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NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - SPRING 2001
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FROM THE EDITOR
Welcome to the real new millennium(for the purists)! This year Threshold issponsored by Napp. Many thanks for their support. The world of pain expands.More people are hearing of the CSAGreport (Services for Patients With Pain).Hopefully, increased awareness will leadto an increase in resources to enableimplementation of the recommendations.Many of you will know that MSPs areinterested in chronic pain, with theformation of a crossparty parliamentaryworking group.Please let me know of news and views.
You can contact me at:
Department of AnaestheticsWalton BuildingGlasgow Royal Infirmary84 Castle StreetGlasgow G4 0SFTel: 0141 211 4621Fax: 0141 211 4622
E mail: john@jparris.demon.co.uk 
 Ruhy Parris
NEWS FROMNBPA COUNCIL
SPRING SCIENTIFIC MEETING
As the two annual fixtures are currentlyMarch and December, it was felt that itwould be more balanced to spread themeetings out a bit more (is this pacing?).The December meeting stays as it is,however the next Spring meeting nowmoves to May. For your diaries, the dateis Friday 11 May 2001, at the usual venue,Pollock Halls of Residence, University of Edinburgh. The theme of the meeting will be
Psychosocial Factors in Chronic Pain
.The secretary, Dr Dil Kapur, willcirculate registration forms imminently.
 He can be contacted at:
Pain Management UnitRoyal Victoria InfirmaryQueen Victoria Road Newcastle upon Tyne NE1 4LPTel/Fax: 0191 282 4412E mail: dilkapur@netcomuk.co.uk  NBPA website: http://www.netcomuk.co.uk/~dilkapur/index.htm
WINTER SCIENTIFIC MEETING8 December 2000Pollock Halls, Edinburgh
The theme of the meeting was
Painin Children
, following last years highlysuccessful
Pain in the Elderly
. Themeeting was kindly sponsored by RDG,Pfizer, Sims Portex, Elan, Rusch, andSearle.The first speaker of the morning wasDr John Currie, Consultant Anaesthetistat the Royal Hospital for Sick Children,Glasgow. He is originally a Liverpoolgraduate, and has worked in Edinburgh,Great Ormond Street, Ayr, and for the lasteight years in Glasgow. He has been theRegional Education Advisor for anaesthetists for the last 18 months. Hisremit was 
 Running a Chronic PainService for Children
. He currently has5 or 6 referrals per month of patients withchronic pain. The approach ismultidisciplinary, and of course involvesthe whole family. Paediatric pain is uniquein that everything occurs with a background of growth and development.He concentrated on the need for adequate infrastructure (space, secretarialsupport) and most of all time. There ismuch emphasis on liaison with other agencies such as schools, physiotherapyand community nursing. He sees childrenwith a wide spectrum of conditions suchas complex regional pain syndrome, painafter surgery (eg phantom limb pain), andalso atypical pains such as facial pain.Being paediatric practice, pain fromcongenital abnormalities such as spina bifida, are relatively common. Terminaldisease also features, whether neoplasticor chronic conditions such as renal failureand cystic fibrosis.The principles of pain management inchildren echo those in adults, withemphasis on adequate information, controlof pain, reassurance, increasing levels of activity, and improving sleep (child and parent!).The team approach cannot beoveremphasised. Pharmacologicalmethods and nerve blocks all have a placealongside encouragement by nursing, physiotherapy, and clinical psychologycolleagues to increase function.Children (as any parent thankfullyknows) grow up, and long term followupof patients is an area where improvedliaison with adult pain services is vital.
 Dr John Currie
The next speaker of the morning wasMs Zoe Sully, Physiotherapist at the Royal National Hospital for Rheumatic Diseases,Bath. She has been involved with the adultPain Management Programme for 5 years.She was then given the remit for developing a feasibility and business planfor an adolescent Pain Management
 
Programme. This has been up and runningfor 18 months. Her presentation was on
Pain Management in Adolescents
.Adolescents (again as parents will attest) present unique challenges. Adolescenceis a period of transition from dependenceto independence (Ed: my own children bear more than a passing resemblance toKevin and Perry), when young people arechallenging boundaries (Ed: youre notgoing out dressed like that!), changingschools, and developing their sexualidentities. There is clinical demand for an adolescent service, indeed some 10%of adults had pain in childhood.Factors associated with adolescent pain presentation are a family in crisis, stress,school and social difficulties, physicaldifficulties, and changes is familydynamics. Pain associated disability(PADS) in a young person includes lowmood / high anxiety, low self confidence,dependence at a time of growingindependence, reduced fitness, poor school attendance, reduced activity andsocial withdrawal. These issues thenimpinge on the wider family. In the programme, again the emphasis is on ateam approach with the psychologist, physiotherapist, occupational therapist,nurse, paediatric rheumatologist, andresearchers.The programme is a 3 week residentialone with parental involvement.Accommodation is B & B to encourageindependence. There is a pool, andtherapy space. Cognitive behaviour therapy is the mainstay of the programmewith skills training, family understandings, physical rehabilitation, goal planning, pacing and relaxation. There areopportunities for sessions for parents /carers only, and conversely sessions for the young people on their own. Followingdischarge, there is a comprehensivesummary for the referrer, and patient.Follow-up occurs 3 months, 9 months and2 years post programme. Telephonesupport is available. Both the young person and their parents are assessed onvarious measures such as pain of child,mood, anxiety and depression. To date,the adolescents have improved on physicalmeasures, and the parents show less stress,anxiety and depression. It may well bethat a major factor is changing theattitudes of the parents who then mediatechange in adolescents.The final speaker of the morning wasDr Norman Lannigan, Chief Pharmacistof Lothian Universities NHS Trust. Hehas previously worked in Perth, Glasgowand Inverclyde. His background is inanalytical chemistry. Special interestsinclude chronic pain, palliative medicine,and quality of pharmaceutical services.He spoke on 
Using Medicines Out of  License  Considerations in Prescribing  for Children
. The Health SelectCommittee (1999) described unlicensedmedicines use in children as anunsatisfactory state of affairs. TheMedicines Act (1968) requires medicinesto have a product license in order to protect society from inappropriatemarketing by manufacturers. It is notintended to prevent competent clinical practitioners from prescribing in the bestinterests of their patients. Indeed, medical practitioners have the right to prescribeunlicensed medicine, pharmacists candispense them, and nurses are allowed toadminister them following the direction of the medical practitioner. Named patient products can be prescribed, alsounlicensed medicines may be used inclinical trials. Medical practitioners canuse unlicensed medicines outwith SpecificProduct Characteristics (SPC).Turner et al (BMJ Jan 1998) estimatedthat 36% of children in hospital receivedan unlicensed medicine during admission,and that 25% of all prescriptions for children in hospital were for unlicensedmedicines. An unlicensed medicine may be used off label (route, dose, age,indication). Manufacturers have adilemma when considering clinical trialsin children such as ethical problems(placebo controlled, exposure of childrento experimental medicines, informedconsent), and also liability issues (adversedrug reactions, long term growth/development). This has implications for  practitioners if prescribing outwith product license as the liability is with the practitioner not manufacturer.In February 2000 a policy statementwas produced by the Joint Royal Collegeof Paediatrics and Child Health and Neonatal and Paediatric PharmacistsGroup Standing Committee on Medicines.The conclusions were to choose medicineswhich offer the best prospect of benefitfor the child with due regard to cost,informed use of unlicensed medicines isnecessary in paediatric practice, health professionals need access to qualitymedicines information, Trusts and Boardsshould support therapeutic practice whichcommands peer support. It is importantto have seamless prescribing solutions between secondary and primary care, suchas using joint formularies, shared care protocols, and of course effectivecommunication.
 Zoe Sully
The afternoon programme was chaired by Dr Mhoira Leng. The first session wasa presentation by Dr Martin Ward Platt,Consultant Paediatrician, Royal VictoriaInfirmary, Newcastle, titled 
 Pain inChildren  Involving Families
. He spokeon the necessity to speak separately to thechild, exploring their particular fears andanxieties. Pain may be a form of communication within the family, anavoidance strategy (school or a familymember), or a safety valve. It takes timeto uncover the real issues, unpick relationships, reveal unspoken fears, andidentify the locus of control (adult or child). A thorough physical examinationis mandatory, and to listen to the storygiven. Once these have been done, it isvital to formulate the problems in termsof how the family sees them and how thehealth professionals see them. Once this
 Dr Martin Ward Platt and Dr Mhoira Leng  Dr Norman Lannigan
 
BOOK REVIEW
Our intrepid physiotherapist, IanStevens, currently in Dunblane (exGlasgow) has contributed a book reviewof Patrick Walls 
 Pain The Science of Suffering 
, below.
Pain The Science of SufferingPatrick WallWeidenfield and Nicholson 1999isbn 0 297 84255 2
Don t judge a book by its cover. Inthis case you could easily ignore thisadvice. The book reviewed here has areally eye catching cover with humanforms interlaced with a myriad of shapes,arrows, squares and a maze of spirals .The maze of shapes makes no sense andthe arrows and lines move easily betweenthe peripheral body to the head and back again.Such is the case with the subject of the book. The contents weave between the periphery to central relay sensations andcognition - no area dominates , all areasare ripe for study, all ripe for intervention.We all like certainties and pain is far from certain. Patrick Wall has spent alifetime studying pain and the contents of this book demonstrate not only a depthof understanding of the subject but a realawareness of the focus of the book - manand his suffering.The book is no dry academic diatribeon a complex perplexing subject but anexample of how scientific medicine can be.The contents of the book are aimed at thelay reader but no one who has an interestin trying to understand pain will bedisappointed by its contents.For Physiotherapists interested inmovement restoration and painis done it is then possible to negotiatesolutions with all parties concerned, andagree ways forward with communicationwith the GP, parents etc.Dr Bob Leckridge from the GlasgowHomoeopathic Hospital, who is thePresident of the Faculty of Homoeopathy,spoke on 
Using Homoeopathic Medicines in Children
. He comes froma general practice background, and has been working using a homoeopathicapproach in the department of developmental neurology, Royal Hospitalfor Sick Children, Glasgow for a number of years. He described chronic pain assomething which cannot be understood interms of tissue damage alone. Heemphasised the importance of narrative based research where the story isrecounted, in detail, in the patients ownwords. Understanding suffering is the keytask of any doctor. Homoeopathictherapeutic modalities are based on liketreats like. Remedies are potentised preparations. Remedies are prepared byserial succussions and dilutions. Naturally, there are questions aboutstandards of training and practice andabout regulation. It is vital to haveevidence based homoeopathy as a wayforward for the future, with meta-analyses, RCTs, outcome studies, caseseries, and qualitative research.The final speaker of the day was Dr Graham Carey, Medical Advisor to theMedical and Dental Defence Union of Scotland, who addressed 
 Legal Issues inthe Treatment of Children
. There are16 has capacity if they understand thenature and possible consequences of the proposed treatment. In Scotland there aretwo relevant Acts, namely the Age of Legal Capacity Act 1991, and the ChildrenAct 1995. In England & Wales courts canoverrule a childs refusal of consent totreatment if under 16, but the situation isless clear in Scotland. In Scotland a childunder 16 can consent to procedures andtreatment for nontherapeutic research, but probably cannot in England & Wales.In England & Wales an unmarried father cannot have access to a childs healthrecords, but the situation is less clear inScotland. Laws keep changing so it isimportant to keep abreast of them wherelitigation involves children.
 Dr Graham Carey
differences in legal aspects betweenEngland and Scotland. Children differ from adults legally with regard to consent,access to health records/Data ProtectionAct, and litigation. Over the age of 16 a person has capacity, but a person under amelioration the book is both relevant andvaluable. For instance on page 153 Wallasks the question. What are theappropriate motor responses to the arrivalof injury signals?They attempt: first to remove thestimulus; second, to adopt a posture tolimit further injury and optimise recovery;and third, to seek safety, relief and cure.The youngest, most inexperienced animalmay attempt a series of these responsestriggered by in- built mechanisms. As theanimal grows in experience, the reactionswill become more subtle, elaborate andsophisticated .If the sequence is frustratedat any stage, the sensation and postureremain.This paragraph alone could perhapsoffer a lifetime of study and on a practicallevel it is one most therapists deal withdaily!The book is full of case histories fromour own familiar culture and contrastsother cultures approaches to dealing with pain. Some cultures display amazingstoicism, some religions encourage itHowever, change the situation, alter thecircumstances and mans biologicalreaction to pain is universal.Interestingly there is a section of the book describing the treatment of painwhose cause is known and approaches tothe management of conditions whosecause is not. For Physiotherapists most of the painful conditions routinely treated arein the second category!For Physiotherapists there areinteresting, challenging discussions on thewaxing and waning in terms of popularityof acupuncture, the important placebo phenomenon and the role of restoring patients to functional health in ongoing pain.Most importantly the book demonstrates the importance of movementin pain and the role that movement has inrestoring bodily health. The book dashesany notions of dualistic interpretations of  pain and does not offer any hope of findinga pain centre . What Patrick Wall doesoffer is a humane need to offer individualcare to individuals suffering pain,something Physiotherapists strive to offer on a daily basis . Given the growth inliterature such as this it is hoped that theunderstanding and management of thosein pain will only improve.
 Ian Stevens BSc MCSP 
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