Acute pelvic pain tends to have a well- in Scotland and indeed had tabled a discussion West Scotland - Anaesthesia defined onset, be of a short duration, of variable of it in the Scottish Parliament in March. This Treasurer intensity and associated with a discreet disease produced a great amount of interest, which Dr Alan Semple process. Chronic pelvic pain often has a poorly resulted in the highest ever number of hits to East Scotland - Anaesthesia defined onset, an unpredictable duration and no the Parliamentary website. One issue, which Threshold apparent biological function. As with other arose, was the fact that, although Pain was a Dr Colin Rae causes of chronic pain, chronic pelvic pain speciality with a formal training pathway under West Scotland - Anaesthesia causes a great deal of distress to the individual the Royal College of Anaesthetists, it did not Membership Secretary with associated disability, suffering and have a Koerner number (unlike England & Dr Mike Basler depression. This has both healthcare and social Wales). This may hamper its recognition and West Scotland - Anaesthesia implications. Patients are often unhappy with allocation of recourses in the health services. Council Members their treatment, have distrust for the medical This point had been made to the Health Minister Dr Mick Serpell establishment and there may be ongoing West Scotland - Anaesthesia and there was to be a meeting with her in the litigation. Those attending pain management Dr Dick Davidson-Lamb next few weeks. clinics may have had multiple investigations, NE Scotland - Anaesthesia Dr Mhoira Leng medical treatments and surgical procedures. Dr. Lisa Manchanda had won the trainee NE Scotland – Palliative Care prize competition with her essay “Is Surgery Sister Anne Kelly The mainstay of management of chronic the Answer?” and was awarded expenses of NE Scotland - Nursing pelvic pain is a multi-disciplinary approach, £750 to attend a pain meeting of her choice Dr Janet Braidwood addressing bio-psychosocial factors affecting (IASP, San Diego, of course!). East Scotland – Anaesthesia their chronic pain condition. Mrs Kath Smith North England - Physiotherapy Several gynaecological conditions can cause Dr Lyndia Green pain. Endometriosis affects one third of women West Scotland – Clinical Psychology Dr Danny McQueen referred to a Gynaecology Clinic. East Scotland - Pharmacology Endometriosis may be present without pain and it is not entirely clear why it does cause pain in some women. It occurs in the reproductive years affecting 10% of the female population. SCIENTIFIC MEETINGS Endometriosis may be related to retrograde menstruation and it has been suggested there is The theme of the Winter Scientific meeting both an immunological and a genetic on Friday 22nd November 2002 is “Hard Nuts component. A full pain history, including to crack”. A good follow on from the last factors associated with the pain and the success meeting on “Urogenital Pain”! or failure of previous treatments should be Murray Carmichael congratulates Lisa obtained. It is important to ask the patient to Manchanda, winner of the NBPA Essay The theme of the Spring Scientific Meeting, describe their worst symptom, their fears and Competition 2002-10-08 Friday 9th May 2003, will be “Pain and beliefs and the effect the pain has on their life. Conflict”. Typical endometriosis symptoms include chronic Financial Report: Dr Alan Semple thanked pelvic pain, dysmenorrhoea, dyspareunia, loss the pharmaceutical trade for their support at Both meetings will be held at the usual of energy and infertility. Examination, these meetings. He then presented the accounts venue, John MacIntyre Building, Pollock Halls, including bimanual palpation of the uterus, may Edinburgh. reveal utero-sacral ligament nodules, pelvic for the year to February ’02. The current tenderness or fixation, a thickening of the recto- financial position remains healthy with assets vaginal septum, adnexal masses or a fixed of £29,385. He had deposited £ 20k into a higher retroverted uterus. interest account, which requires a notification REPORT FROM SPRING time of 3 months. The accounts were proposed for approval by Dr Carmichael and seconded SCIENTIFIC MEETING Most patients will proceed to have a Friday 10th May 2002, diagnostic laparoscopy. Treatment of by Dr Macrae. Pollock Halls, Edinburgh endometriosis includes both medical and surgical options. Medical treatments include GNRH Threshold: Dr Ruhy Parris was retiring analogues, Danazol and the oral contraceptive from her position as Editor of “Threshold” and There was an excellent attendance at the pill. These treatments are not free from side would be replaced by Dr Colin Rae. She was Spring Scientific Meeting on Urogenital Pain. effects and tend to produce only short-term thanked for her hard work and high standard of RDG Medical, NAPP Pharmaceuticals, benefit. Surgical treatments include laparoscopy journalism. Pharmacia, Pfizer, Chiesi and Elan and haemo-coagulation/laser of areas of Pharmaceuticals kindly sponsored the meeting. endometriosis. Few studies have looked at the Research Group: Dr Mick Serpell long-term outcomes from these treatments and Dr Murray Carmichael, Chairman of the summarised the recommendations of a steering those that have do not demonstrate good results. North British Pain Association, gave a warm group, which had been formed to encourage welcome to both delegates and speakers. research activity within the NBPA membership. A case history was presented of a 28-year- The title of the first lecture was “Pain in Gynaecological Disease” given by Dr Paul old nulliparous lady with chronic pain. She had A.O.C.B. Dr Carmichael announced that Dewart, Consultant Gynaecologist, St. John’s a long history of painful periods, which had led several new council members were required to Hospital, Livingstone. to prolonged sickness from work and also replace the departure of Drs. Kapur, McCubbin, resulted in deep dyspareunia. This patient’s Stuckey and Liz Mcleod. Also, the position of His talk commenced with a description of highest concerns were her fertility, her Secretary was vacant. Members were asked to the causes of pelvic pain. The differential relationship, work, her quality of life, treatment consider nominations over lunchtime. At the diagnosis of chronic pelvic pain includes both options and recurrence of the problems. The start of the afternoon session proposed new gynaecological and non-gynaecological causes. importance of finding out a patient’s priorities council members were all accepted by acclaim. The former includes endometriosis, and worries was emphasised. Dr Dewart moved on to discuss visceral afferent neurones also have This lecture was followed by a talk on the dysmenorrhoea, which may be primary or cannabinoid-1 receptors and endocannabinoids “Clinical Management of Urogenital Pain”. We secondary and dyspareunia. Normal such as anandamide can attenuate viscero- were privileged to have Dr Beverley Collett, investigations include microbiology, ultrasound visceral hyper-reflexia, turpentine-induced c fos Consultant in Anaesthesia and Pain and endometrial biopsy. Pharmacological expression and turpentine-induced referral Management from Leicester Royal Infirmary to management revolves around modification or hyperalgesia. Endogenous cannabinoids give this talk. suppression of menstruation and the use of physiologically antagonise the pro-hyperalgesic appropriate analgesics. Dyspareunia may be effect of nerve growth factor and act both Chronic pelvic pain affects 38/1000 women classified as superficial or deep. A full history centrally and peripherally. in the UK. Of all the laparoscopies performed must be taken and examination performed. to investigate pelvic pain, 40% demonstrate no Infective causes should be excluded and There followed a discussion of the potential abnormality. Chronic pelvic pain leads to laparoscopy may be required to exclude other for cannabinoids as an effective treatment in this 70,000 hysterectomies being carried out every diagnoses. Management includes counselling, area. year in the USA. Of attendees to the Urogenital relaxation, dilators, lubrication, physiotherapy Pain clinic, 30% have undergone hysterectomy. and treatment of any specific causes. Chronic Following an excellent lunch, the afternoon pelvic pain in general may respond to scientific session began with an entertaining Chronic pelvic pain is a complex problem psychological treatment approaches including lecture on “Urinary Tract Pain” given by Mr with gynaecological, urological, gastrointestinal cognitive behavioural therapy, which may Peter Paterson, Consultant Urologist at Glasgow and musculoskeletal aetiologies as possible involve the patient’s partner. Royal Infirmary. contributing factors. There does seem to be an increased incidence of both sexual and physical Discussion at the end of the lecture included This proved to be a very interesting overview abuse in women with chronic pelvic pain, which the relevance of adhesions to chronic pelvic pain of urological pain syndromes, concentrating on suggests that psychological factors can also be and whether there is a role for awake three main topics: loin pain haematuria important. laparoscopy to allow accurate determination of syndrome, essential testodynia and prostatitis. the exact location of pain. Treatment should involve a multidisciplinary Loin pain haematuria syndrome. As in many approach provided by a team consisting of a other chronic pain conditions, the evidence for gynaecologist, psychologist, pain clinician, treatment options in loin pain haematuria physiotherapist, nurse and secretary. All syndrome is poor. Options include patients referred to the Urogenital pain clinic Sulphinpyrazone, retrograde injection of will receive a multidisciplinary assessment and Capsaicin, surgical sympathectomy, renal auto formulation of a joint management plan. transplantation and renal denervation. The psychologists aims are to enable the Testicular pain. This may present post- patient to control their pain, reduce their vasectomy, associated with epididymal swelling disability, promote well being and address any or infection or as essential testodynia. One psychological morbidity. Strategies include reassuring factor is that testicular neoplasia relaxation, stress management, distraction and tends to be painless and is relatively easily other pain management techniques. Disability excluded with testicular ultrasound. However, can be reduced by encouraging a progressive Dr. Paul Dewart and Dr. Andrew Rice if examination of the testicle is normal, there is increase in activity and modifying pain little to be gained by an ultrasound examination. behaviour with the ultimate aim of returning the We were privileged to have Dr Andrew Rice, Mr Paterson stresses the importance of taking a individual to employment. Advice is given on Senior Lecturer in Anaesthesia, University full sexual history and exploring psychological nutrition, sleep and physical exercise. Patients College, London giving the next lecture titled factors that may be contributing to the chronic may suffer from anxiety and/or depression and “Physiology of Visceral Nociception” . pain problem. The exact aetiology of essential may have a history of abuse. Treatment may testodynia has not been determined but one involve marital and family counselling and sex He started with a description of the visceral theory is that there is an increase in pressure therapy. nociceptors and sensory afferents, which travel within the testicle. with autonomic fibres and visceral pain Physical treatments include active and pathways in the dorsal columns of the spinal Chronic prostatitis. This may be bacterial, passive muscle stretching, active and passive cord. He outlined the hypothesis of visceral associated with recurrent urinary tract infections lumbar flexion exercises, abdominal muscle hyperalgesia. With persistent tissue injury and and positive bacteriological culture. It is usually strengthening exercises, joint mobilisation and inflammation, a subject may develop both treated with prolonged courses of antibiotics posture instruction. King et al in 1991 looked primary and secondary hyperalgesia, due to with some patients proceeding to a transurethral at 132 patients with CPP. They found a variety peripheral and central sensitisation. He resection of their prostate. There is a condition of physical problems including faulty posture, described research in a rat model of turpentine- known as abacterial prostatitis with a similar iliopsoas shortening, decreased lumbar flexion, induced bladder inflammation, which presentation but negative bacteriological increased pelvic floor muscle tone, loss of demonstrated marked changes in intravesical culture. This may be an allergic phenomenon passive hip rotation and abdominal weakness. pressure and contraction following and there have also been cases of radiation- inflammation. induced prostatitis. The consultant in pain management provides advice about oral medication, trigger point There followed a brief description of the Mr Paterson finished with an interesting injections, peripheral nerve blocks, sympathetic factors involved in dorsal horn neurone conclusion that perhaps self-stimulation may be nerve blocks and joint injections. sensitisation and c-fos gene expression in as beneficial as any other treatments. response to afferent nociception. Many The nurse acts as a co-ordinator, educator receptors and neurotransmitters may be involved and health promoter. They will also act as in this process including sodium channels, liaison between the pain team and ward staff. vanilloid receptor 1, nerve growth factor, cytokines, serotonin, histamine and bradykinin. The title of the next lecture was “Overview There is increased expression of nerve growth of Sexual Abuse” given by Dr Rhiannan Pugh, factor in inflamed viscera and nerve growth Consultant Psychiatrist in Psychotherapy, Royal factor itself can induce features of visceral Edinburgh Hospital. The organisers were very hyperalgesia. There is evidence in addition that grateful to Dr Pugh for stepping in at short antagonism of nerve growth factor can attenuate notice. visceral hyperalgesia. The prevalence of sexual abuse in the Intravesical nerve growth factor provokes general population is estimated to be 12% of visceral hyper-reflexia and induced c fos women and 8% of men from a survey by Baker expression in spinal cord neurones. Primary Dr Beverly Collet and Mr Peter Paterson and Duncan. 20% of these individuals will subsequently develop psychopathology. In a PAIN NEWS AND GOSSIP survey of 100 psychiatric in-patients, 19% reported a history of child sexual abuse. Murray Carmichael, our Chairman, has retired from the Western General in Edinburgh. Psychiatric Condition Percentage suffering I am sure everyone would like to wish him a from childhood sexual long and happy retirement. Despite his retiral, abuse he has returned to work his own locum. Now Schizophrenia 60% that is dedication. Drug Abuse 44% Eating Disorders 51% Congratulations to Dr. Lyndia Green on becoming a mother in law. Congratulations also Sexual Dysfunction 90% to Dr. Pauline Adair on her recent marriage, new Somatisation Disorder 55% job and new house! Glasgow is delighted to welcome her as our new Consultant Clinical Dr Pugh emphasised that there was not Psychologist for pain management. Dundee’s necessarily a cause and effect relationship loss is Glasgow’s gain. between a psychiatric disorder and childhood sexual abuse or vice versa. Individuals who have suffered childhood sexual abuse however may develop psychological problems including depression and anxiety, low self-esteem, guilt and sleep disturbance. They may have borderline personality disorders and develop eating disorders. There is increased incidence Dr. Rhiannan Pugh of problem behaviours such as self-harm, drug use, promiscuity/prostitution, running away typically rigid patriarchal set up with a dominant from home and conduct disorders. Individuals father and a passive mother ceding duties to a may also have problems with social daughter. The oldest daughter is likely to be relationships. They have an increased incidence the first victim and the commonest age group of social withdrawal and are more likely to be being 8 – 12 years. The onset is normal in abusive relationships. A previous history of insidious. The victim usually fears that they will Pauline Adair and Lyndia Green childhood sexual abuse is present in 35% of be punished, blamed, not believed, and have a perpetrators of sexual abuse. fear of abandonment. Dr Pugh emphasised that Ruhy Parris is very proud of her son Iain, healthcare professionals should be encouraged who you may remember from the last issue of Dr Pugh then moved on to talk about incest. to routinely ask about a history of childhood Threshold. He has gained 9 A stars in his This more commonly occurs in a family with a sexual abuse. GCSE’s. Well done, Iain.
Dr. Theresa Houseman, Clinical
psychologist from Glasgow Royal and Stobhill CROSS PARLIAMENTARY GROUP ON CHRONIC PAIN has left to take up a new post working in Lanarkshire in the diabetes service. We wish The next meeting of this group is in November. There was a constructive meeting with Mary her well. Her post has recently been advertised Mulligan, Deputy Health Minister on 24 th June 2002. There was agreement reached that the and we hope a replacement will be appointed recommendations of the CSAG report should be implemented. soon.
Alison Crofts (physiotherapy, Glasgow
Royal) has left to take up a new job in Sports Medicine at Hampden. We would like to welcome her replacement, Holly Daniel from North Carolina.
Dr Lars Williams, Specialist Registrar in
Anaesthesia is the new Glasgow Pain Fellow. This is a new post for one year. It is hoped that this post will be recognised for training in Pain Management by the Royal College of Anaesthetists. During this time Lars is visiting all the clinics in Glasgow and is also planning visits further afield. There is increasing interest Liz Beattie, Sara Brookes and Kath Smith Lisa Manchanda and Bill Macrae, Glasgow from trainee Anaesthetists in chronic pain from Ashington management.
As mentioned in the last issue of Threshold,
new Greater Glasgow Health Board guidelines CAPTION COMPETITION have been issued to primary care. There are separate protocols for treatment of back pain, As there have been no entries for large joint pain and neuropathic pain and last issues caption competition we are standard referral forms to the chronic pain in a rollover situation! Entries for this service are now in use. They were launched at issues competition should be sent to the a well attended meeting on the 7th of March in Editor and will be announced in the next the Milton Hotel. In addition, the back pain issue. The prize will be an even bigger early intervention service is now up and running. book token. It will be interesting to see the effect this has on referral patterns to the chronic pain service.
I apologise for the Glasgow slant but you
can update me with news from the regions at the meeting in November.