painJune 2018 Volume news 16 Issue 2 a publication of the british pain society

Credit: Studiovin Focus on pain research day Consent in Pain Medicine ISSN 2050–4497 Increasing access to psychological services (IAPT) and pain services

PAN_cover_16_2.indd 1 03/05/2018 6:14:25 PM Third Floor Churchill House 35 Red Lion Square London WC1R 4SG United Kingdom Tel: +44 (0)20 7269 7840 Fax: +44 (0)20 7831 0859 Email [email protected] www.britishpainsociety.org

A company registered in England and Wales and limited by guarantee. Registered No. 5021381. Registered Charity No. 1103260. A charity registered in Scotland No. SC039583. contents The opinions expressed in PAIN NEWS do not necessarily reflect those of the British Pain Society Council. PAIN NEWS JUNE 2018

Officers Co-opted Members Regulars Dr Andrew Baranowski Mr Neil Betteridge President Representative Chronic Pain Policy Coalition 46 Guest Editorial – Jenny Nicholas Prof. Roger Knaggs Mr Kevin Bowers 47 From the new Editor – Dr Rajesh Munglani Honorary Secretary co-Chair, Patient Liaison Committee 49 From the President – Dr Andrew Baranowski Dr Heather Cameron Ms Felicia Cox 51 From the Honorary Secretary – Prof. Roger Knaggs Honorary Treasurer Editor, British Journal of Pain and 52 Spotlight – Andreas Goebel Representative, RCN Dr Arun Bhaskar President Elect Prof. Sam Eldabe Chair, Science & Research Committee News Dr Ayman Eissa Honorary Secretary Elect Dr Barry Miller 54 Pain in military veterans study day Representative: Faculty of Pain Medicine 56 Focus on pain research day Dr Glyn Williams Dr Rajesh Munglani Honorary Treasurer Elect 58 Patients’ voices at the heart of the society Editor, Pain News Elected Dr David Walsh Professional Perspectives - Margaret Dunham, Prof. Sam Ahmedzai Chair, Scientific Programme Committee Dr Peter Brook Ms Margaret Whitehead Associate Editor co-Chair, Patient Liaison Committee Dr Neil Collighan 60 Consent in pain medicine: law and implications for practice Dr Ashish Gulve Dr Amanda C de C Williams 66 Social and cultural influences on pain, pain behaviour and treatment Dr Tim Johnson Representative: Science Dr R Krishnamoorthy Secretariat Dr Sarah Love-Jones Informing practice Jenny Nicholas Dr Zoey Malpus Chief Executive Officer Dr David Pang 71 Applying clinical audit to support educational package to improve compliance of Casey Freeman performing observations for patient-controlled analgesia and epidural analgesia Secretariat Manager 77 Audit on chronic pain duration – comparison to national audit data 81 The launch of National Neuromodulation Registry – 2018 83 Audit of Medial branch block 1-year outcomes 2010-Dec 2016 88 ‘A practical guide to incorporating pain education into pre-registration curricula for healthcare professionals in the United Kingdom’: the new BPS pain education free- to-access webbook 90 Increasing access to psychological therapies and pain services

PAIN NEWS is published quarterly. Circulation The Editor welcomes contributions 1300. For information on advertising including letters, short clinical reports and End Stuff please contact news of interest to members, including Neil Chesher, SAGE Publications, notice of meetings. 92 Book review 1 Oliver’s Yard, 55 City Road, Next submission deadline : 29th London EC1Y 1SP, UK. June Tel: +44 (0)20 7324 8601; Email: [email protected] Material should be sent to: Disclaimer: Dr Rajesh Munglani The Publisher, Society and Editors cannot PAIN NEWS Editor be held responsible for errors or any The British Pain Society consequences arising from the use of Third Floor Churchill House information contained in Pain News; the views 35 Red Lion Square and opinions expressed do not necessarily London WC1R 4SG United Kingdom reflect those of the Publisher, Society and Email [email protected] Editors, neither does the publication of advertisements constitute any endorsement ISSN 2050-4497 (Print) by the Publisher, Society and Editors of the ISSN 2050-4500 (Online) products advertised. Printed by Page Bros., Norwich, UK At SAGE we take sustainability seriously. June 2018 Volume 16 Issue 2 We print most of our products in the UK. pain news These are produced using FSC papers and a publication of the british pain society boards. We undertake an annual audit on materials used to ensure that we monitor our sustainability in what we are doing. When we print overseas, we ensure that sustainable papers are used, as measured by the Egmont grading system.

Credit: Studiovin Focus on pain research day Consent in Pain Medicine Issn 2050–4497 Increasing access to psychological services (IAPT) and pain services https://www.britishpainsociety.org/ for-members/pain-news/

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Guest Editorial Jenny Nicholas Pain News 2018, Vol 16(2) 46 © The British Pain Society 2018

It was a pleasure education into pre-registration curricula Guest-editing this edition has given me to see so many for healthcare professionals in the United new insight into different aspects of of you recently Kingdom’. And will be pivotal as we producing Pain News. Dr Arasu Rayen in Brighton, and celebrate the IASP Global Year for has held the reins for nearly 5 years and I hope you Excellence in Pain Education, ‘Bridging sadly, the March issue was his last. I enjoyed this the gap between knowledge and want to take this opportunity to thank year’s ASM as practice’ in 2018. Arasu for the marvellous job he has done much as I did! Our spotlight features Dr Andreas over the past few years, including the As it has every Goebel, a Consultant in Pain Medicine, improvements he has made in both style year in my one of the many who makes up the MDT and content of Pain News. I hope the 11-year tenure membership of the Society. content he has compiled over the years here at the Society, it has inspired me to As always, we update you on other has challenged your point of view and broaden my thinking and try something recent events organised by the Society provided you with useful information. We new so here I am, writing my first ever and introduce you to more of the key have appointed a new Editor, Rajesh ‘Guest Editorial’ for Pain News. people who make up our Committee’s, Munglani who writes his first editorial for It’s not hard to find inspiration when who work together to achieve our Pain News in this issue. working with the diverse group of people mission to ‘enable best pain management I would also like to thank our Associate the Society brings together. With a for all’. Editors, Margaret Dunham, Christina variety of topics, ranging from If any of this content has inspired your Liossi and Sandeep Kapur, who also medicolegal issues, to audits, this edition thinking, we are always looking to hear worked closely with Arasu to ensure your alone has a little bit of something for from our Members. Perhaps you’d like to quarterly newsletter is interesting and everyone. contribute your own article or feature as informative – in short, a ‘must read’. Our Pain Education SIG has written our ‘Spotlight’ in the future? Please do let I hope you enjoy reading this issue of about it’s new free to access web book us know by emailing us at newsletter@ Pain News as much as I/We have ‘A practical guide to incorporating pain britishpainsociety.org. enjoyed pulling it together for you!

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From the new Editor Rajesh Munglani Pain News 2018, Vol 16(2) 47­–48 © The British Pain Society 2018

THIS IS US ... or why we need a multidisciplinary pain society so as not to miss the gorilla in the room.

‘Many of the truths we cling to Depend greatly on our point of view’ Obi-Wan Kenobi

Having reached the age of 55, I now realise that I have very likely lived more than half my life. This could be depressing news but in fact my maturing, like a fine wine, has been accompanied by a number of effects. I have found both the strength of my opinions and the tone of my bodily structures are now both very much less firm (or indeed, in the case of An early summer wild flower meadow, Cambridgeshire - or is it an MDT discussion in my body, now really quite saggy in parts). progress? In fact, the majority of my previously longstanding and rigidly-held medical by the phenomenon of inattentional bias asked 24 radiologists to perform a opinions have altered, sometimes in or selective looking. familiar lung nodule detection task. A damascene moments. gorilla 48 times larger than the average But I’m in good company with others: How not to miss the gorilla nodule was inserted in the last case. it is well known that the opinions of most Simons and Chabris conducted a set of 83% of radiologists did not see the gorilla scientific studies are eventually proved to experiments in which observers watched on the x-ray. Eye tracking revealed that be wrong. Richard Smith, former Editor a video of two teams of basketball the majority of those who missed the of the BMJ, stated provocatively players, one clad in white shirts and the gorilla looked directly at the location of “scientists are [more] interested in other in black shirts, passing basketballs the gorilla, (Drew et al (2013))5. funding and careers rather than truth”. amongst themselves. The observers It would seem that even trained Indeed, Ioannidis’ paper on ‘Why Most were instructed to count the number of observers operating in their domain of Research Findings Are Wrong’ is one of passes made, either by the white team expertise are vulnerable to inattentional the most cited papers in PLoS1-3. or the black team. Part way through the blindness, and indeed may be more Professor Ioannidis states that [with time] task, either a woman with an umbrella or prone to it. it is more likely that research claims will a person dressed in a gorilla costume Further studies have suggested that if prove to be false rather than true, but unexpectedly walks through the centre of an image is expected in a particular area also that for many current scientific fields, the action, remaining clearly visible for of a screen, then placing that same claimed research findings may often be about five seconds before exiting. 35% of image further away from the usual area simply accurate measures of the the observers failed to notice the woman reduced the absolute chance of seeing prevailing [scientific, medical] bias. with the umbrella and 56% failed to it6. All of this is worrying, and suggests Other studies show how easily the notice the gorilla4. that in fact experts may be rather too most well-intentioned and careful But surely, the training of expert biased, and have too narrow a field of scientists and medics can be misled or observers would allow them to perform view. One might also conclude that misperceive. This is perfectly illustrated better? In 2013, a team of psychologists specialists in a field are always in danger

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Rajesh Munglani

treatments. Based upon their analysis, bygone age this journal might have been we can conclude it is unlikely that any called ‘The Proceedings of the BPS’ to single pain treatment method (physical, reflect this more reflective approach). I pharmacological, psychological, would welcome contemplative pieces interventional etc) is likely to work when that intertwine both personal observation applied to an unselected population of and opinion, whilst acknowledging patients severely affected by pain. collective MDT peer experience set in the Thus, whilst it is necessarily right that landscape of prevailing scientific most patients with chronic symptoms knowledge with the ultimate aim of either self-manage or are assessed and further promoting a holistic and person- treated in primary care and in centred approach for those who are in Can you spot the gorilla? By kind permission community-based pain clinics, large pain and are suffering. I look forward to of Professor Trafton Drew, Psychological numbers may well still benefit from MDT- hearing from you. Science, 2013;24 :1848-1853 based secondary and tertiary pain services. Note It is clear that we have to work 1. As an additional tangent I would state of becoming too blinkered in their together, otherwise we may miss that a thoughtful examination of past approach, particularly if their usual spotting the gorilla. observations may prove useful, e.g. patient group is already highly selected. the ancient Egyptians, reportedly using This is where there is strength in a The purpose of Pain News mouldy bread to disinfect wounds, were clearly foreshadowing Sir multi-disciplinary team. Different We have research papers in journals (and Alexander Fleming, who discovered on perspectives allow one to approach the we now know whose findings are unlikely same problem with different biases and 28 September 1928 that Penicillin to be enduring with the passage of time mould inhibited staphylococci colonies priorities and, as such, a combined and the progress of knowledge) and also in a petri dish. MDT with their multiple viewpoints an endless 24-hour (transient) news allows a shift of focus from our own cycle in terms of Twitter, Facebook and References specialist perspective to a more (and the internet. Is there a niche for the 1. The BMJ Blogs, 2014 - Medical Research – still a probably more useful) patient focussed British Pain Society Newsletter in this scandal! by R Smith 2. The Guardian, Science, September 2013 – Not approach. endless media stream? The Faculty of Pain Medicine core breaking news: many scientific studies are As I take over editorship of this ultimately proved wrong! standard document states that complex newsletter, my vision is to encourage the 3. PLoS Medicine, August 2005, Vol 2, Issue 8 - Why most published research findings are false. by J P. patients need a multi-disciplinary acknowledgement of alternative approach, simply because the A. Ioannidis viewpoints by the potent mix of new ideas 4. http://www.theinvisiblegorilla.com/gorilla_ presentation (and causation) of such pain in medical and scientific findings, multi- experiment.html 5. Psychology Science, 2013 September; 24(9) is likely to be multi-factorial in any disciplinary perspective and combined individual complex pain patient7. There are 1848-1853 - The invisible gorilla strikes again: with (priceless) individual clinical Sustained inattentional blindness in expert likely to be many such patients indeed, as experience and opinion. I think this is best observers. by T Drew et al. 8 6. Psyche, 6(14) December 2000 - Sustained inattentional demonstrated by Fayaz et al in 2016 , described as taking the long view. who found that moderate to severe blindness: The role of location in the detection of We can now see that the answer to a unexpected dynamic events. by Most, et al. disabling chronic pain probably was particular problem may change with time, 7. Faculty of Pain Medicine of the Royal College of Anaesthetists, October 2015 - CSPMS: Core experienced by 10% to 14% of the that a treatment that was considered population. Those patients severely standards for pain management services in the UK acceptable in the past now is no longer 8. BMJ Open 2016; 6:e010364- Prevalence of affected by chronic pain are more likely so (such as hemi-glossectomy for chronic pain in the UK: a systematic review and meta-analysis of population studies than not to have significant associated stuttering1). The answers may change (and multiple) medical, psychiatric and 9. https://www.england.nhs.uk/wp-content/ but the questions are often eternal, such uploads/2013/06/d08-spec-serv-pain-mgt.pdf psychological co-morbidities and will likely as the question of what exactly pain is, 10. http://www.gov.scot/Resource/0053/00533194.pdf 11. Raine, et al. 2014 Improving the effectiveness of need more help than one single specialist and how it is linked to the human could possibly hope to provide9-11. multidisciplinary team meetings for patients with condition. chronic diseases: A prospective observational The need for such a multi-disciplinary So, I would encourage you all to study NIHR Health Services and Delivery Research. 12 Vol 2 Issue 37 October 2014 ISSN 2050-4349 approach is supported by Turk et al. , submit articles for consideration of who reviewed the efficacy of pain 12. Lancet 2011: 377:2226-35 - Treatment of chronic publication to this Pain News (or in a non-cancer pain by D Turk, et al

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From the President Dr Andrew Baranowski Pain News 2018, Vol 16(2) 49­–50 © The British Pain Society 2018

All change Editor. He has carried this responsibility The Communication Committee ... with great professionalism. However, his (written by Arun Bhaskar) Whereas the photograph brightening up our day also Notable Activity (since AGM in May Society is its needs to be mentioned! This important 2017): members, the position for the Society will be taken on •• Expansion of Communications backbone is by Rajesh Munglani. Committee with Sam Ahmedzai, the Secretariat. Stephen Humble and Pete Moore We are very actively promoting the British Pain Life never stands still ... pleased to be Society (BPS) on various social media In my last Pain News commentary, I able to platforms. informed you that Anthony Chuter had announce that •• Significant increase in regional and stepped down as Chair of the Patient Ken Obbard national networks and print media Liaison Committee (PLC) and that has realised with BPS representation for Margaret and Kevin were now joint chairs one of his comments and opinions – thank you bringing their unique experiences to the dreams and he will be moving on to work Sam Ahmedzai, Roger Knaggs and PLC. The PLC has now met on several at the Zoological Society of London (ZSL). Casey Freeman. occasions and at the last meeting they Ken has been responsible for •• Increased presence on Twitter and started to prioritise their plans. Two membership and many of the committees Facebook – thank you Stephen things that I have picked up on are that for the past 10 years. He introduced and Humble and Sam Ahmedzai. the PLC wishes to review the role of the supported many changes over the past •• Wikipage on the BPS. Patient Reference Group, how that few years, facilitating membership •• Sam Ahmedzai as webmaster with Group interacts with the Society and how applications, collecting of membership support from the Secretariat. the Society works with them. Building up dues, redesigning the website, supporting •• GDG set up for Cancer Pain, our relations with this group could SIG events and much more. Recently, he Neuromodulation and PMP potentially result in major gains for pain has been at the forefront of our publications. medicine. Currently there are 400+ membership review and has provided his •• Publications completed – document patients and carers in that group. significant wealth of experience in on position statement on epidural Another exciting development for the supporting that. The Chairs of the SIGs steroids along with FPM. PLC will be the production of short change but for many years Ken has been information videos on understanding pain there to ensure that there is consistency for patients. Don’t be surprised if you are and good communication. We wish him The Education Committee (written approached to take part. all the best: by Sam Ahmedzai) At this year’s AGM we also said Notable Activity (since AGM in May goodbye to outgoing Vice Presidents; Work, work and more work ... 2017): Martin Johnson and Paul Wilkinson, and Reviewing the reports from the various Paul Cameron, Elected Council Member, SIGs and Committees for Council, I was Short-term changes as their terms of office came to an end. impressed by the dedication of the few 1. We have sent out a survey to all They have all been a huge support to the members engaged in activities on behalf members asking for their suggestions Society and their contributions over the of all members and the Society (and of for future study days in 2018 and years have been invaluable. course you can also volunteer!). Below are 2019. We offered specific days a few examples of the sort of things going available to us at Churchill House, but Editor of Pain News ... on. I can only mention a few and I hope also opened the possibility of other Arasu Rayen has decided to step down that those not mentioned understand that venues around the country. We will from the important task of Pain News I have a limit to how much I include. follow this up with other surveys

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02_PAN773575.indd 49 23/05/2018 3:10:51 PM From the President

Dr Andrew Baranowski

targeted at specific disciplines, and the continuing interest in acute and •• Communication: continue our consumers. inpatient pain management. This interest communication with members and 2. Through the website, emails and was made clear from the attendance at use social media to promote pain social media, we will ask the the Persistent Post-Surgical Pain: education; membership and wider ‘followers’ of Challenges and Approaches day prior to •• Networking: within the BPS, with BPS for their views of future the 2017 ASM which APSIG ran with partner organisations and educational activities. Specifically, we BPS support. It celebrated the IASP internationally with IASP SIGs. will seek the level of interest in global year against pain after surgery. Thank you to Felicia Cox and Jane The above illustrates a very small (a) Regional events – in the North Quinlan who, with the APSIG committee, part of the significant activity by (e.g. Manchester) and South ensured the success of this day. members. What I would like to do is to (e.g. Bath) Stephan Schug introduced the day and acknowledge the activities of our (b) Joint meetings with other related many attendees were delighted to meet members outside of the Society as organisations (e.g. Royal him. (He continued to work hard for Colleges, FPM, APM, well. Acute Pain during the following ASM.) RoyalPharmSoc, British I would be interested in seeing whether Psychological Society, and our membership would also like to Association for Palliative Medicine) Pain Education Special Interest acknowledge their colleagues. Group (written by Emma Briggs and My proposal is that members write Long-term strategic plan Alison Twycross) to me at presidentawards@ I am keen to gauge the interest of Every 2 years, the committee meet at the britishpainsociety.org naming an Council and the wider membership of BPS to devise a 2-year strategy, key individual or Team and highlighting moving to a more online platform for priorities that are aligned with the SIG such achievements. Depending on educational (and possibly SIG) events: aims and are achievable in the time and the number, we receive we will publish resources available. The 2017–2019 those that show outstanding (a) Pilot-testing of e-learning via Pain priorities are as follows: dedication to Community website (Zoey Malpus has done a lot of background work •• Launch the undergraduate document 1. Patient-centred approach; here and we need to agree with 2. The MDT; Executive a budget and plan for and plan an evaluation of its impact; 3. Innovation. implementation with a pilot set of •• Support and promote the IASP Global modules by summer 2018). Year of Excellence in Pain Education; (b) Online educational events – using •• Educational practice: plan ASM The proposal needs to come from Facebook, LinkedIn, webinars and workshops and a SIG study day; two colleagues and have a 100 word other bespoke platforms. •• Educational research and innovation: maximum citation. Proposals may be activities that stimulate, engage in or submitted at any time, and details of Acute Pain Special Interest Group disseminate research and innovation; recipients will be published in Pain News (written by Ruth Day) •• Develop resources for healthcare and on our website. The membership of the SIG has grown professionals to enhance patient May I wish you all the best for a great by over 15% this year – an indication of education skills; Summer.

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From the Honorary Secretary Professor Roger Knaggs Pain News 2018, Vol 16(2) 51­ © The British Pain Society 2018

One of the Treasurer elect and Dr Ayman Eissa has Gillian Chumbley and Amanda Williams issues with been appointed as Honorary Secretary will be included in the September issue writing a elect. We are very grateful to Glyn and of Pain News. column several Ayman for accepting to take on these months prior important roles for the Society. Special Interest Groups (SIGs) to publication With three incoming executives being We held a meeting recently that was is that it can current Council members, it meant that attended by the Chairs of some of the be very difficult there were vacancies for seven Council 14 Special Interest Groups (SIGs) of the to predict what members. It was pleasing that there was Society together with Chairs of some of is going to be significant interest and as we had eight the key committees and current topical and nominations you will have been aware of executives. One of the recurring themes relevant. By the need for an election. The results of during the meeting was that of the time you the ballot are reported below: engagement; engagement both between read this, we Thus, Sam Ahmedzai, Peter Brook, Neil Council and the SIGs, and between will have met in Brighton for our 51st Collighan, Ashish Gulve, Ramanarayanan SIGs and their members. Some may Annual Scientific Meeting (ASM). Krishnamoorthy, Sarah Love-Jones and consider SIGs are the lifeblood of the David Pang are our new elected Council Society as they offer the opportunity to Election results members. Many thanks to all candidates discuss and interact with colleagues Some may say that elections have become for putting their names forward. throughout the country interested in one a bit of theme to my columns over recent The Society relies on the commitment of the many varied aspects of pain issues. However, this year there have been and dedication of members in order to medicine that they cover. Reviewing requests for nominations for a number of ensure the smooth running on a daily membership applications, it often key positions in the Society and the results basis. As I enter my last year as Honorary surprises me the number of people who of these elections were announced at the Secretary, I am slightly disappointed that request membership of numerous SIGs. Annual General Meeting in Brighton. there were no nominations from other While there is nothing wrong with this, I professions. The British Pain Society is doubt it is possible to contribute to all the only multidisciplinary society for pain President elect SIGs in the same way. So do think about professionals in the United Kingdom, so There was only one nomination for those SIGs that you wish to make an when nominations for elected Council President elect. According to the active contribution to and do so on a members are announced next do think regulations, there is no requirement for a regular basis. about whether you have the time and voting process, and hence, Dr Arun vision to contribute to the further vision Bhaskar has been appointed President and development of the Society. 52nd Annual Scientific Meeting elect this year and will become President So, coming full circle to where I began this from 2019 for a 3-year period. Honorary membership column. Planning has already begun for Many congratulations to Arun, who Honorary membership is one of the few the 2019 ASM to be held in Belfast. One becomes our new President elect. ways that the Society can recognise the of the first priorities is to identify plenary achievements of people who go beyond speakers and there will be the opportunity Honorary Treasurer elect and the course of ‘doing the day job’ in for members to submit proposals for Honorary Secretary elect support of the British Pain Society or topical workshops. Please do consider These positions are elected by current pain management more widely. At the nominating a good or engaging speaker Council members. It gives me great Annual General Meeting, Professor Kate that you have heard at other conferences pleasure in announcing that Dr Glyn Seers and Mrs Vidyamala Burch were or contributing to a workshop proposal to Williams from Great Ormond Street awarded honorary membership. make the ASM programme next year as Hospital has been appointed Honorary Citations provided by Emma Briggs, good as this year.

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Regulars Spotlight – Andreas Goebel Pain News 2018, Vol 16(2) 52­ © The British Pain Society 2018 Andreas Goebel Liverpool and Bristol

The width and breadth of BPS membership is testimony to the diversity within the organisation and in the pain world. The Editorial Board would like to acknowledge this richness by shining a spotlight on some of our members. In this edition, we speak to Andreas Goebel.

1. What first chronic pains and immune-treatments for 6. Where can we find you in your brought you in these conditions. spare time? What is your favourite contact with the way to spend a weekend or a BPS? 4. How do you think the BPS has Sunday afternoon? changed from when you first The BPS is my became a member to now? I like hiking, biking, swimming, reading professional and holidaying, but we spend most of organisation as a Perhaps there is now a more our weekends closely aligned with our doctor in pain medicine. When we conscious focus to improve members’ children’s schedules! moved to the United Kingdom in 2001 I experiences and participation. When Currently I am campaigning for a joined soon after. reading the Pain News, there appears to popular vote on the final deal from have been a risk to the very existence of negotiations which became necessary 2. What was your role in the BPS? the BPS recently, which I don’t recall following a large referendum recently What excited you about this role? from when I first joined. held in the United Kingdom.

My role so far has been as a member of 5. If you were President of the 7. What would be impossible for the BPS Science & Research Committee. BPS for a day, what would you to give up? In that role, I have also convened a recent you do? workshop on UK pain research (see It’d be really hard to give up good elsewhere in this edition) – I found it very Hmm – I suspect it might be quite food. exciting to bring people from a large variety limited what a President can do – 8. Any life achievements you are of research backgrounds together under nevertheless, if there are no hidden particularly proud of? the BPS umbrella, united in their wish to treasures which I could perhaps look at seek better solutions for people suffering during that day which only a president Our two daughters. from chronic pain from different angles. may see, then I would love to get a group of philosophers together and ask 9. Anything else you’d like to tell 3. What are you best known for them to come up with an answer to the people about yourself? professionally? question of why in Pain Medicine we are still in Stone-Age with regard to pain I am member of a socially engaged lay I have set up a successful regional relieving treatments, whereas the Buddhist group (SGI-UK); I miss CRPS clinic in Northern England; my remainder of Medicine has moved on – opportunities for forest walks and chairing of the UK CRPS Guidelines, and there’s got to be a cultural reason German food! that I conduct research into the underpinning our insufficient research I would like to thank the Editors for autoimmune causes of non-destructive progress. inviting me.

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News Pain in military veterans study day Pain News 2018, Vol 16(2) 54­–55 © The British Pain Society 2018 Amanda C de C Williams University College London

The needs of military veterans with pain, (specialist nurse) and Suzanne Brook literature, where diagnosis of PTSD and and torture survivors with pain, made up (specialist physiotherapist). The veterans, TBI is partly driven by its qualifying the two halves of February’s BPS from various wars, often have not only veterans (and their families) for VA Education Day. Both were excellent, with multiple physical problems but also healthcare, worth many thousands of speakers from research, policy and fragmented lives: for many, the army dollars. On a positive note, he observed clinical settings, and the questions and provided stability, a community, a that veterans are now seeking help discussions showed there were purpose and a valued identity, and the sooner, a mean of 2 years after service in experienced clinicians in the audience loss of these when discharged can make Afghanistan and 3.3 years after service in too. All of us will come across these huge demands on adjustment, and they Iraq, compared to 13 years after serving groups in our clinical work, whether we may feel abandoned and purposeless. in Northern Ireland and 15 years after the recognise them/they disclose their origins Their internalised military culture tends to Falklands War. or not, and it was a pity that the day was make for attempts to ‘push through the not better attended. pain’, to prove themselves by feats of strength and endurance, such as in the Pain in torture survivors and Paralympics or Invictus Games, but refugees Pain in military veterans these are usually followed by collapse The afternoon was introduced by The first speaker was Emily Mayhew of and a sense of defeat, as well as Amanda Williams, who emphasised the the Imperial College Centre for Blast considerably increased pain. The pain very high rates of chronic pain in torture Injuries, who is a historian currently management programme draws on survivors and the very poor evidence on studying the medical records of those with which we are all familiar, but effective treatment. A recent systematic amputees from World War I, although avoiding guided imagery because of review and meta-analysis (Baird, Hearn & here she spoke mainly about her work on flashbacks; trying not to overtax Williams 2017, Cochrane Database of Afghanistan. She described the concentration and memory affected by Systematic Reviews) found only three ‘unequivocal saves’ there from providing traumatic brain injury (TBI), blast and randomised controlled trials (RCTs) of trauma units in the field rather than posttraumatic stress disorder (PTSD); pain treatment for torture survivors. One distant from the likely point of injury, but and of course, the emphasis is on careful was from Korea and involved hands-on the emerging understanding of profound planning of physical activity rather than physical manipulation; the other two were and widespread damage from blast ‘going for it’. Initial results are good, from Europe and involved cognitive– injury, from astroglial scarring in the brain despite the very severe psychological behavioural treatment with biofeedback. to delaying healing, with no treatment at and social problems of some of the Results for pain and distress were no present. Many blast injuries in veterans. change or no change of clinical Afghanistan are to children. The last speaker was Walter Busuttil, a significance, while the Korean physical She was followed by Andrew psychiatrist who described the effects of treatment claimed efficacy for reducing Baranowski, describing a charity-run pain combat and of torture, reviewing models disability. None assessed quality of life or management programme for UK military of PTSD and the notion of moral injury, changes in healthcare use. So, the veterans with chronic pain, in which as a when the individual’s moral framework is picture overall is dismal. We just do not doctor he has quite an active role not shattered. He returned to the earlier know whether torture survivors’ pain is only in assessment but also in explaining concern with minimal TBI after blast even harder to treat than equivalent pain pain and addressing other medical exposure, differentiating it from post- in our clinical populations. RCTs are problems of the veteran population. concussion syndrome and presenting difficult and expensive to run, and torture Three of his colleagues from the with symptoms in common with PTSD. survivors are a very heterogeneous programme then spoke: Jannie Van Der He alerted the audience to the problems group, so rather than proceed with Merwe (clinical psychologist), Claire Fear of reading the American research group trials, it was recommended to do

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Pain in military veterans study day

N-of-one studies, to share data and to intended by the 2014 Immigration Act in The last presentation was by Susan benchmark against standard treatment action. Childs (clinical psychologist) and Bianca outcomes. Stephen Morley’s book on She suggested several courses of Kuehler (pain consultant) from Chelsea single-case methods has just been action. One is always to ask patients and Westminster hospital, where they published by Routledge and makes about violence, since this could well regularly run a pain management group N-of-one studies straightforward and identify them as a member of an exempt for torture survivors, addressing the meaningful. Finally, we were reminded group when they seek secondary care; question of whether their one-stop pain that rehabilitation is a human right for this requires access to interpreting, rather clinic specifically for survivors of torture torture survivors, alongside asylum and than trying to manage without. All was the right decision. The patients they reparation, and that treatment needs to decisions about care should be recorded see are a mix of those whose torture has proceed with an understanding of the in writing, particularly about urgent care. already been clearly identified as the human rights context. We should ask our Trusts about their cause of pain, and those who develop The first speaker in the afternoon was policies on decision-making around chronic pain later in life and have a Jennie Corbett, a policy and advocacy identifying exempt groups – is it clear? Is history of torture. Their pathway through officer from Doctors of the World UK the information where it is needed? – and pain and other services, before the pain branch, describing entitlement – and about charging. clinic was set up around their needs, was non-entitlement – to healthcare for The next speaker was Juliet Cohen, often distressing and even undocumented migrants, a group that who has worked for many years writing retraumatising, without identifiable includes those who have not claimed medicolegal reports for torture survivors benefits in pain relief or rehabilitation. asylum and those who have been as well as doing research. She started Re-routing patients had proved cost- refused asylum, among them many with definitions of torture and some neutral, and their assessment, any survivors of torture. Of this group, 89% recent prevalence studies: up to 50% of investigations and treatments proceeded are not registered with a general medical Syrian refugees may have been tortured. with careful discussion of what they practitioner (GP), and although primary She gave a moving account of the involved and whether that was care is an entitlement, about 40% have difficulties of disclosing torture by those acceptable. It also provides a safe been refused when they tried to register. who have lost all trust in authority and environment in which people’s accounts She also outlined the complex had their beliefs in a just and reasonable are believed, and they can describe their arrangements around secondary care, world destroyed; they are also ashamed history at a pace that suits them. where all but certain exempt services and avoidant of describing some torture, Comparison with a local fibromyalgia (A&E, communicable diseases, family particularly when it is sexual or cultural, patient group established similar levels of planning) are charged at 150% of the or breaks taboos, and she advised depression, but many symptoms of normal rate, to undocumented migrants. always asking for details and exploring PTSD and anxiety, and far greater intake Refugees and asylum seekers, and those euphemisms. For instance, we should of psychotropic and psychoactive drugs in detention, are also officially exempt, ask a survivor who says ‘I was beaten’ by survivors of torture. This justified but the complexity of the rules means where s/he was beaten, with what, separate treatment, and the low rate of that many are wrongly refused care or where, with restraint as well and so on. attrition strongly suggests that it suits are told they will be charged. She noted She reminded us that many blunt force patients well. that many hospitals put far more trauma injuries heal without scars, as The whole day showcased resource into recovering these costs than does much sexual torture, and that considerable and diverse expertise in the they do into identifying the vulnerable creates particular problems for pain community and wider and the individuals who have a right to exemption medicolegal reporting. She also practical ways in which pain treatment and those who cannot pay are reported reminded us of cultural differences in and rehabilitation could be improved for to the Home Office for debt. Because the narrative and expression of emotion: lack both military veterans and survivors of National Health Service (NHS) also of eye contact, because of shame, or torture. If you wish you’d been there, why shares patient records with the Home respect or gender norms, is commonly not set up an education day or half day Office and with immigration authorities, misunderstood as evasiveness. And she nearer you? 2019 will be the International this is often the beginning of deportation advised her audience to be careful of Association for the Study of Pain (IASP) for vulnerable torture survivors and other accepting a ‘friend’ or family member as year for pain in vulnerable populations, refugees. In 2016, 2,000 people were an interpreter: he or she may not be a among which are torture survivors, and apprehended on the basis of this sharing friend and may be controlling the patient resources including fact sheets and slide of information: the ‘hostile environment’ and what she/he says. sets will become available.

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News Focus on pain research day Pain News 2018, Vol 16(2) 56­–57 © The British Pain Society 2018 Andreas Goebel Liverpool and Bristol

Antony Jones, a Manchester Nick Shenker – the Chair of the special allow others to see the type of research rheumatologist and researcher who interest group on chronic pain within the being done, fostering crosstalk and investigates pain-induced brain activation British Society for Rheumatology (BSR) – collaborations. All participants were patterns, raised the idea in 2016 – we and I. Following encouraging discussions equally important to the meeting’s should have a day where UK pain with Heather Cameron, the BPS success; everyone was encouraged to researchers come together. In 2017, the Treasurer, the BPS agreed to underwrite submit e-posters, and all participants BPS Science & Research Committee the event and provide administrative received the same funding support. chaired by Sam Eldabe discussed and support, but we were also successful in We were extremely pleased that the confirmed a desire to reach out to other obtaining external funding from the Pain event was oversubscribed. The Focus on UK pain research communities. Relief Foundation in Liverpool, the Pain Research day was held on 7 March Ultimately, we may wish to thank the neuromodulation society (NKUSI), a 2018 at the Royal College of Arthritis Research UK (ARUK) charity for research fund held by Dr Shenker, Anaesthetists in London and was in my acutely fashioning our vision towards a NIHRCRN and ARUK. view a roaring success. Researchers joined-up approach to achieve more and We invited active UK pain researchers from many different pain fields including better pain research. ARUK had asked from a wide range of fields such as MSc and PhD students in pain research people with musculoskeletal conditions epidemiology, community-based pain gathered, chatted, listened and made about their priorities – responders put research, molecular pain research, plans. Martin Johnson welcomed ‘sorting out pain’ first. And when ARUK clinical trials, pain-psychology, participants on behalf of the BPS. Colin analysed search terms that had led psychophysics pain research, brain Wilkinson, a patient suffering from a people to the ARUK website, again pain imaging, genetics and others. Human rheumatic disorder outlined how it is in came on top – ARUK consequently pain conditions included neuropathic fact his pain that impacts on his quality of decided to put 20% of their overall pain, but also musculoskeletal pains life, pain which cannot be sufficiently budget over the next 5 years into such as back pain and fibromyalgia, relieved by the various biological drugs supporting pure pain research in which affect such a large percentage of successfully applied to keep his musculoskeletal conditions. I reviewed patients in our clinics. Our funding rheumatic disorder biologically at check. submissions as member of their grant allowed arranging an invitation-only Although his joints are preserved more committee, and it stuck me that there is event, free of charge, and indeed with than it has ever been possible in the a whole world of research out there, almost full recompense of all travel history of rheumatic disorders, the largely which we don’t often see at BPS expenses. We invited 95 UK participants unknown factors responsible for his pain meetings; researchers originally – the maximum which our space would are not tackled by these same biological interested in the biology underpinning comfortably hold. Hayley Mccullough, drugs. We then had major funders joint inflammation in rheumatic conditions the Research Administrator at the presenting their visions for supporting UK have now started to focus on chronic Liverpool Pain Research Institute, pain research, including Wellcome Trust, pain in a wide range of musculoskeletal expertly led communication with MRC, NIHR, NIAA, Pain Relief conditions. They bring a wealth of participants, in close contact with Ken Foundation and ARUK, and we listened methodologies and approaches which Obbard at the BPS. We asked to an example of excellence in joined up can enrich our collaborations. participants whether they would like to thinking between funders and So, we dreamed up and devised the present their work in short oral researchers presented by Lesley Colvyn ‘Focus on Pain Research’ day to harness presentations, or as posters, and we from the Scottish Pain Research the potential for collaboration dormant in selected 13 speakers from among those network. We are very grateful for this our different pain research fields. The interested. The idea was to have simple massive presence of UK funders; it convening team included Sam Eldabe, presentations which would primarily became clear that some funders are

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Focus on pain research day

more obviously up to speed on pain A total of 13 speakers highlighted I am aware that it was not possible to research than others – I am hoping that expertise across our wide field of UK be fully inclusive, in part due to our the truly outstanding presentations from pain research. They largely succeeded limited space. If you are a UK pain some prominent funders might also in presenting such that feedback researcher interested to be invited in entice other funders to further up their indicated the audience gained an the future, please would you write to game – after all we are talking about a understanding – which is wonderful – Hayley. very large proportion of the population we largely avoided unnecessary jargon. The contents of presented e-posters affected by this health problem; given the It also became clear that there was not and also a video recording of the whole wide and huge impact of chronic pain, half enough time for chatting, despite a day are available at: https://www. research into these conditions, their long lunch break and good time britishpainsociety.org/mediacentre/ causes, prevention and treatment keeping. Taking this forward, we may events/focus-on-pain-research-meeting/. proportionally still receive relatively little wish to do it again in the future, perhaps For further information, please contact: funding. as a 2-day event. [email protected]

Psychology for Pain Medicine Study Day 6th June 2018, Royal College of Anaesthetists, London

An informative and interactive study day on Psychology for Pain Medicine. The day will include lectures and workshops with Clinical Psychologists and Pain Medicine Consultants.

Topics covered will include psychological interventions, pain clinic consultation and interview skills, and the nuts and bolts of psychology for pain medicine.

https://www.rcoa.ac.uk/education-and-events/psychology-pain-medicine-study-day

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News Patients’ voices at the heart of Pain News 2018, Vol 16(2) 58­–59 the Society © The British Pain Society 2018

Margaret Whitehead and Kevin Bowers Co-Chairs of the Patient Liaison Committee, of the British Pain Society

Margaret Whitehead introduces the new sadly, see clinicians and politicians as Kevin Bowers and until June 2014 I was co-Chairs of the Patient Liaison part of the problem rather than partners gainfully employed as a manager for a Committee (PLC). in finding solutions. Thankfully, attitudes large food retailer; I loved my job as it Every patient is different and their pain are improving. gave me an opportunity to engage with unique; so how can patient involvement As co-chairs, our combined customers and colleagues on a daily in the British Pain Society (BPS) seek to experience has focused our minds on basis. It taught me how to listen and effectively represent the patient voice and steering the PLC to achieve realistic recognise how important it is to hear the make a meaningful difference? This is the improvements. We have therefore set thoughts and opinions of others and that challenge faced by the new co-chairs of ourselves two key priorities for our first by listening you can improve. I the PLC. Working with eight other lay year. The first is embedding the work of discovered how the knowledge and members and four professional the PLC in every workstream of the BPS; experiences of the people working in and members, I co-chair this standing part of this includes raising the profile of the users of an environment can lead to committee with Kevin Bowers (who the patient voice within the BPS and better ways of doing things and improve introduces himself below). Together, we across the wider community. the experience for everyone. are responsible for ensuring there is a The second priority is developing the My journey with pain began in January patient voice throughout the BPS. Society’s patient reference group. 2009. My wife Karen was pregnant with The PLC advises on service Because pain is so personal, the PLC my second daughter Bethany and my improvement, patient liaison and cannot hope to have a meaningful eldest daughter Lauren was 7; I woke up education while raising the profile of pain impact without seeking to try to in severe pain in my lower right within the public, professional and public represent the diversity of people living abdomen. I thought it was a stomach realms. The role is surprisingly onerous; it with pain across Britain. This is no mean bug, but after a day it was unbearable is not just about sitting on committees feat. The patient reference group was and I saw my general practitioner (GP). but voluntarily working alongside council set up under the leadership of the The initial thought was appendicitis so I members to ensure the BPS is truly previous PLC chair, Antony Chuter, and was sent to A&E and later admitted to multidisciplinary by involving patients as we aim to extend its contribution to hospital. After a few days, having given partners in every facet of the Society’s further support the work of the Society consent for an appendectomy, which did work. Recruitment to the committee can and its members. not happen, I was discharged. The pain prove difficult because volunteer I am very excited to be working with persisted and after many more doctors’ members have work and family Kevin, members of the PLC and pain appointments and a few more possible commitments while also living with clinicians across the country on issues I diagnoses, I was told that I had persistent, and often extremely care about. We stand on the shoulders epididymitis and prescribed antibiotics. debilitating, pain. of lay members who have volunteered The infection cleared but the pain didn’t; My background in policy development their time, energy and expertise over I’d now been off work for a couple of and running a health networking many years. If you know a person living months and was starting to get organisation makes me acutely aware of with pain who might like to get involved, desperate. My GP referred me to an the difficulties of putting fine words and encourage them to get in touch via this urologist, but the appointment was a few great ideas into practice. Too many times link http://eepurl.com/ZaIkv. months away, so I made a private over the past quarter of a century, I have appointment. Following the initial seen organisations and professionals pay Kevin Bowers consultation and a local anaesthetic lip-service to public and patient Following my appointment as co-chair of injection, which stopped the pain, I had involvement, without really ‘getting it’. the Patient Liaison Committee, I thought an elective orchiectomy. My pain was Likewise, I have met lay-members who, I would introduce myself. My name is nearly gone with just occasional flare-ups

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Patients’ voices at the heart of the Society

and I returned to work. A year later, people of all ages and all backgrounds and I started speaking up more. I put though I was back to my GP again in with varied and different conditions that things from the PMP into practice and agony, this time I was referred to the have left them with chronic pain and they eventually began to accept my pain and local pain team, but once again the wait can be themselves, no pretending to be the limitations it places on me; I allowed time was too long so I went private. I well, no putting on a face, no worrying if myself to live again; I went back to drama, was introduced to the concept of they need to move around or they can’t a hobby that had been a passion for me; I chronic pain and that like my diabetes it attend just a haven. had, of course, had to adapt my wouldn’t be taken away but that it could In 2014, I was back in the hospital, my involvement, smaller parts, move into be managed. I was prescribed pain which had progressively worsened directing and so on, but I could still do it! I gabapentin, solpadol and nortriptyline was now unbearable. Again appendicitis began to want to do more, I started by and advised to try acupuncture. The was a possibility but quickly ruled out, I talking to PMP patients about the support medication lowered the pain to a saw the pain consultant while in the group, then I was asked to be a volunteer manageable level and I found the hospital and my medication was changed as a peer supporter in a follow-on program acupuncture helped too; I’m not sure to morphine from codeine and I was to PMP, I speak to medical students to whether it was the needles or the discharged to be treated in the give them a patient perspective on chronic discussion I was having with the community. I saw a psychologist, an pain and now I’m here. practitioners and possible psychological occupational therapist and a consultant; I With my pension, our finances began benefits it gave me. I was back to work was placed on the Pain Management to improve and with that we could fall albeit with some changes and was Program (PMP) and personally sought out into a routine that worked for us as a almost living the way I had. a mindfulness course through family; PIP and other benefits meant we The acupuncture team led me to a Breathworks. I didn’t return to work and could get a car adapted for me to drive local pain support group they had helped eventually retired through ill health, a tough meaning. I could help out more and not form a few years earlier. Keeping pace thing at 42, you don’t get to prepare, to have to rely on others. Emotionally things with pain in Southampton has now been plan the things you’ll be doing with your improved for me and my family; things going for 13 years; it meets three times a new found free time, you’re home alone still get stained, but generally we’ve all month, a coffee morning, a craft session with lots of time to think. I had dark times, accepted that our lives have changed. and the main meeting usually with a once asking my wife whether it would be It’s not all bad, I’ve made some real guest speaker. My attendance initially better if I wasn’t around anymore? I don’t friendships, people who help me and I was sporadic, I’d go if I could get away think I meant it but I felt I had to ask the hope I’ve made a difference to people. from work but I found it helped me. They question. Things were tough both There are three legs to how I cope with have no membership fees or emotionally and financially, with the latter my pain outside of the medication and commitments, just a small donation for also massively impacting the former. I mindfulness: family and friends, drama tea and coffee or towards the cost of the could no longer tolerate the acupuncture, and support, the support I get from craft supplies; it is an environment where even the first needle was too much; I was others and I hope the support I can give. people with a shared issue, chronic pain, struggling with what to do, who I was and It’s looking at the doors that have can meet, chat and share if they want where I was going? I eventually started to opened in front of me and not at the their experiences of pain. They have go to all of the support group meetings, ones that have closed behind.

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Professional perspectives Consent in pain medicine: law and Pain News 2018, Vol 16(2) 60­–65 implications for practice © The British Pain Society 2018

Rajesh Munglani Consultant in Pain Medicine, St Thomas Hospital, London Giles Eyre Barrister, Associate Member, 9 Gough Square, London Manohar Sharma Consultant in Pain Medicine, The Walton Centre NHS Foundation Trust, Liverpool

Part 1: medical paternalism control over one’s own body, even Plato is quoted as saying, ‘free-born versus patient autonomy where medical treatment is involved. It doctors who mainly treated free-born is the patient, not the doctor, who patients, describe to (their patients) the I swear by decides whether surgery will be nature of the illness, often not revealing Apollo the performed, where it will be done, the whole truth regarding the condition Healer, by when it will be done and by whom it or its prognosis and then prescribing Asclepius, by will be done. (Linden J Allan v. New medicine to them only after obtaining Hygieia, by Mount Sinai Hospital (1980) their consent’. Sometimes, a person Panacea, and 28 OR 356) trained in speaking to the public or by all the gods doctors trained to persuade were called and Due to the restrictions of space, there in to help obtain consent. Interestingly, goddesses, are obvious limitations to this article in no such consent was required of doctors making them the number and details of cases that treating slaves.6 my witnesses, can be citied. The aim is to present in as The idea that the status of the patient that I will carry concise a fashion as possible ... ‘to the would determine the level of consent out, according man on the Clapham omnibus’ our view required is also mentioned elsewhere. to my ability and judgment, this oath of the implications of the current Critobulus, an eminent Physician was and this indenture. position of medical consent in English only persuaded to operate on Alexander law upon medical practice with special the Great, after Alexander openly I will use treatment to help the sick reference to pain medicine following the declared prior to the operation that his according to my ability and judgment, groundbreaking decision of the condition was incurable. Other powerful but never with a view to injury and Supreme Court in the case of patients such as kings would offer a wrong-doing.1 (Hippocrates, 460– Montgomery 2015.3,4 sword to the physician before an 370 BC) (in italics)1 operation, symbolising that they consented to be operated. This way, it Every human being of adult years The decline of medical was also stated, if God willed the and sound mind has a right to paternalism healing, then the physician would boast determine what should be done with Medical paternalism has held sway over and if not, then the latter would not be his body, and a surgeon who medicine since the beginnings of a doctor/ blamed.5 performs an operation without his patient relationship. Such paternalism is Dalla-Vorgia7 notes that from ancient patient’s consent commits an assault assumed in ancient systems of medical 5 times, physicians have, at least on for which he is liable in damages. practice such as ayurvedic medicine. occasion, been driven to seek consent (Schloendorff v Society of New York The Hippocratic oath, while holding of their patients either because of Hospital 103 NE 92 (1914) at 93–94, the physician to account over his actions, respect for their patient’s autonomy or per Cardozo J) implicitly assumes the agreement of the patient and/or the relatives to whatever from fear of the consequences of a Without a consent, either written or course of action the physician decides. failure. oral, no surgery may be performed. However, there was also evidence of Sutherland in her recent (and excellent) This is not a mere formality; it is an obtaining patient’s consent in ancient book on A Guide to Consent in Clinical important individual right to have times.5 Negligence, Post-Montgomery8 states

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Consent in pain medicine: law and implications for practice

that in terms of consent, medical law has in the process of obtaining consent to tell a patient about the various possible been significantly behind medical treatment. courses of treatment would be another guidelines in this country. Many Courts outside the UK common (peer) group of doctors. To understand why this was and how law jurisdictions had already recognised However, the problem with using the the recent Supreme Court ruling of that obtaining consent through the Bolam test (which was actually about the Montgomery (2015) has profoundly provision of sufficient information was a standard of medical practice and clinical changed this, one needs to understand vital part of a doctor’s duty, for not to do negligence) in the area of information the different roles of a doctor: so could well constitute a case of battery disclosure is that this test is more or assault. concerned about professional consensus (a) On one hand, diagnosis and and standards than with the rights, treatment and on the other; concerns and priorities of the patient. (b) a separate but equally vital area of Laying the ground work for The peculiarities of a particular patient disclosure of information to obtain consent and the rise of patient are not considered and non-medical consent. autonomy considerations are irrelevant under the While some would argue that patients Bolam test. The fundamental issue has been that can only make decisions based on what until recently the test of legal consent doctors tell them about the options for used in the UK courts was based on the treatment, it is recognised that patients Issue of consent prior to case of Bolam.9 make decisions about such matters not Montgomery Bolam was a case about clinical always for medical reasons alone, that is, The case of Sidaway in 1985 tried to negligence, and deciding whether a there are individual non-medical, patient- challenge the right of doctors to decide particular course of medical action would specific factors which influence a what to tell patients. In this case, the be considered professionally responsible patient’s consent. Claimant suffered from pain in the neck, by a body of the doctor’s colleagues. In the Montgomery 2015 case, which right shoulder and arms. Her The judge in the case, McNair J, will be described in more detail later, the neurosurgeon took consent for a cervical looking at a case of possible clinical Claimant’s legal team, Lauren Sutherland cord decompression but did not include negligence, said the following: QC then junior counsel with James in his explanation the fact that in less Badenoch QC, argued that a doctor has than 1% of cases the decompression A doctor is not guilty of negligence if a duty of care in the performance of caused paraplegia. Unfortunately, she he has acted in accordance with a treatment and the making of a diagnosis developed paraplegia after the spinal practice accepted as proper by a but that there is a separate moral or operation.13 responsible body of medical men ethical duty which relates to information The Court rejected her claim for skilled in that particular art .... Putting disclosure. damages, stating that as the law then it the other way around, a doctor is The provision of that information permits stood consent did not require an not negligent, if he is acting in patients to make choices about what risks elaborate explanation of remote side accordance with such a practice, they are prepared to run, and these effects. merely because there is a body of (ultimately medical) choices of the patient However, Lord Scarman provided a opinion that takes a contrary view.10 depend on factors that may transcend dissenting judgment and said the Bolam professional medical training and test should not apply to the issue of Therefore, the decision in Bolam knowledge. Many studies suggest that informed consent and the doctor should (applied and accepted in many non-medical factors and patient-specific have a duty to tell the patient of inherent subsequent cases including the factors are important. Sutherland quotes in and material risks of treatment proposed. important case of Bolitho in 199611,12) her book, the Fadum and Beachamps Clearly, though the claim was rejected, was essentially about how to judge a study, that 88% of subjects made this was not a unanimous endorsement doctor in performing the duty of a doctor decisions based on factors external to the of the Bolam principles but despite Lord in areas of diagnosis and treatment. (medical) information given. Scarman’s dissent, Lord Diplock stated However, the Bolam/Bolitho tests were To put it simply, the decisions of that it was up to a doctor to decide what also being applied to (and certainly not Bolam, Bolitho and other previous were the risks the existence of which a distinguished from) another equally decisions of the Court essentially rested patient should voluntarily be warned of important area of a doctor’s duty, that of on the premise that the person who and this should be just as much an the disclosure of information to patients would best decide what a doctor should exercise of professional skill and

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judgment as any other part of a doctor’s medical judgments for the informed 99% certainty, and therefore with a much comprehensive duty of care to the decision of the patient. greater certainty than required for proof individual patient. The duty to provide the patient with on the balance of probabilities she would Lord Scarman, on the contrary, information should not be defined by the have suffered no adverse consequence. asserted the duty of providing amount of information the doctor thinks This roll of the dice approach to information was distinct from the duty to the patient should know, but by the considering likely clinical outcome in this take care and treatment. He stated, in information the patient needs to enable judgment caused natural consternation 885–886 of the judgment, that the them to make an autonomous choice among clinicians, but it had a profound doctor’s concern is with health and the (Sutherland, 2015: 30). effect on the consenting issues in that a relief of pain. These are medical A further notable progression occurred risk of 1%–2% was now considered by objectives but a patient may well have in in the case of Chester v Afshar.15 Miss the Court something that a responsible mind circumstances, objectives and Chester was referred to Mr Afshar, a group (i.e. Bolam’s ‘responsible body’) of values which may lead him to a neurosurgeon, for lower back pain. He clinicians would consider a complication difference decision from that suggested told her that surgery was a solution, but to have to tell a patient about as it may by purely medical opinion. (the judge found at first instance) he did change the clinical course regardless of A further case, Pearce v United Bristol not inform her of the 1%–2% risk of the the standard of surgery (which was never Healthcare Trust 1999,14 also looked at operation going wrong, even in the best an issue). what information was appropriate to hands. She suffered a complication, disclose. The case concerned an called cauda equina syndrome. The The case of Montgomery v expectant mother whose baby had gone judge found that there was a causal Lanarkshire Health Board 2015: to term. The consultant obstetrician took connection between the failure to inform the death of medical the view that she should wait and have a and Miss Chester’s injuries – and if she paternalism normal delivery rather than proceed to had been informed, she would have The Montgomery case has been cited caesarean section at an earlier date. The sought further advice or alternatives. many times, but a short description of its mother was not warned of the risk the There was no question that the surgery facts is both profoundly disturbing and baby could die in utero (with a known was performed other than to a good helpful to understand why the Supreme risk of 0.1%–0.2%) which is in fact what standard. The issue was of the failure to Court has changed the law in this happened. The question was whether provide the information to obtain valid country. The Medical Protection Society she should have been warned of that risk consent at the time, that is, if she had has also given a good summary of this to assist in selection of the option of been told she would have hesitated at case.16–18 delivery. the time and not had surgery on that In 1999, Nadine Montgomery gave The issue came down to what was occasion. birth by vaginal delivery. The birth was considered a significant risk that should The important part to understand in complicated by shoulder dystocia and be disclosed and Lord Woolf reluctantly this judgment is that the Claimant during the 12-minute delay, Sam, her focused on a 10% risk that would trigger accepted she would have probably had baby was deprived of oxygen and a duty to disclose. He held that at a the operation at some point in the future. subsequently diagnosed with cerebral 0.1%–0.2% risk it was not considered to The Court accepted her testimony that if palsy with ongoing lifelong fall within the category of significant risk8 she had been told about the risks, she consequences. (p. 93). would not have had the operation at the Mrs Montgomery was diabetic and The importance, as mentioned again time, but instead she would have gone small in stature and the risk of shoulder by Sutherland, is whether one decides a away and thought about the risk and dystocia was thought to be 9%–10%. risk is relevant to an imaginary (most likely) gone ahead with the Despite her expressing concern to her reasonable patient or whether one operation on another date. Since the consultant about whether she would be should consider the subjective position of chances of the operation going wrong on able to deliver her baby vaginally, the the particular patient. any occasion was 1%–2%, if she had doctor failed to warn Mrs Montgomery of This leads to the point of what is gone away and thought about it and the risk of serious injury from shoulder known as therapeutic privilege of filtering come back and had the operation on dystocia or offer her the alternative information. It was argued in another the date then the chance was possibility of an elective caesarean section. Montgomery that the medical profession only of 1%–2% again, therefore she Mrs Montgomery brought a claim, should not be permitted to filter would not have suffered a cauda equina alleging that had she been advised of the information or substitute their own best on a subsequent occasion with a 98%– 9%–10% risk of shoulder dystocia

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associated with vaginal delivery of the risk of shoulder dystocia and given In fact, the medical authorities had (notwithstanding the risk of a grave the option of a caesarean section. Mrs been arguing for some time for a less outcome was small, less than 0.1% risk Montgomery was awarded £5.25 million paternalistic role; the BMA handbook on of cerebral palsy), then she would have in damages for the injury sustained by medical ethics in 1984 (31 years before opted for delivery by caesarean section her child. the Supreme Court Judgment in and that this would have prevented her Montgomery) stated that a patient’s trust child’s injury. that (their) consent to treatment should All the medical experts, and indeed the But we were here all along: the not be misused is an essential part of the (defendant) treating obstetrician at the role of GMC in Montgomery relationship with (their) doctor. For a time, when asked what they would likely As stated by Lord Brodie,19 what doctor even to touch a patient without have wanted had they been in Montgomery did was radically to rethink consent may constitute as assault. Mrs Montgomery’s position, agreed they just what should be understood by the would have wanted a caesarean section notion of consent to treatment and to Implications of Montgomery too but the Defendants in the case endorse (as the GMC had been stating The emphasis is now on the individual’s maintained their position that a for many years) a model of a therapeutic right of autonomy or self-determination. reasonable body of obstetricians would relationship in which, when it comes to Patients are now recognised as having not have informed Mrs Montgomery of deciding treatment, the focus is turned the right to make choices about their the risk. That is, they stated it was the upon the patient and the patient’s rights own health once they are properly treating doctor’s right to choose what to and responsibilities. informed of risks and benefits, and the tell the patient and that a reasonable Under this model, first it is for the law now recognises they may have body of responsible peer doctors would doctor to fully explain the options to the individual (non-medical) factors which not have advised of the risk. patient, setting out the potential benefits influence the choices they make. The Supreme Court rejected the and risks of each option, including that of As the result of Montgomery, the test Defendant health board’s argument and having no treatment, taking into account now recognises the right of the individual ruled that the Bolam test was no longer matters which would be expected to be patient to receive full information and to suitable as a test for deciding what significant to that patient or which, on participate in decisions about their own information should be provided in order discussion are found to be significant. health8 (p. 16ff). to obtain valid consent. The Supreme Second, it is for the patient, who has An immediate difficulty arises if a Court decided that the discussion of been properly informed, to weigh up patient were to ask for treatment the risks with patients, and the extent to what they have been told about potential doctor considers is not of benefit to which a doctor may be inclined to benefits and risks and then to decide them. The GMC state in their 2008 discuss risks with patients, should not be upon what option is best for them, taking guidance that the doctor should discuss determined by what was established into account both clinical and non-clinical the issues with the patient, explore their medical practice: considerations important to them. reasons for the request and if after It is the patient not the doctor who is discussion the doctor still considers A doctor is under a duty to take taken to be the person best able to make treatment will not be of overall benefit, reasonable care to ensure that a the necessary choices, once they have they do not have to provide the treatment patient is aware of any material risks been equipped to do so by the doctor but they should explain their reason to involved in any recommended explaining in a way the patient can the patient and explain any other options treatment, and of any reasonable understand what the available choices that are available, including the option to alternative or variant treatments. The may involve. seek a second opinion. test of materiality is whether, in the As Sutherland points out the GMC circumstances, a reasonable person in was represented at the hearing of the the patient’s position would be likely to Supreme Court although it had not been Principles of consent post- attach significance to the risk, or the represented at previous hearings. The Montgomery doctor was or should reasonably be Supreme Court was provided with the The GMC has provided a framework for aware that the particular patient would GMC position on patient consent as consent which all medical practitioners be likely to attach significance to it. already in ‘Consent: patients and doctors are expected to be familiar with making decision together’ GMC 2008’.20 (‘Consent: patients and doctors making The Supreme Court ruled that Mrs (Note: The consent guidance is separate decision together’ GMC 2008). Briefly, Montgomery should have been informed from Good Medical Practice.) the principles include the following:

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the patient is again consented and (a) Listen to patients and respect their It is not the purpose of this article to the further consent and process views about their health; provide a definitive or approved medical clearly documented prior to the (b) Discuss with patients what their course of action but the following procedure. diagnosis, prognosis, treatment practices need to be demonstrated to In Jones versus Royal Devon and and care involve; have been performed: Exeter NHS Foundation Trust 2015, Mrs Kathleen Jones had been added to (c) Share with patients the information 1. A provision of information which will the waiting list to have surgery they want or need in order to make allow for the understanding of this performed at the Royal Devon & Exeter decisions; particular patient. The complexity of Hospital by a highly respected and (d) Maximise patients’ opportunities, information and issues that needs to well-known consultant spinal surgeon and their ability, to make decisions be considered means that in practice of her choice, only to discover, on the for themselves; the prior provision and consideration morning of the operation, that it had (e) Respect patients’ decisions. of written information (e.g. a patient never been intended that he was to information leaflet or similar and a perform it. There is recognition of the complexity copy of the clinic letter) followed by a Instead, it was to be carried out by a and uncertainty in medical information subsequent discussion is most likely more junior and much less experienced and practice and the difficulty in applying to achieve this. This consenting spinal Fellow at the hospital. appropriate information to a specific process will take time and usually Unfortunately, the operation went badly individual. require more than one occasion and and Mrs Jones was left with serious and In relation to consenting a patient and should not be rushed. The fact that it permanent injuries as a result. warning of the risks of treatment, the has taken place and the key points The Claimant’s evidence was accepted Supreme Court ruling of Montgomery discussed must be recorded. that she was not told in advance who (2015) has retrospectively superseded 2. A discussion of those particular was in fact to operate, and the evidence the older tests (in Bolam, Bolitho, factors that are likely to matter to this of the spinal fellow who said that she had Sidaway, Pearce, Afshar, etc.) by particular patient. Risks or been told during the consenting imposing on a doctor the duty to take complications which may not concern procedure some days before was another patient may be very important rejected. The court further found that the reasonable care to ensure that a to this one. Claimant would not have agreed to have patient is aware of any material risks 3. That care has been taken to ensure the operation performed by a involved in any recommended that this patient understands what are replacement, had she been told in treatment, and of any reasonable the implications of any treatment advance, and ruled that it was too late alternative or variant treatments. which is being suggested, what for her to be expected to exercise alternative or variant treatments exist informed choice when, moments before A risk is material if a reasonable person together with their implications and the operation, she was eventually told by in the patient’s position would be likely to the implications of not going ahead a theatre nurse that her surgeon of attach significance to the risk, or if the with the proposed or any active choice was not available: doctor was or should reasonably have treatment. been aware that the particular patient ... although there was no breach of would be likely to attach significance to it. Consent and who does the duty to warn the claimant of the risks So, doctors must now ask themselves procedure? of the operation, it was an three questions:21 It should also be noted that a patient infringement of her right ‘to make an who has consented to treatment by informed choice as to whether, and if 1. Does this patient know about the Doctor A but on the day of the procedure so when, and by whom to be material risks of the treatment I am is presented with Doctor B may have operated on’. Unless a remedy is proposing? grounds for complaint should there be an provided in the present case that right 2. Does this patient know about adverse consequence to the procedure if would be a hollow one.22 reasonable alternatives to this the choice of doctor was material to the treatment? process of consent. In our view, the full implications of this 3. Have I taken reasonable care to Therefore, where there is such a judgment on NHS practice have not yet ensure that this patient knows this? change of personnel, it is important that been fully appreciated.

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Implications for clinical practice fully and the patient needs to be given It is therefore important that care is in pain medicine adequate time as needed to reflect always taken to ensure that consent is We have deliberately concentrated on and consider whether to accept them. appropriate, fully informed and the changes in the legal basis for the Currently, patients are often given little transparent. consenting processes and the law’s new or no time just before surgery, for In part 2 of this article, we will discuss emphasis on the autonomy of the which they have been carefully the further judgments that have taken individual to override the knowledge and consented, to consider the use of place subsequent to Montgomery and expertise of the doctor in choosing the invasive regional anaesthesia (e.g. give thought on how to develop consent ultimate course of action. It is clear and brachial plexus block, spinal other, forms and process which account for the understood now that assessing whether regional block) and their effects on implications of Montgomery. a risk is material is not a matter for short- and long-term outcome and experts, but, for a well-informed patient. the possible serious (but fortunately There are a number of areas where rare) complications. References 6. That consent of a patient for a 1. https://en.wikipedia.org/wiki/hippocratic_oath this will come into play in pain medicine 2. Public Domain. https://commons.wikimedia.org/w/ and in particular may give rise to issues procedure by a particular individual, index.php?curid=164808 with regard to consent to treatment and say a consultant in pain medicine, 3. Montgomery V Lanarkshire Health Board [2015] does not automatically give any other UKSC 11. the provision of information to the 4. https://en.wikipedia.org/wiki/montgomery_v_ patient. The basic principles are as person the right to perform the same lanarkshire_health_board follows: procedure without further discussion 5. Kumar N. Informed consent: Past and present. and further consent. Perspective Clinical Research 2013; 4(1): 21–5. 6. Dean-Jones L, and Rosen RM. Ancient concepts 1. That the natural history of the pain This may well mean that the consent of the Hippocratic (Studies in ancient medicine). condition needs to be considered, is not automatically extendable or Leiden: Brill Academic Publishing (Hardcover). valid for a junior doctor or indeed an 7. Dalla-Vorgia P, Lascaratos J, Skiadas P, et al. Is that is pains may get better, or worse, consent in medicine a concept of only modern but usually they are persistent extended scope physiotherapist to times? Journal of Medical Ethics 2001; 27: regardless of treatment. perform the same procedure. Where 59–61. the patient has given a highly specific 8. Sutherland QCL. A guide to consent in clinical 2. That there is very little evidence that negligence post-Montgomery. London: Law Brief any treatment in pain medicine will consent and the seniority, training and Publishing, 2018. reliably make a long-term difference to skill of the individual performing the 9. Bolam V. Friern Hospital Management Committee procedure may be important to that [1957] 1 WLR 582. the condition of a patient. 10. https://en.wikipedia.org/wiki/bolam_v_friern_ 3. That certain treatments may produce particular patient, the original consent hospital_management_committee long-term change but may also be may no longer be valid. The procedure 11. Bolitho V. City and Hackney Health Authority [1996] might even then be considered to 4 All ER 771. associated with (potentially 12. https://en.wikipedia.org/wiki/bolitho_v_city_and_ catastrophic) risks. amount to an assault. hackney_ha 4. That certain treatments may or may One further implication arises where a 13. https://en.wikipedia.org/wiki/sidaway_v_board_of_ patient turns up to a pain clinic to be governors_of_the_bethlem_royal_hospital not be more efficacious than other 14. Pearce and Pearce V United Bristol Healthcare treatments, but do carry greater risks. seen by a specialist in chronic pain NHS Trust [1998] EWCA Civ 865, [1999] PIQR P53. This is particularly relevant in the case who in fact is not a doctor. The 15. https://en.wikipedia.org/wiki/chester_v_afshar practitioner should make it very clear 16. https://www.medicalprotection.org/uk/for-members/ of particulate steroids for neuraxial news/news/2015/03/20/new-judgment-on-patient- use. The choice about the who it is who is actually examining the consent composition of the injectate now lies patient, whether it is a senior or a 17. https://www.supremecourt.uk/decided-cases/ junior doctor, a physiotherapist or docs/UKSC_2013_0136_judgment with the patient who should be 18. https://en.wikipedia.org/wiki/montgomery_v_ informed of the current medical range another healthcare professional and lanarkshire_health_board of opinion in the matter. their medical background. The patient 19. Brodie L. Preface. In: Sutherland QCL (ed.) A guide may be expecting to be seen and to consent in clinical negligence post-Montgomery. 5. That patients need to be given London: Law Brief Publishing, 2018. adequate time to consider the examined by a (senior) doctor but 20. General Medical Council. Consent: patients and proposed treatment and particularly instead be examined by somebody doctors making decisions together. London: GMC, else than a (senior) doctor. To 2008. Available online at http://www.gmc-uk.org/ where invasive treatments may be guidance/ethical_guidance/consent_guidance_ associated with serious complication misrepresent oneself and examine a index.asp and with no clear benefits in terms of patient could be seen as an assault. 21. https://www.bmj.com/content/350/bmj.h1481 7. It should be remembered that consent 22. http://www.outertemple.com/2015/10/james- long-term outcome are recommended. counsell-wins-damages-injuries-spinal-surgery/ These issues need to be discussed can be withdrawn at any time.

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Professional perspectives Social and cultural influences on pain, Pain News 2018, Vol 16(2) 66­–70 pain behaviour and treatment © The British Pain Society 2018

Kholoud Alharbi Consultant in Anaesthesia & Pain Medicine, Residency Programme Director, King Fahd General Hospital, Jeddah, Kingdom of Saudi Arabia Arun Bhaskar Consultant in Pain Medicine, Pain Management Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK

Introduction Figure 1. Top right image, bottom middle image and bottom right image are Chronic pain is a complex phenomenon published under CC BY-SA 3.0 licenses.9-11 that encompasses various biological, psychological and social aspects. There are social and cultural factors which influence patients’ understanding and behaviour towards pain. This can vary depending on the context, situation and environment ranging from being stoic or emotive. Stoic patients tend to less express pain outwardly, and if the pain impacts on their social interactions might contribute towards their social isolation. Emotive patients externalise their pain and prefer to verbalise it to people around them and expect their empathy to validate their pain and suffering. Often people coming from Mediterranean, Hispanic and Middle Eastern backgrounds are good examples of emotive (expressive) patients, while people from Northern European and Asian cultures are examples of stoic patients. However, these cultural stereotypes could misinterpret individuals’ pain and distress, which in turn can lead to serious errors of judgement. Despite that, broad generalisations of human depending on their perception of the Individuals within cultures behaviour and culture could be pain problem and unique personality. An Western culture and stoicism considered within a framework that understanding of the impact of culture Stoicism was a school of thought and directs human experience of pain, but on the pain perception and expression philosophy that flourished among ancient individuals within cultures are not was identified in the early work of the Romans and Greeks. It was popularised confined to the same set of expected anthropologist, Mark Zborowski, who by the writings of Marcus Aurelius, beliefs. Still, the individual person’s suggested that the expression of pain Seneca and Epictetus and to this day it experience of pain could manifest itself and suffering is socially learned and has is considered as one of the most sublime in behavioural and emotional responses cultural significance. philosophies of Western civilisation.

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There is a long history of stoicism in the patients attribute their pain to Another common practice among Western culture in which the bearing of predestination, supernatural spirits such Muslims is invoking God’s blessing upon the pain and suffering, discomfort or as evil eyes and in accordance to God’s the person or object that is being hardship without complaint or any will. The concept of ‘Pain as the Will of admired by directly expressing display of feeling or emotion. Healthcare God’ provides an opportunity to atone appreciation with name of ALLAH. In professionals are now aware and for their worldly sins and earns greater Arabic it is customary to say understand the effect of culture in these reward in the afterlife. Masha’Allah, which means ‘God has attitudes; some of the elderly patients willed it’. Reciting from the Holy Qur’an may hold back about their pain. Evil eye three times per day, it is also used as a However, the new generation has moved Evil eye is a curse believed to harm means of personal protection against the from being stoic to being more anyone who had been praised evil eye. expressive within the context of their excessively for his or her success or The Hamsa Hand found in West Asian culture and beliefs. This awareness could received admiration beyond what they cultures is a hand-shaped talisman with a establish a basis for comparison that truly deserved. People who believe in the blue or green eye and it represents the allows seeing where beliefs and attitudes evil eye also believe that this curse has five fingers of the hand; it is an apotropaic are likely to impact on human behaviour the ability to cause physical and mental against the evil eye. In some Muslim towards pain. illnesses. The belief in the evil eye was cultures, it is called the ‘Hand of Fatima’, common to European, Middle Eastern and in some Jewish cultural practice, the Asian culture and stoicism and North African cultures as well as Hamsa is also referred to as the ‘Hand of Patients from Asian cultures are other tribes all over Asia. In Islam, the evil eye Miriam’. examples of stoicism, which links directly is a common assumption and it is to the strong cultural values about self- believed that individuals have the power African culture behaviour. In Asian societies, behaving in to look at people or objects to cause The Tswana and Afrikaans cultures of a dignified manner is crucial with some them ill feeling and harm. Belief in the evil Southern Africa did not believe in the evil behaviours and attitudes like complaining eye is based upon the statement of eye like most of other cultures. Tswana frequently or drawing attention in a Prophet Muhammad ‘The influence of an culture believes in the ‘power of the negative way considered as indicative of evil eye is a fact ...’ (Sahih Muslim, Book ancestors’ as the cause of their illness or poor social skills. In many Asian 26, No. 5,427). pain. In their rituals, for protection, they traditions, maintaining harmony in Attempts to ward off the harms of the try to connect spiritually with their interactions with others in a positive way evil eye in different cultures have resulted ancestors, which could be their is important, so an individual who may be in a number of amulets, talismans and deceased parents, grandparents or other feeling pain, discomfort or sadness might lucky charms to turn away harm or evil elders, as it is believed that the souls of hide their true feelings, as expressing their influences and/or to bring good fortune to their ancestors will protect them most of distress because it is not considered as the possessor (see attached figure). Discs the time. In the Afrikaans culture, pain is ‘accepted behaviour’. Moreover, in Asian or orbs, consisting of concentric blue and a private matter; it is believed that pain societies, people are treated as per their white circles representing an evil eye, are should not be expressed to others and social ranking, which are based on common talismans in West Asia. Nazar is no treatments sought for it if possible. variables such as education, age, sex another attractive blue-eye charms; its and occupation. Healthcare professionals name deriving from Phoenician word are often considered as a person of high meaning sight, surveillance or attention. It Expression of pain on the status, so some patients feel that they is a common belief among Muslims in the background of social and should not be bothered with their Middle East and Mediterranean that the ethnic beliefs complaints about pain and suffering. talismanic power of a nazar will be able to The relationship between pain defend against the envious looks perception, ethnic identity and Middle Eastern and Mediterranean containing the destructive power of the socioeconomic status made an attractive culture evil eye. This charm is frequently seen in subject for many anthropological studies. Middle Eastern and Mediterranean Turkey in the houses, cars or worn as For example, studies carried out to people are more likely to verbalise both beads around the neck. It is now popular evaluate the aetiology and prevalence of physical and emotional pain as part of among tourists to buy it as souvenir on a back pain in Native Aboriginal their emotive behaviour. Most of the time visit to Turkey. communities revealed that more than half

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of the adults in this community 10 where pain could be rated as mild and perceived harmful effects such as experienced chronic back pain, but had (1–4), moderate (5–6), and severe sedation and the risk of potential never sought any medical advice or visit (7–10). However, people in some addiction. The Tswana does use some healthcare professionals for treatment cultures attach great superstition to herbal preparations with a narcotic effect, because of their cultural beliefs. particular numbers. Another cultural but can still refuse to take opioid Healthcare professionals should be obstacle for the expression of pain is the medications. The reluctance to use aware of the dichotomy between cultural limitation of language to convey pain opioids is also prevalent in Western or personal beliefs and professional experiences; different cultures describe culture, but with better patient education, clinical opinion about the causes of pain. pain and pain experiences differently. In most people find its use acceptable for The cultural background determines how Western culture, words such as ‘sharp, pain relief under medical supervision. pain (physical and emotional) is throbbing, stabbing or aching’ are used experienced by the individual and to describe the nature of pain, and these Religious and spiritual aspects communicated to others and may not descriptions are well understood and of pain represent the medical explanation. In accepted by patients there. Those The use of religion for comforting the sick developing countries, people, especially words are not necessarily used or have through spiritual healing or faith-based those with limited education, tend to the same significance for patients from remedies is consistent within cultures express and explain their pain based on other cultures. In tribal cultures, telling that are grounded in religion, such as their religion, spiritual views and the role stories or using symbols from the natural Islam and the Christian faith. This exploits of supernatural powers. This may be in world like lightning, trees with deep the beliefs of the individual and their contrast to the logical or scientific spreading roots, spider webs, bee stings family that the illness, injury and pain are explanations, which is more common in or the tones of drums and flutes are very caused by a higher power. The Western and industrialised countries. influential in relating one’s feeling of pain. acceptance and tolerance of pain are Ramer and colleagues have highlighted Another group of symbols used are demonstrating and validating a person’s that it is critical to know pain has both those of evil spirits or jinhs that are faith and staunch belief in their religion. personal and cultural meanings; hence, believed to be the cause of illness and Devout Muslims offer their pain to Allah the feelings of the patient may be pain in which patients usually talk about as thanks for his goodwill for allowing understood by those within the same their suffering as punishment for being worthy of the treatment. The culture but may not be appreciated by previous sins. Catholic faith teaches that the will of the those outside that culture. Almighty gave them pain and would give Cultural perceptions of pain the strength to bear it similar to how Pain and cultural beliefs treatments Jesus Christ suffered for them. Buddhists Pain is a qualitative phenomenon and In the discussion on cultural values about believe in accepting the suffering as a experience, and despite incorporating the treatment for pain, we will come form of spiritual growth in itself. Native quantitative assessment of pain to the across a lot of difference in the attitudes Americans thought that the blessing of overall evaluation, there is still no and stigma across many cultures. Some medications by the tribal medicine man accurate way of measuring how much cultures believe that injections are more makes the medicine ‘stronger and more pain a person is experiencing. The effective than pills, while in other cultures, potent’ which puts the patient’s mind at currently available pain measurement people believe that the larger pills work rest. tools do not work equally across better than the smaller ones or the bitter different cultures. For example, one medicine is stronger and more effective scale uses smiling and frowning faces to than the medicine that tastes better. Experiences from a pain clinic signify their pain where a smiling face Most cultures still stigmatise the use of in Saudi Arabia suggests no pain and frowning suggests opioid medications. In some cultures, The patient and their family maximum pain (e.g. Wong-Baker scale); intravenous pain medication would be The people of the Kingdom of Saudi but smiling does not suggest feeling preferred to oral opioid analgesics even if Arabia share the common cultural good in many cultures. In some Asian the tablets or capsules were proven to aspects with Arabs and Muslims cultures, people tend to smile when they be highly effective. Patients from other worldwide. Health beliefs in the Saudi are embarrassed or even angry. Another Asian societies such as the Filipino, culture has its own considerations, some popular measurement tool is the Indian or Afrikaans reject pain of it is in common with other Arabs and Numerical Rating Scale (NRS) from 1 to medications because of their undesirable Muslim cultures, while others are very

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unique to Saudi culture. One of the money for their services or ask for recommended that the choices shall be commonest beliefs that Saudis share donations. left to the patients and their families after with other Muslim cultures is that of Spiritual healing is also widely fully informing them about the associated predestination. They attribute that the practised by Saudis which is of particular risks and potential complications. occurrence of disease is already concern; this is employed in conditions Pilgrimage to Makkah (Hajj) is obligatory predestined as the will of Allah in which that have a poor prognosis or for which for the adult Muslim who is physically, they do not perceive illness as a form of there is no existing curative medical mentally and financially able to do it. The punishment; some cope well with the treatment. The principal modality spiritual Hajj is an exhausting journey that takes diagnosis of a terminal illness in terms of treatment is the recitation of verses of the about 4–5 days during which one will have acceptance and may not even seek Noble Qur’an and specific sayings of the to do certain rituals visiting different Holy medical treatment. Breaking bad news Prophet Muhammad (peace be upon places. This is often associated with some can be very challenging to the healthcare him). Holy water (Zamzam), which is health risks such as trauma due to provider because the authority of the obtained from the Holy Mosque in congestion and overcrowding, heat patients’ family overrules the individual’s Makkah (Mecca), and food supplements exhaustion and heat strokes. autonomy. This is one of the unique like honey and black cumin (nigella Another important healthcare features of the Saudi culture in which seeds) are considered as healing agents. challenge is the gender-specific decisions taken by the patient could In contrast to other Islamic beliefs, the consideration. In Saudi culture, a male often be rejected and reshaped use of amulets is seen as an member leads the family in which he is according to the will and wishes of the unacceptable behaviour in Saudi culture. the ultimate, but not absolute, decision family. It is expected that the bad news Healthcare professionals would be maker. However, the female family are intimated and discussed with the advised to show respect towards members have their own influences on family first rather than to the patient; the spiritual or traditional practices and this is the ultimate decision before it is made. It family would then decide on how, when more likely to foster a good relationship is highly recommended for healthcare and whether this is to be communicated with the patients and their families. provider who is interviewing patients of to the patients. Often, the patients are the opposite gender to have one of the kept in the dark about their prognosis. Challenges in delivering treatment family members present or a nurse to act Healthcare professionals often have to The worship rites in Saudi Arabia have a as a chaperone. Some of the male deal with the conflicting interests lot of implications on the delivery of patients would not want to be examined between ethical obligations towards the healthcare. Being Muslims, praying by a female doctor or nurse and even if patient and the family’s appeal for regularly five times a day, fasting for they agree may request that the doctor withholding vital information from the Ramadan and pilgrimage to Makkah are wear gloves before touching them as patient. very important to the devout individual. skin contact with a male who is not a Patients who are limited by their illness or close relative is considered ‘haraam’ by Traditional medicine pain will suffer a lot from the feeling of guilt some conservative Muslims. Even taking Traditional medicine is still one of the if they couldn’t do it at all or do it with a a history could be a challenge particularly accepted modalities of treatment among degree of autonomy; some people would when you need to assess the impact of Saudis in both rural and urban areas in request assistance from a family member pain or illness in their social life; varying degrees. Traditional treatments to do pilgrimage and prayers on their information about sexual health and include herbal medicine, cauterisation, behalf. The rituals of the prayer involve behaviour, drug dependency or alcohol chiropractic manipulation, fracture certain specific movements such as consumption, mental health depression, reduction by traditional bonesetters, standing, bowing, prostrating sitting and aggressive behaviour, irritation and stress cupping and dietary treatment. kneeling which for some patients could be are to be obtained in a sensitive and Interestingly, most traditional healers are a very painful experience. Fasting during discreet manner. It may be best to illiterate people who inherit the job from the Holy month of Ramadan could be a approach this during a subsequent visit their close family members and have no challenging task for patients who are after establishing a good rapport with the formal training in any field of medicine. unwell, but some prefer to continue patient, and the family has a more trustful However, they treat the whole spectrum fasting against medical advice; this is relationship with the healthcare providers. of diseases with varying degree of despite common knowledge that severity ranging from the common cold according to the scriptures, they are Conclusion to fractures and even cancers. They exempted by Allah from this mandate due The critical influence of cultural and social often charge the patients large sums of to their ill health. It is therefore factors on pain, pain behaviour, and pain

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management should always be taken type of medication is preferred or and psychosocial functioning in chronic pain into consideration when evaluating accepted in their culture. patients. Pain 2000; 84(2–3): 347–52. 6. Vowles KE, Rosser B, Januszewicz P, et al. patients from different cultures. As Everyday pain, analgesic beliefs and analgesic healthcare professionals, it is our role and behaviours in Europe and Russia: An References duty to help and advocate on behalf of epidemiological survey and analysis. Eur J Hosp 1. Al-Shahri MZ. Culturally sensitive caring for Saudi Pharm 2014; 21: 39–44. the patients for what is appropriate and patients. J Transcult Nurs 2002; 13(2): 133–8. 7. Zarei S, Bigizadesh S, Pourahmadi M, et al. acceptable for them within their cultural 2. Kaki AM. Pain clinic experience in a teaching Chronic pain and its determinants: A population- hospital in Western, Saudi Arabia: Relationship of context. We should learn to anticipate a based study in Southern Iran. Korean J Pain 2012; patient’s age and gender to various types of pain. 25(4): 245–53. patient’s needs with respect to their pain Saudi Med J 2006; 27(12): 1882–6. 8. Zborowski M. Cultural components in response to management and to initiate important 3. Lovering S. Cultural attitudes and beliefs about pain. J Soc Issues 1952; 8(4): 16–30. pain. J Transcult Nurs 2006; 17(4): 389–95. discussions based on their cultural, 9. Wikipedia, Blue eye, https://en.wikipedia.org/wiki/ 4. Ramer L, Richardson JL, Cohen MZ, et al. File:Blue_eyes.JPG (accessed 14 May 2018). social and religious background. It is Multimeasure pain assessment in an ethnically 10. Wikipedia, WPVA_khamsa, https://en.wikipedia.org/ important to explain the rationale behind diverse group of patients with cancer. J Transcult wiki/File:WPVA-khamsa.svg (accessed 14 May 2018). Nurs 1999; 10(2): 94–101. the use of specific medications and give 11. Wikipedia, Ruby Eye, https://commons.wikimedia. 5. Stroud MW, Thorn BE, Jensen MP, et al. The org/wiki/File:Ruby_Eye_Pendant.jpg (accessed 15 the patients the choice of deciding which relation between pain beliefs, negative thoughts, May 2018).

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70 Pain News l June 2018 Vol 16 No 2

10_PAN773597.indd 70 23/05/2018 3:33:14 PM 775272PAN Applying clinical audit to support educational package to improve compliance of performing observations for patient-controlled analgesia and epidural analgesiaApplying clinical audit to support educational package to improve compliance of performing observations for patient-controlled analgesia and epidural analgesia

Informing practice Applying clinical audit to support Pain News 2018, Vol 16(2) 71­–76 educational package to improve © The British Pain Society 2018 compliance of performing observations for patient-controlled analgesia and epidural analgesia

Martin Galligan Lead Nurse Acute Pain, Homerton University Hospital

Introduction Surgery continues to play an important Box 1. role in the treatment and management of 5–7 patients with cancer with surgical 1. Impact of uncontrolled pain resection being used for both primary Risk of developing into chronic pain tumour resection and as an intervention Increased risk of atelectasis or respiratory infection due to inability to deep breath in the management of complications.1 and cough The exact incidence of surgical resection in the cancer population varies Increased cardiovascular stress (tachycardia, hypertension) which increases stress significantly depending on the location, on the body and wound breakdown type and extent of disease. For example, Reduced mobility increasing risk of DVT 80% of people with breast cancer will Increased anxiety and stress have surgical resection compared with 6% of people with liver cancer.2 Impact on endocrine, gastrointestinal and immune system. Pain is the most common symptom Delayed discharge reported by patients in the post-operative setting. It is estimated that 80% of patients will report pain in the general Box 2. post-operative setting with around 75% of these describing it as moderate to Patient-controlled analgesia (PCA) severe.3 Despite advances in pain PCA is the method by which the patient can self-administer a pre-set dose of IV management patients continue to report opioid through use of a medical device.8 This bolus function can also be combined moderate to severe pain that is poorly with a continuous background infusion of opioid via the same device with the aim controlled.4 Uncontrolled pain can be of improving pain control. This results in a patient receiving a continuous supply of detrimental to patient recovery (see IV opioid plus potential additional boluses as requested by the self-demand button. Box 1) and there is evidence to suggest There is large variability across the literature as to what the ideal PCA protocol is; it that prolonged periods of uncontrolled is advisable that this should be tailored to individual patient’s needs.9 pain can suppress immune function The use of continuous opioid infusion alongside PCA bolus significantly increases the which, in turn, can have an impact on risk of developing respiratory depression due to the continuous infusion of the opioid prevention of further tumour growth.5 regardless of the patient’s respiratory rate or sedation level.10 If a patient’s respiratory The most common methods of post- rate falls below 10 breaths per minute, this would result in a respiratory depression. In operative pain control are patient- these circumstances, it is recommended that the opioid is stopped and high-flow controlled analgesia (PCA) (see Box 2) oxygen is administered to the patient. It may be necessary to reverse the opioid if the and epidural analgesia (see Box 3).12 symptoms are severe using an opioid antagonist (naloxone).

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These methods are inherently safe; however, there is a significant risk of Box 3. adverse effects and as a result both Epidural analgesia methods require an increased level of observation. The epidural space is located between the dura mater and the vertebral wall of the Due to the inherent risks of using both spine. Nerves entering and leaving the spinal cord pass through the epidural PCA and epidural analgesia, it was space. Epidural analgesia involves a continuous infusion of local anaesthetic and/ decided to undertake an evaluation of or opioid into the epidural space to provide pain relief. practice. Clinical audit was used to This is a more effective method of controlling pain in the post-operative setting evaluate compliance in completing PCA when compared with parenteral opioid administration.11 and epidural-specific observations Due to the location of the epidural space, there is risk of adverse events such as against trust policies. Clinical audit was formation of an epidural haematoma. This can occur when there is trauma to chosen over service evaluation as it is an epidural blood vessels resulting in bleeding in the epidural space. The risk of this effective way to establish if healthcare is occurring is greatest at insertion and removal of the epidural catheter.9 being provided in line with agreed and However, the risk of developing a haematoma is low and estimated at 1 in accepted standards. It allows care 100,000.10 It is essential to continue sensory and motor block observations for a providers and patients to know whether period of time after the epidural catheter is removed.11 This is to identify the their service is doing well and identifies presenting symptoms of a haematoma that can take the form of sensory loss, loss 13 where improvements could be made. in motor power or back pain.9 If the haematoma is identified and treated with surgical intervention within 8 hours of presenting symptoms, the chances of a Audit standards partial or good recovery are significantly increased; however, if this is not identified Although it is acknowledged that frequent and treated within 8 hours, can result in permanent neurological damage.10 observations are required to identify adverse events in patients receiving PCA or epidural analgesia,10 there is no national standard as to how often these Methodology Educational interventions observations should be performed. The audit was undertaken in three Informal feedback from staff involved in Therefore, in line with trust policies, the phases along with educational the care of these patients identified that following standards were utilised: interventions in order to improve there was a lack of knowledge with compliance. regard to what observations were need. •• All patients with continuous opioid It is important to note that study took Following each phase of the audit, the infusion via PCA must have place in a specialist cancer centre with pain clinical nurse specialist implemented respiratory rate and sedation level 92 beds meaning that the number of educational interventions with the aim of observations performed every hour patients receiving these types of improving knowledge and awareness. and documented on observation analgesia is relatively small compared to Three sets of interventions were chart. a large teaching hospital. implemented. •• All patients with epidural analgesia must have dermatome sensory level and motor power checked once per shift or every 8 hours and continued for 48 hours following removal of Phase 1 Phase 2 Phase 3 epidural catheter. Initial baseline audit performed in Retrospective audit in Given the risk to patient safety if the July 2015 (retrospective analysis of February 2016 complications described earlier were to approximately 60 patient notes that Phase 3 final spot were identified from the acute pain go unnoticed, and according to trust check audit in ward round handover list) policy, it was expected that 100% of August 2016 patients would have these Spot check audit of five observation Spot check of five observations fully performed and charts in August 2015 charts in April 2016 documented.

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Intervention phase 1 (for a 6-month Box 4. period following phase 1) July 2015 •• Ward-based teaching over a period of Ward-based teaching 6 months during staff handover times to highlight importance and frequency The Pain Clinical Nurse Specialist attended each ward at pre-arranged times of observations (see Box 4). (normally handover times) and engaged in informal teaching with the staff •• Redesign of ‘in-house’ epidural study highlighting importance of the following: day with more emphasis placed on 1. Performing observations; observations and safety, including a 2. Potential complication; new session on PCA that highlighted safety aspects and the need for close 3. Frequency of observations; observations (see Box 5). 4. General Q&A discussing specific concerns. •• Discussion of audit results at monthly ward sisters’ and matrons’ meeting Pain Team ‘Road Show’ to highlight patient safety risk. Information board was taken round all wards with three panels each focusing on •• Design of a Pain Team ‘Road Show’; an aspect of pain management. this took the form an information Panel 1: board that was rotated through all clinical areas that outlines Trust pain assessment tools and information on how to perform accurate bedside requirements for observations along pain assessment. with other pain topics. The information Panel 2: board was left in a visible area in the clinical environment with a pain clinical PCA and epidural care with a focus on care and management with additional nurse specialists being available to emphasis on observations and safety. answer any related questions during Panel 3: handover times (see Box 4). Opioid prescribing and administration focusing on different formulation of Intervention phase 2 over 1 month immediate release and modified release opioids. (following repeat audit February 2016 phase 2) •• Repeat of ward-based teaching over a Box 5. period of 1 month during staff handover times to highlight importance In-house epidural study day: and frequency of observations. •• Results were discussed at monthly The study day is mandatory for all staff caring for patients with epidural analgesia ward sisters’ and matrons’ meeting and must be completed every 2 years. This is run by the pain clinical nurse specialists and includes support from anaesthetic registrars, critical care outreach to highlight patient safety risk and nurses and a medical device trainer from a device company. A multiple choice need for increased observations. test consisting of 20 questions on content covered during the day is mandatory at •• Pain clinical nurse specialist worked the end with an expected pass mark of 100%. alongside nursing staff in the clinical areas with a focus on patients with Programme PCA and epidural analgesia where Anatomy, physiology and pharmacology of epidural analgesia; there was no improvement following Management of epidural complications; first round of interventions. Care and removal of epidural analgesia; Intervention phase 3 over 2 months (following spot check audit in April Epidural infusion pump training; 2016 phase 3) Care and management of PCA; •• Further round of ward-based Simulation centre in managing complications; teaching over 2 months; •• Increased engagement with pain link Knowledge test. nurses to model best practice in

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Applying clinical audit to support educational package to improve compliance of performing observations for patient-controlled analgesia and epidural analgesia

Prospective audit in February 2016 Figure 1. Retrospective audit Figure 3. Retrospective audit Four out of five (80%) had observations performed in July 2015 of 14 PCA performed in February 2016 of 23 recorded on the observation chart, which observation charts PCA observation charts is a significant improvement from baseline spot check (Figure 4).

Phase 3 audit Prospective audit August 2016 A total of 13 patients with continuous backgrounds via PCA were identified (Figure 5). Of the 13 patients, 8 (62%) had hourly observations documented on observation chart and 5 (38%) had 2-hourly observations documented. Results PCA observation results Figure 2. Prospective audit Epidural observations’ results Phase 1 (July 2015) performed in August 2015 of five Phase 1 A total of 14 patients with continuous PCA observation charts A total of 10 patients who had received background infusion via PCA were epidural analgesia were identified during identified in the retrospective audit in July the retrospective audit (Figure 6). Of the 10 2015 (Figure 1). In 14 patients, 3 patients patients, 9 did not have sensory-level or (21%) had hourly observations motor power observations performed in documented. the 48-hour period after removal. One patient was discounted as they were Prospective audit of five charts receiving palliative care and observations No hourly observations were recorded on were not required. observation chart. Observations were being recorded 4 hourly (Figure 2). Prospective audit Following these results, educational One out of five patients had sensory- interventions phase 1 was introduced level and motor power observations over a period of 6 months. performed for 48 hours following clinical areas. Some ward-based pain removal (Figure 7). link nurses undertook local audits in Phase 2 audits their own areas to improve standards; Retrospective audit in February 2016 Phase 2 •• Further engagement by pain clinical A total of 23 patients with continuous Retrospective audit of eight patients nurse specialist with ward sisters and background infusion via PCA were One out of eight (12.5%) patients had matrons regarding improving identified (Figure 3). Of the 23 patients, 7 48-hour observations completed, four compliance. (30%) had hourly respiratory and (25%) had observations documented for sedation observations recorded on 24 hours and five (62.5%) had no observation charts; this represents a observations documented (Figure 8). Audit timeline negligible improvement of 9%. Prospective audit One out of five (20%) patients had Phase 2 Phase 2 Phase 3 observations documented and four out of Phase 1 Retrospective Prospective Audit Final Audit July -Aug 2015 Audit April2016 August 2016 five (80%) had observations documented February 2016 for 24 hours (Figure 9).

Phase 3 Prospective audit took place in August 2016 Education Intervention1 Education Intervention 2 Education Intervention 3 Of the 10 patients, 7 (70%) had epidural observations documented for 48 hours

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Applying clinical audit to support educational package to improve compliance of performing observations for patient-controlled analgesia and epidural analgesia

Figure 4. Prospective audit Figure 7. Prospective audit Figure 9. Spot check audit performed in April 2016 of five PCA performed in August 2015 of five performed in April 2016 of five observation charts Epidural observation charts epidural observation chart

Figure 8. Retrospective audit Figure 10. Prospective audit Figure 5. Prospective audit of 13 performed in February 2016 of eight performed in August 2016 of eight PCA observation charts performed epidural observation charts. epidural observation charts in August 2016

lack of knowledge and understanding by to the increase in compliance during the nursing staff surrounding the care of spot check audit. Figure 6. Retrospective audit patients with these devices. From this, it It is also interesting to note that with performed. In July 2015 of 10 was then clear that a series of the epidural observations, we saw partial epidural observation charts educational interventions are needed in compliance, in that observations were order to improve knowledge and clarify being recorded for 24 hours and not the misconceptions and concerns recommended 48 hours. This was surrounding the care of these patients. encouraging as it shows greater Following phase 1 of educational awareness surrounding the need for interventions, the phase 2 audit of both these observations but further work was PCA and epidural analgesia was still needed. Therefore, following results undertaken. Unfortunately, the from the prospective audit in April 2016, retrospective results did not show a an educational intervention phase 3 was significant increase in compliance so this implemented followed by a phase 3 after removal and 3 (30%) had epidural was then followed by phase 2 prospective audit in August 2016. observations documented for 24 hours educational intervention and by The result of the phase 3 audit showed (Figure 10). prospective audit as planned in the phase a significant improvement from baseline. 2 audit pathway. There was a significant Although 100% compliance has not been Discussion improvement in compliance during the achieved, there have been significant The results of phase 1 retrospective and prospective audit. There was a gap of improvements at the phase 1 audit, where prospective audits identified a cause for 2 months between the retrospective and no device-specific observations were concern with regard to compliance in the spot check audit, and during this period, performed other than the standard completion of observations. The results a further 2 epidural study days were held 4-hourly observations, to the stage 3 audit from phase 1 audit generated discussion with the updated content. This additional where the majority of patients had the within the clinical areas and identified a period of teaching could have contributed required level of observations performed.

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At this stage, a small majority had either the use of e-learning in pain education had 4. Pogatzki-Zahn EM, Segelcke D, and Schug A. 2-hourly observations for respiratory rate a significant benefit in improving knowledge Postoperative pain – From mechanisms to treatment. Pain Reports 2017; 2: E588. or 24-hour epidural observations. and understanding surrounding pain 5. Hughes RG. Patient Safety and Quality: An Evidence– These audits demonstrate that an assessment and management. The current Based Handbook for Nurses. Rockville, MD: Agency intense period of education and staff e-learning system records each individual for Healthcare Research and Quality, 2008. 6. Baratta JL, Schwenk ES, and Viscusi ER. Clinical engagement resulted in a change in as they access the programme and they consequences of inadequate pain relief: Barriers practice and attitude towards the care of are unable to print off a certificate of to optimal pain management. Plastic and these devices. This, in turn, may improve completion until they have completed all Re­constructive Surgery 2014; 134(4 suppl 2): 15s–21s. patient safety. the relevant knowledge questions 7. Chung J, and Lui J. Postoperative pain It is significant to note that there have throughout the learning package. management: Study of patient’s level of pain and not been any adverse events relating to satisfaction with health care provider’s responsiveness to their reports of pain. Nursing & patient safety with regard to PCA and Health Sciences 2003; 5(1): 13–21. epidural analgesia within the trust. This Conclusion 8. Hudcova J, McNicole ED, Quah CS, et al. Patient emphasises the importance of performing controlled opioid analgesia versus non-patient The use of clinical audit has allowed the controlled opioid analgesia for postoperative pain. timely observations to ensure that adverse identification of potential patient safety Cochrane Database of Systematic Reviews 2015; events do not occur. This in turn can allay risks by an evaluation of current practice. 6: CD003348. complacency, which is a significant barrier 9. Dougherty L, and Lister S. The Royal Marsden Following a period of intervention and Manual of Clinical Nursing Procedures, 9th edn. 14 in engaging staff to change practice. staff education, clinical audit has Chichester: Wiley Blackwell, 2015. The combination of ward-based demonstrated a clear improvement in 10. Schug S, Palmer GP, Scott D, et al. Acute Pain teaching, study days, engagement with Management: Scientific Evidence, 4th edn. West current practice and as a result has End, QLD, Australia: Australian and New Zealand ward-based pain link nurses and best improved patient safety in relation to College of Anaesthetists, 2015. practice role modelling has been epidural analgesia and PCA by providing 11. Macintyre PE, and Schug SA. Acute Pain demonstrated through audit because it is Management: A Practical Guide, 4th edn. Boca a continuing package of learning in the Raton, FL: CRC Press, 2015. an effective strategy to improve practice form of monthly study days, yearly pain 12. Grass J. Patient controlled analgesia. Anesthesia & and increase staff knowledge.15,16 It is also update study days, e-learning packages Analgesia 2005; 101: S44–S61. the recommended method of implementing 13. NHS England. Clinical audit, https://www.england. and continued prospective audits of nhs.uk/ourwork/qual-clin-lead/clinaudit/ (2017, a change in practice in the clinical documentation to maintain and improve accessed 17 February 2017). environment.17 However, this was not easy current practice in the care of patients 14. Gesma D, and Wiseman M. How to implement to accomplish as pressures on nursing staff change in practice. Journal of Oncology Practice with PCA and epidural analgesia. 2010; 6(5): 257–9. on the wards make it increasingly difficult to 15. McGeever L. An alternative to link nurses: Sharing release staff from the ward environment to specialist skills in colorectal care. British Journal of attend educational activities.18 References Nursing 2013; 22(5): s19–s23. 1. Arain MR, and Buggy D. Anaesthesia for cancer 16. McMillan SC, Hagan M, and Small BJ. Training For this reason, alternative methods of patients. Current Opinion in Anesthesiology 2007; pain resource nurses: Change in their knowledge delivering education activities for ward staff 20(3): 247–53. and attitudes. Oncology Nursing Forum 2005; to improve care standards are in 2. National Cancer Intelligence Network (NCIN). Major 32(4): 835–42. Surgical Resections England 2004–2006. London: 17. National Institute for Health and Clinical Excellence development. This will take the form of NCIN, 2009. (NICE). How to Change Practice: Understand, e-learning package covering the main 3. Chou R, Gordon D, de Leon-Casaola OA, et al. Identify and Overcome Barriers to Change. aspects of pain management and Management of postoperative pain: A clinical London: NICE, 2007. practice guideline from the American Pain Society, 18. Ousey K, and Roberts D. Improving access to CPD assessment. The use of e-learning the American Society of Regional Anaesthesia and for nurse: The uptake of online provision. British modules allows clinical staff to undertake Pain Medicine, and the American Society of Journal of Community Nursing 2013; 18(2): 78–83. additional learning at any time and not Anaesthesiologists’ Committee on Regional 19. Keefe G, and Wharrad H. Using E-Learning to Anaesthesia, Executive Committee, and enhance nursing student’s pain management impact on staffing levels on the clinical Administrative Council. Journal of Pain 2016; 17(2): education. Nurse Education Today 2012; 32(8): areas.18 Keefe and Wharrad19 found that 131–57. e66–e72.

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Informing practice Audit on chronic pain duration – Pain News 2018, Vol 16(2) 77­–80 comparison to national audit data © The British Pain Society 2018

Pradeep Ingle Advance Pain Trainee Thanthullu Vasu Consultant and Head of Pain Management Services, University Hospitals of Leicester NHS Trust

•• The onset of chronic pain and the The questionnaire asked four The Faculty of Pain Medicine (FPM), first appointment at the Pain Clinic; questions on when the pain started, Royal College of Anaesthetists •• Visiting the general practitioners (GP)/ when the patient visited GP, when conducted a national audit on the doctor for the pain and the first the patient was referred to pain duration of chronic pain in preparation for appointment at the Pain Clinic; clinic and when the first pain the Joint FPM / BPS Parliamentary •• Getting referred to the pain clinic and clinic appointment happened. An reception in October 2017. The audit had the first appointment at the Pain illustration of questionnaire is shown four key questions on how long the Clinic. below. patients suffered with chronic pain and how long they have waited in the system 1. This audit was done nationally in September 2017; our pain services at University Hospitals of Leicester NHS Trust (UHL) also had the opportunity to participate in this audit. Having participated in this national audit, we wanted to compare our results with the national audit. To do this, we wanted to extrapolate and extend the audit to 30 patients. We obtained the permission from our Trust Audit department again and followed the local protocols.

Methodology To compare with the results of the national audit, we wished to retain the same four questions in the original audit to avoid inference bias. The questions that were audited include the time duration between

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Audit on chronic pain duration – comparison to national audit data

We prospectively collected the data anonymously for 30 patients between August and September 2017. This was done for patients who attended our chronic pain services and out-patient clinics.

Results Our audit results showed that patients consulted GP at an average of 4.36 months after their pain started. An average of 57.4 months was taken before the GP or Specialists decided on referring them to our chronic pain service. After referral, the patients waited for average of 1.96 months before seen in our clinics. The range of duration between identification of pain problem to getting advice from the GP/Specialist was 0–36 months. The range of duration between advice from GP/Specialist to referral to pain services was 0–284 months. The range of duration between referral for Pain Services to new patient appointment was 0–5 months. Duraon in months The medians and the modes were 40 calculated as follows: 35 Duraon (months) 30 between Pain Median Mode idenficaon and 25 (months) GP Visit 20 Identification of 0 0 months Mean pain to advice 15 from GP Advice from GP/ 27 (Multiple) 10 Specialist to Pain N/A 4.36 services referral 5 Paent number Referral to new 2 2 months 0 patient 0 30 appointment GP: general practitioners.

The mean duration from the initiation of pain problem to the first pain clinic appointment was 63.96 months, with a range of 5 months to 27 years.

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Audit on chronic pain duration – comparison to national audit data

Duraon in months 300 250 Duraon (months) from GP visit to 200 Pain Services 150 referral Mean 100 57.4 50

0 Paent number 14710 13 16 19 22 25 28

Duraon in months 6

5 Duraon (months) between Pain 4 services referral to 3 New Appointment 1.96 Mean 2 1

0 Paent number 14710 13 16 19 22 25 28

80 71.64 74.4 UHL data 62.16 63.96 Naonal Data

60 Comparison to Naonal Data

40 A=Pain Onset to GP referral to Pain Clinic (Months) 20 B= Pain Onset to First Pain 1.96 3.5 Clinic Appointment(Months) 0 C=GP referral to First appointment in Pain ABC Clinic(Months)

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Audit on chronic pain duration – comparison to national audit data

since the pain started to be seen in the pain clinic (mean wait of 6 years in national data). The time elapsed between the GP referral to the pain clinic appointment was 1.96 months in UHL, whereas it was 3.5 months in the national audit. In summary, we feel that the referral time to pain clinic could be reduced by better awareness and utilisation of pain services. Our data were comparable and better than the national data, though there is room for further improvement. Early referral to pain services has a potential to reduce patients frustration, improve clinical outcome and minimise the overall costs involved in patient care.

3 Discussion healthcare resource consumption. The References Chronic pain affects 7.8 million people in Faculty of Pain Medicine stresses the 1. Black S. Audit of pain duration. Transmitter our country and has a major impact on importance of early screening to (Autumn), p. 24. Available online at https://www. 2 4 rcoa.ac.uk/system/files/FPM-Transmitter- people’s lives. The 150th Chief Medical minimise the burden of chronic pain. AUTUMN-2017.pdf (2017, accessed 21 November Officer’s report (2009) illustrated the need The aim of our audit was to compare 2017). for specialist pain clinics all over country our data with the national audit. 2. 150th Chief Medical Officers Report. Available online at http://webarchive.nationalarchives.gov.uk/+/ and better coordination of services Compared to the national data, the http://www.dh.gov.uk/en/Publicationsandstatistics/ around patient’s needs.2 This document duration from pain onset to referral to Publications/AnnualReports/DH_096206 (2009, clearly stresses the need for early pain clinic and pain onset to first pain accessed 21 November 2017). 3. Wang CK, Hah JM, and Carroll I. Factors intervention to stop pain becoming a clinic appointment was shorter by 9.44 contributing to pain chronicity. Current Pain and persistent problem. and 10.44 months, respectively. We still Headache Reports 2009; 13(1): 7–11. Delay in access and treatment to pain feel that this waiting time is long for these 4. Early pre-screening for complex/problematic pain: Stakeholder engagement. Available online at can cause increase in frustration to suffering patients. It is unfortunate that https://www.rcoa.ac.uk/system/files/FPM- patients, with a result of increased patients have waited more than 5 years STKHOLDER-COMP-PAIN.pdf (2014).

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Informing practice The launch of National Neuromodulation Pain News 2018, Vol 16(2) 81­–82 Registry – 2018 © The British Pain Society 2018

Simon Thomson Consultant in Pain Medicine and Neuromodulation, Basildon and Thurrock University Hospitals NHS Foundation Trust

The 1 February 2018 may be just a kick 3. National Institute of Health and Care Management System (QMS) providing a and a punch to you, but to all of us at Excellence - NICE complete framework under which we Neuromodulation Society of UK and 4. Medicines and Healthcare Products deliver solutions Ireland (NSUKI) it was the Kick Off of Regulatory Agency - MHRA We live in times where information is something important. After 10 years, with 5. National Health Service of England - essential to provide healthcare. the collaboration of like-minded NSUKI NHSE The aims of the NNR are:- colleagues, we finally launched the 6. Association of British Healthcare National Neuromodulation Registry Industries - ABHI 1. Protect Patients (NNR). This has been collaboration 7. Patient Representative 2. Raise Quality Standards between NSUKI and Northgate Public 3. Promote equitable access Services (NPS) The research and publication group is 4. Support Your Professional NNR is not only a long-term in collaboration with Exeter University Development longitudinal observational data source and Medical school. 5. Support Clinical Audit and Service but also a register of devices and NSUKI have commissioned NPS to Review patients who are implanted with spinal provide the NNR system and technology 6. Support Clinical Research cord stimulator (SCS) (including dorsal services for the secure recording, 7. Support Value based healthcare root ganglion), peripheral nerve storage and reporting of patient data. stimulator (PNS) or intrathecal drug The NPS Service also captures This registry will delivery devices (ITDD). electronic post-operative patient Data fields have been honed to a bare questionnaires, and this data is linked to 1. Track both patients and implants minimum in order to reduce the burden the registry. Northgate PS manage 2. Record activity and compare with of data collection commensurate with many national registries including the NHS data usefulness. It literally takes 5 minutes to National Joint Registry since 2006 and 3. Compare relevant outcomes input all the data required. National Vascular Registry since 2014. to baseline over a long time NHS number, demographic detail, The establishment of all of the NPS period diagnosis, severity (EuroQol five- developed registries has involved NPS 4. Provide information relevant to equity dimensional descriptive system working closely with stakeholders, of access, diagnosis, device (EQ5D-5L)), occupational status, type of industry, the professions, and regulators performance, refractory pain time procedure, device model/serial number to develop the process by which 5. Be a resource for research, service and anatomical target form the baseline information is collected and review and clinical audit data set with patient global impression of disseminated. NPS work with external effect, EQ5D-5L and occupational status stakeholders to ensure compliance with Since launch in February 2018 we at follow up. the requirements of patient have 17 Trusts that have started data The governance board includes the confidentiality and information collecting. We estimate that there are following: governance. 30–40 centres nationally so we are on The NNR is hosted with an NHS server the face of it doing well. The aim is to be 1. NSUKI board and can only be accessed from NHS 75% compliant within the first year. There 2. Representatives from relevant Royal sites. NPS’ Information Security are many centres that have not yet Colleges, Faculty of Pain Medicine, Management System (ISMS) is ISO started to participate and we will be Society of British Neurological 27001:2005 compliant. NPS also working hard to try to bring them on Surgeons - FPM and SBNS operates an ISO9001 compliant Quality board.

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The launch of National Neuromodulation Registry – 2018

The aim is to attract all centres to where the governance, funding and data The NSUKI NNR team includes participate. We hope that this will be a outputs are secure. Miss Stana Bojanic, Mr Roger natural part of your neuromodulation Oge Swaby oge.swaby@northgateps. Strachan, Dr Ganesan Baranidharan, service. If you already collect data on com is Northgate PS project leader and Professor Sam Eldabe and Dr Simon your own databases then if the data are is your first point of contact in order to Thomson. compliant and consent has been get your Super User Log In details. She Under the auspices of ABHI, we collected then bulk drops of data to NNR can also provide necessary information collaborated with four device may be possible if the users want to for your Caldicott Guardian and your IT manufacturers for funding grants and avoid duplicating database entries. department. product listings – we thank Abbot, Although there are other The training video link is https://www. Boston Scientific, Medtronic, Nevro and neuromodulation registries around the youtube.com/playlist?list=PLvXZcD1R2y all other stakeholders listed as the world, only the NNR is truly national sUtEC98h3zzuCr56wUrgHDA governance board. Follow the Society on twitter

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Informing practice Audit of Medial branch block 1-year Pain News 2018, Vol 16(2) 83­–87 outcomes 2010-Dec 2016 © The British Pain Society 2018

Janine Mendham Pain Consultant Bristol

Low back pain is responsible for branch diagnostic blocks were diagnostic block, but the majority of considerable suffering across the world undertaken prior to subsequent patients who had a positive block and is responsible for substantial costs denervation in 156 patients. A record of reported scores of 8/10 or better. in healthcare (1,2). 90% of adults all procedures performed was kept and experience low back pain at some time patients were followed up after at least Denervation procedure during their life, and if the pain persists 1 year either by letter or telephone. The patient was admitted on a separate more than 3 months it is frequently occasion but usually within a month of associated with anxiety and depression Technique the diagnostic block. An aseptic that has a huge impact on work and Clinical examination technique was used and C-arm social functioning (3). Many treatments There are no definitive ways of fluoroscopy was used to confirm the have been tried all with limited success diagnosing pain arising from the facet position of the needle. 1% lidocaine was and none with any lasting effect. The joints. Criteria usually used are: pain on used to numb the skin and recent NICE guidance (4) suggests extension, pain on lateral flexion on the subcutaneous tissue. An 18G RFL NSAIDs, codeine and rehabilitation ipsilateral side, pain on rotation and/or needle was then inserted until contact should be recommended as part of a pain on palpation over the facet joints. with bone was made and then multidisciplinary approach, as this is These are the criteria used for this audit. positioned between the supero-medial likely to confer benefit in terms of If the patient only had pain on one side border of the transverse and superior reduced pain and disability that lasts they had unilateral blocks, if they had articular processes, and the inferior more than 1 year (5). The current pain on movement in both sides they had portion of the lateral neck of the superior guidance also supports the use of a bilateral block. In most cases the articular process at the and the nerve medial branch denervation for people medial branches at L3 and L4 were was stimulated at 100Hz and 2Hz. with chronic low back pain when: blocked if the patient had non-specific Successful positioning was confirmed low back pain. when stimulation was felt at less than •• Non-surgical treatment has not 0.5V and muscle contraction was seen worked for them and but there was no leg movement. 1% Diagnostic block procedure •• The main source of pain is thought to lidocaine was used to numb the nerve An aseptic technique was used and come from structures supplied by the and denervation was carried out for 120 C-arm fluoroscopy was used to confirm medial branch nerve and seconds at 80°C. (Baylis RF Generator the position of the needle; 1% lidocaine •• They have moderate or severe levels with Radiopaque radiofrequency was used to numb the skin and of localised back pain (rated as 5 or cannula). more on a visual analogue scale, or subcutaneous tissue and a 22G needle equivalent) at the time of referral. was then positioned. In most cases, L3 and L4 were selected for diagnostic Results Diagnostic medial branch blocks to try blocks. Each branch was blocked with 206 patients had diagnostic medial to make a diagnosis of facet joint– 1 mL 1% lidocaine. The patient was branch blocks between 2010 and 2016. induced chronic low back pain are reviewed about 30 minutes after the 156 went on to have denervation. These recommended by the current NICE procedure and any improvement patients were sent a letter after 1 year to guideline prior to undertaking documented. Improvement on 0–10 find out how many still had meaningful radiofrequency denervation. scale, 0 being no improvement and 10 pain relief. This paper describes an audit of being complete pain relief, was Of the 50 patients who did not outcome data of a single pain consultant documented. A score of 5–10 was proceed to denervation, 3 (6%) had over a 5-year period where 206 medial accepted as evidence of a positive sustained relief from the local anaesthetic

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Audit of Medial branch block 1-year outcomes 2010-Dec 2016

alone and did not require denervation, Overall improvement for 5.74 months with a range of 2 weeks to 42 (84% demonstrated no improvement >1 year of all 11 months. with LA and therefore did not proceed to patients = 42/206 = 20.4% denervation, and 5 (10%) did improve Of those who improved <1 year, the but declined or did not attend for mean duration of improvement was denervation. 156 patients proceeded to denervation. Of these 64, (41%) showed no improvement at 6-week follow-up, 42 Duration of improvement Numbers of patients (27%) were still improved after 1 year, 25 (16%) did improve but the effect ranged <1 month 1 from 2 weeks to 11 months with a mean 1–3 months 4 duration of 5.74 months, 5 (3.2%) 4–6 months 12 patients died and 20 (12.8%) could not 7–9 months 5 be contacted. 10–12 months 3

Age Local only Improved Improved No better No reply Better with LA DNA RFL Died (years) – no better >1 year <1 year after RFL (N = 20) only (N = 3; no (N = 5) (N = 5) (N = 42) (N = 42) (N = 25) (N = 64) RFL needed)

31–40 2 2 0 0 0 0 0 0 41–50 5 3 2 2 3 0 0 0 51–60 9 5 3 9 3 0 1 0 61–70 5 8 6 18 5 0 2 0 71–80 16 22 10 20 3 3 1 4 81–90 4 1 3 14 6 0 1 1 91–100 1 1 1 1 0 0 0 0

Site Local only Improved Improved No better No reply Better with LA DNA RFL Died – no better >1 year <1 year after RFL (N = 20) only N = 3 (no (N = 5) (N = 5) (N = 42) (N = 42) (N = 25) (N = 64) RFL needed)

Right 8 13 7 19 7 2 1 1 Left 8 14 6 14 0 0 2 2 Bilateral 26 15 25 31 13 1 2 2

Improvement after diagnostic block (%) Improved >1 year after RFL Improved <1 year after RFL Did not improve

50 3 3 2 60 1 6 5 70 4 6 4 80 20 9 30 90 5 1 13 100 8 0 6 No local (warfarin) 1 0 3 Patient insisted on RFL despite no 0 0 1 improvement with LA

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duration and had become immobile they Age of patients were given an aggressive therapeutic programme of exercise, biofeedback and autogenic training techniques at least 10 days prior to consideration of facet joint denervation. Facet denervation was not looked upon as a primary therapeutic approach and they felt the psychophysiological oriented programme was essential to accomplish any degree of pain relief. The technique they used was as follows: A diagnostic block with a 19g spinal needle using 1.5mls 0.25% bupivacaine. A positive block was recorded if there was pain relief for 2-8 hours. RFL outcomes For the denervation they used 1% lidocaine, a 12G needle positioned at L3-4, L4-5, L5-S1 bilaterally. They used a pulse duration of 1 millisecond, at 25pulses/sec and 2-3 volts. Paraspinal muscle contraction was seen routinely. They made 3 lesions at 80-82°C for 50s lesion, first in a lateral central position repeated superiorly and caudally each for 50s. They demonstrated a long-term benefit in 30-40% patients but commented that `facet denervation alone is quite inadequate to get most patients rehabilitated and a more aggressive approach of physical exercise and psychophysiological rehabilitation is necessary.’ Diagnosis of facet joint pain capsule for back pain, using a Degenerative changes of zygapophyseal percutaneous scalpel technique. He Radiofrequency denervation joints, more commonly known as the reported a 99.8% `success’ rate, which Radiofrequency denervation prevents the facet joints, are thought to account for encouraged C. Norman Shealy (8) to use conduction of nociceptive impulses 10-15% of patients with low back pain the technique in 29 patients at the Pain through the use of electrical impulses. (6) There are no symptoms or clinical Rehabilitation Centre Wisconsin in 1972. Radiofrequency energy is delivered along findings pathognomonic for facet joint He found very striking relief in over half of an insulated needle in contact with the pain. Pain referral patterns overlap his patients but 6 patients developed a target nerves. This focused electrical considerably, and may radiate to the huge haematoma prompting him to look energy heats and denatures the nerve. buttocks, thigh, groin and sometimes at less invasive methods of producing This may allow axons to regenerate with lower leg, hip and flank. There is poor the same outcome, denervation. time, requiring the repetition of the correlation between MRI findings and His management of early back pain radiofrequency procedure. response to diagnostic medial branch was aggressive including electrical Although many such procedures are blocks and there are high false positive stimulation to the back, ice applications, carried out in the UK by Pain clinicians rates for diagnostic blocks. False positive analgesia, acupuncture and bupivacaine and radiologists, there are a number of blocks range from 25-41% injections into the facet joints all taking variations in technique and there is still In 1971 W.S Rees (7) reported 2000 place during the course of an inpatient no high quality evidence for its patients in whom he had severed the stay. They were also encouraged to effectiveness and little information on posterior rami supply of the facet articular mobilise. If they had pain for a longer duration of effect.

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The length of pain relief after suggested criteria only resulted in 20% of References radiofrequency denervation is patients having pain relief for more than 1 1. Lambeck LC, van Tulder MW, Swinkels IC, et al. The trend in total cost of back pain in the uncertain. Data from randomised year, and even after a positive diagnostic Netherlands in the period 2002 to 2007. Spine controlled trials suggest relief is at least test this only increased to 27%. This finding 2011; 36: 1050–8. 6 -12 months but no study has is similar to that by Cohen et al who 2. GBD 2016 Disease and Injury Prevalence Collaborators. Global, regional and national reported longer-term outcomes. Pain compared outcomes of patients with 0, 1, incidence, prevalence and years lived with disability relief for more than 2 years would not or 2 diagnostic blocks before denervation for 328 diseases and injuries for 195 countries, 1990- be an unreasonable clinical (9). The study demonstrated that 33% of 2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390: 1211–59. expectation. The economic in the UK patients had a successful outcome at 3 3. Koes BW, van Tulder MEW, and Thomas S. suggested that radiofrequency months if they had no diagnostic block. In Diagnosis and treatment of low back pain. BMJ denervation is likely to be cost effective contrast, the percentage success fell to 2006; 332: 1430–4. 4. NICE Guideline (NG59) Low back pain and sciatica if pain relief is above 16 months (4). If 16% and 22% respectively after 1 or 2 in over 16s: Assessment and management. radiofrequency denervation is repeated, diagnostic blocks. Cohen therefore London: NICE. we do not know whether the outcomes recommended that it is more cost effective 5. Kamper S, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for and duration of these outcomes are to undertake denervation without a chronic low back pain: Cochrane systematic similar to the initial treatment. (2) diagnostic block first. review and meta-analysis. BMJ 2015; 350: h444. Although pain becomes increasingly A recent series of papers in the Lancet 6. Cohen SP, and Raja SN. Pathogenesis, diagnosis and treatment of lumbar zygapophyseal (facet) joint more common with age, older people may discuss the major global challenge of low pain. Anesthesiology 2007; 106: 591–614. respond less favourably to denervation. back pain, which is now the number one 7. Rees WES. Multiple bilateral subcutaneous Brewer et al (10) reported of 45 patients cause of disability globally (12). Cohen et al rhizolysis of segmental nerves in the treatment of the intervertebral disc syndrome. Annals of General (mean age 74 years) undergoing (13,14) present the evidence and Practice 1971; 26: 126–7. denervation, 57% patients initially reported challenges of prevention and treatment of 8. Shealy CN. Facet denervation in the management a favourable outcome but only 23% low back pain and discuss the continued of back and sciatic pain. Clinical Orthopedics and Related Research 1976; 115: 157–64. showed benefit at 10 months. The mean use of treatments without evidence 9. Brewer R, Rho R, and Lamer T. Radiofrequency duration of benefit was 3 months. There throughout the world wasting health-care lumbar facet denervation in the elderly. Journal of were no predictors of outcome and none resources and subjecting patients to Pain and Symptom Management 2004; 27(2): P97–8. improved after repeat procedure investigations and treatments that do not 10. Juch JNS, Maas ET, Ostelo RWJG, et al. Effect of Consistent with these findings, Juch et affect outcome. The NICE guidelines were radiofrequency denervation on pain intensity among al (11) reported the results of 3 published prior to the evidence patients with chronic low back pain: The Mint randomized clinical trials. JAMA 2017; 318: 68–81. randomised clinical trials with chronic low subsequently presented from the MINT 11. Cohen SP, Williams KA, Kurihara C, et al. back pain originating in the facet joints, studies (11) that do not support the use of Multicenter, randomized, comparative cost- sacroiliac joints, a combination of both, or medial branch denervation. Treatments effectiveness study comparing 0, 1 and 2 diagnostic medial branch (facet joint nerve) block intervertebral discs, compared with a shown to be effective include graded treatment paradigms before lumbar facet standard exercise programme. No exercise programmes to target radiofrequency denervation. Anesthesiology 2010; improvement was seen in the intervention improvements in function and prevent 113: 395–405. 12. GBD 2016 Disease and Injury Prevalence groups above that achieved by the worsening disability. As low back pain is Collaborators. Global, regional and national exercise programme after 3 months. such a major problem and is getting worse incidence, prevalence and years lived with disability Based on this study the authors felt this because of the ageing and increasing for 328 diseases and injuries for 195 countries, 1990- 2016: A systematic analysis for the Global Burden of procedure should not be recommended world population, perhaps it is time to Disease Study 2015. Lancet 2016; 388: 1545–602. and should only be used in a research address widespread misconceptions in the 13. Foster N, Anema JR, Cherkin D, et al. Prevention setting. There remains a possibility that population and among health professionals and treatment of low back pain: Evidence, challenges, and promising directions. Lancet. Epub radiofrequency denervation could be about causes, prognosis and effectiveness ahead of print 21 March 2018. DOI: 10.1016/ beneficial in a subset of patients if of different treatments for low back pain, S0140-6736(18)30489-6. selection methods could be improved. and deal with fragmented and out-dated 14. Hartvigsen J, Hannock MJ, Kongsted A, et al. What low back pain is and why we need to pay The results in this audit show that a models of care (15). attention. Lancet. Epub ahead of print 21 March diagnostic block did not predict a In summary, the data presented here 2018. DOI: 10.1016/S0140-6736 (18)30480-X successful outcome from denervation in demonstrate that facet joint denervation 15. Buchbinder R, van Tulder M, Öberg B, et al. Low back pain: A call for action. Lancet. Epub ahead of this group of patients. A clinical diagnosis alone does not appear to be beneficial in print 21 March 2018. DOI: 10.1016/S0140- of facet joint pain made using current the long term for the majority of patients. 6736(18)30488-4.

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Appendix 1 Medial branch block follow-up letter Is your back still better than before you attended the Pain Clinic? Please circle Yes No

If so how much better is your pain out of 10 where 0 is no better and 10 is completely better (Please circle) 0 1 2 3 4 5 6 7 8 9 10 No better Completely better

If your pain has returned how long did the pain relief last approximately? ......

Are you able to move around more easily? (Please Circle) Yes No

Do you take fewer painkillers? (Please Circle) Yes No

Would you have the same procedure again? (Please Circle) Yes No

June 2018 Vol 16 No 2 l Pain News 87

14_PAN773603.indd 87 23/05/2018 3:40:03 PM 776588PAN ‘A practical guide to incorporating pain education into pre-registration curricula for healthcare professionals in the United Kingdom’: the new BPS pain education free-to-access webbook‘A practical guide to incorporating pain education into pre-registration curricula for healthcare professionals in the United Kingdom’: the new BPS pain education free-to-access webbook

Informing practice ‘A practical guide to incorporating Pain News 2018, Vol 16(2) 88­–89 pain education into pre-registration © The British Pain Society 2018 curricula for healthcare professionals in the United Kingdom’: the new BPS pain education free-to-access webbook

Sailesh Mishra Chair, Pain Education Publication Working Party

Dear Friends, changing focus of pain education in the professional registration. When the I am excited to inform you of the launch past few years, this document was content editing was completed, we of the British Pain Society’s teaching edited and updated further to keep it wanted this document to be available to document ‘A Practical Guide to relevant in the current time. Allow me to all healthcare professionals and Incorporating Pain Education into Pre- stress that while this document is by no educators in pain management in an Registration Curricula for Healthcare means a one stop handbook of pain easy readable format. We felt having it in Professionals in the United Kingdom’. education, it is a very useful resource and an interactive webbook format would be For those of you who attended the guidance tool for healthcare the most preferred and cost-effective British Pain Society’s Annual Scientific professionals across multiple specialities way. Our most sincere and heartfelt Meeting (ASM) in Brighton last month, involved in various level of thanks to Dr Amelia Swift, Senior you may have noticed the fliers about interdisciplinary pain education. Lecturer in Nursing at University of this document’s launch event. This With this year 2018 being celebrated Birmingham, her colleague Ms Marjorie exciting new pain education document by the International Association for Study Collaco and the University of Birmingham had its launch event at the general body of Pain (IASP) as the Global Year for for supporting us with their valuable time meeting at the ASM. This document is Excellence in Pain Education, the launch and resources that made the creation of aimed at serving as a reference point and of this document at the BPS ASM is very this interactive webbook possible. as a useful resource for pain educators in timely. Following on from the earlier draft I would request you to have a look at their academic and clinical roles. This of this document, the British Pain the interactive webbook and use it as a webbook contains several educational Society’s Pain Education SIG constituted reference point for your day-to-day tools and techniques for teaching pain a working party that took on the teaching in pain management. While its management to pre-registration responsibility of content editing, content is pitched at pre-registration healthcare professionals across different communication with the stakeholders, students in general, its use can be specialities, including doctors, nurses, public consultation, content finalisation, extended to build initial concepts for physiotherapists, psychologists, seeking approval of the BPS Council and teaching pain management to Healthcare pharmacists and other allied healthcare transfer to an easily readable free-to-use Professionals at higher levels. This professionals. electronic format and the launch of this document has a useful list of suggested This document has had an interesting webbook at the general body meeting at reading materials as well as references journey. It was created from a pool of the ASM. We changed the phrasing in and external links that can help build up ideas from an educational task force of the title of the document from and reinforce key concepts in pain the BPS back in 2013. It progressed ‘Undergraduate’ to ‘Preregistration’ to management education. further under the umbrella of the Pain acknowledge that in certain professional We have suggested a feedback Education Special Interest Group (SIG) of curriculums, students completed their process and we would be grateful to you the British Pain Society in 2013. Keeping graduation and even post-graduation if you could send us your feedback via with the changing times and the courses before proceeding with their the British Pain Society.

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A practical guide to incorporating pain education into pre-registration curricula for healthcare professionals in the United Kingdom’: the new BPS pain education free-to-access webbook

Phase 1: Original Working Party members Nick Allcock (Chair), Neil Berry, Eloise Carr, Justin Durham, Alison Griffiths, Sarah Henderson, Roger Knaggs, Katherine Murphy, William Notcutt, Ian Power, Ian Semmons, Ann Taylor, Alison Twycross, Maggie Whittaker and Paul Wilkinson Following changes in SIG Committee membership, a second working party edited the document and provided additional content: Phase 2: Completion Working Party members Sailesh Mishra (Chair), Emma Briggs, Joanne Etherton, Amelia Swift, Kate Thompson The Pain Education Special Interest Group would also like to thank and acknowledge the contributions from Patricia Roche, Sharon Wood and members of both the SIG and BPS. We are grateful for the additional authors who shared their educational practice and experience: Additional authors Sally Curtis, Laura Dennison, Kathleen Kendall, Paul Kinnersley, Helen Makins, Elizabeth Metcalfe, Pete Moore, Mike O’Connor and Marcia Schofield Terminology The terms undergraduate and pre-registration are both used in this document to describe the formal programme of study for healthcare professionals that lead to entry onto a register with a regulatory body such as the Health & Care Professions Council and Nursing & Midwifery Council. Some disciplines also have a pre-registration programme at Master’s (postgraduate) level, and the recommendations for this document equally apply. Why this document is needed? This curriculum set out to be interprofessional and was created by a multiprofessional group who share a keen interest in promoting effective and innovative pain education. This document provides a British perspective on a global pain management issues and makes use of a wide range of case studies to help promote engaging, enjoyable and, where possible, interprofessional pain education. How to use this document? This document is developed as a useful guide and reference source to pain educators who teach pre-registration healthcare professionals in multiple specialities within their clinical and academic roles. While this is by no mean an exhaustive textbook to pain education, it is aimed at providing educators with practical strategies to maximise the learning outcomes of their target participant groups, and there is a list of additional resources for further reading and continued professional education. At the time of going to press for this edition of pain news, we were into the process of finalising the interactive webbook link in the British Pain Society Website. Please go to https://www.britishpainsociety.org/ and search within ‘preregistration education’.

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15_PAN776588.indd 89 23/05/2018 3:40:43 PM 773604PAN Increasing access to psychological therapies (IAPT) and pain servicesIncreasing access to psychological therapies (IAPT) and pain services

Informing practice Increasing access to psychological Pain News 2018, Vol 16(2) 90­–91 therapies and pain services © The British Pain Society 2018

Zoey Malpus Manchester University NHS Foundation Trust, Manchester, UK

Amanda C de C Williams University College London, London, UK

Several British Psychological Society and chronic pain. In 2018/2019, all workinpsychiatry/nccmh/ (BPS) members have raised concerns Clinical Commissioning Groups (CCGs) mentalhealthcarepathways/ with Council regarding local are being asked to recruit additional staff improvingaccess.aspx), where there is developments where pain services were and commission Improving Access to considerable emphasis on working being offered by increasing access to Psychological Therapies–Long-Term collaboratively with existing specialist psychological therapies (IAPT), Conditions (IAPT-LTC) services, with MDT pain services. In other areas, competing at the commissioning level additional baseline funding from April despite concerted attempts by pain but providing a less than expert service 2018. management centres, liaison with IAPT- and providing only psychological We are all aware of the huge gap LTC services has not proved possible. rehabilitation, with no medical or between available pain management These were types of concerns raised by physiotherapeutic input. The two services that provide psychological help BPS members and Council have asked psychologists on Council, Zoey Malpus and the number of people with chronic to be investigated further. Hannah Twiddy (elected) and Amanda Williams pain who could possibly benefit, even if recently devised a BPS member survey, (co-opted), were asked to investigate not requiring a full-scale pain and this again highlighted examples of and report back. management programme. So, in poor liaison with existing MDT pain Before we describe what we found, principle, this seemed a good way to services and in some cases direct and what is happening now, some extend pain provision, but only if patients competition, clearly at odds with national readers will need a little background to are appropriately triaged according to implementation guidance. IAPT. It stands for ‘Increasing access to need, through liaison with existing Recent discussion with the IAPT-LTC psychological therapies’ and was an multidisciplinary team (MDT) pain national development team confirms that initiative by the last government to services, and if IAPT workers were they too are concerned and keen to provide more accessible evidence-based adequately trained in understanding pain know specific details about these help with anxiety and depression (and other long-term conditions). The first difficulties in an effort to try to improve problems, with a shorter wait, from and second waves of extension into the situation. therapists trained for a year in cognitive– long-term conditions were almost More worryingly, the roll-out to LTCs behavioural therapy techniques. exclusively for diabetes, COPD and envisaged a 10-day advanced training Established in 2008, this has largely been cardiovascular problems. The third wave for IAPT workers which is not successful, with good results and shorter is just beginning, expanding considerably compulsory and so is not routinely used. waits to start treatment. The current Five the number of services that offer help It is not clear that this provides enough Years Forward View for the National with chronic pain. understanding of pain, and we were Health Service (NHS) includes the However, the two ‘ifs’ above seem not particularly concerned to see chronic decision to extend the remit of IAPT to be met in all cases. In some areas, pain labelled in the implementation services to the psychological needs there is good liaison between existing guidelines above not as a long-term associated with long-term conditions and MDT pain services and the IAPT service, condition, but as ‘medically unexplained’. ‘medically unexplained symptoms’, such resulting in appropriate allocation of This has been raised at the highest level as diabetes, chronic obstructive patients to services, as envisaged in the in IAPT, where there is agreement that pulmonary disease (COPD), Implementation Guidelines recently this is completely inappropriate, but there cardiovascular problems, chronic fatigue released (http://www.rcpsych.ac.uk/ is a determined lobby behind the

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Increasing access to psychological therapies (IAPT) and pain services

guidelines that refuses to engage with able to contribute more to training over direct them to the implementation the last 50 years of pain science and the next months or years. Our concern is guidelines; also, do not hesitate to offer continues to hold that anything not not only that patients are poorly served, training and supervision on pain and to visible to the naked eye or radiography and often drop out of treatment early discuss what they are offering and where starts and ends in the head and can be feeling (justifiably) that their pain is not it may fall well short of the evidence safely diverted away from pain expertise: understood, but also that it can inoculate base. We would strongly encourage you this includes all neuropathic pain, post- them against future referral to and to make links with your local IAPT-LTC stroke pain, and many other problems engagement in well-informed service. Only by engaging in such that we routinely treat with all the psychological intervention for pain collaboration can we hope to identify the resources of the pain clinic. In late management. areas of unmet need and encourage March, we took part in a webinar for So, please let the BPS know if you are them to use the additional funding to IAPT clinical leads keen to develop pain having difficulties locally with best model local services for the benefit pathways, and we hope that we will be collaboration with IAPT-LTC services and of patients with persistent pain.

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June 2018 Vol 16 No 2 l Pain News 91

16_PAN773604.indd 91 23/05/2018 3:41:18 PM 773605PAN End stuffEnd stuff

End stuff Book review Pain News 2018, Vol 16(2) 92­–93 © The British Pain Society 2018

kinds of conditions they are likely to the assistance of visual learning aids, come across in paediatric physical pictures, medical photography and therapy but also about the ways in diagrams. Whereas some textbooks can which, as a clinician, one can apply this overwhelm and confuse the reader with knowledge and evidence in the practical large bodies of text and lengthy, setting. The editors aim to take the core academic sentences, Campbell’s skills of a paediatric physical therapist Physical Therapy for Children, fifth such as clinical reasoning and decision edition, is written in a factual, easy to making and guide the reader in the ways read manner, giving the reader time to in which these core skills can be absorb the information and then allow enhanced with greater knowledge. They this information to be consolidated aim to emphasise the importance of further with the use of supporting integrating evidence and research in day- diagrams or pictures. My one critique of to-day practice and how the information this textbook is that the pictures and Campbell’s Physical Therapy for provided in the textbook can be used to photographs used are at times Children Expert Consult, 5th Edition. further an individual’s clinical practice. unnecessarily dated, which in today’s Authors: Robert J. Palisano, Margo The textbook is divided into five key technologically advanced world can Orlin & Joseph Schreiber. sections; Section 1 Understanding Motor sometimes lose the desired effect. I think ISBN: 9780323390187 Performance in Children, Section 2 it may be something to consider Reviewed by Ruth Bayliss, Management of Musculoskeletal updating for any further editions. It can Specialised Paediatric Physiotherapist Conditions, Section 3 Management of be hard to achieve the editors’ aim of Neurological Conditions, Section 4 translating knowledge to practice when Management of Cardiopulmonary faced with a black and white photograph Campbell’s Physical Therapy for Conditions and Section 5, which is newly of an infant from decades gone by. Children, fifth edition, by Robert J. added in the Fifth Edition of Campbell’s The textbook itself is well structured Palisano, Margo N. Orlin and Joseph Physical Therapy for Children, Special and each of the five sections is clearly Schreiber is an extensive textbook Settings and Special Considerations. The signposted. It is easy to pick out outlining and detailing the vast scope of first four sections beautifully explain the relevant areas of interest and turn to the paediatric physical therapy. The different specialities within paediatric correct page, making it a great point of exhaustive list of conditions that can physical therapy, whilst outlining the reference for any clinician in need of a affect children from birth to adolescence relevant conditions associated within thorough yet concise explanation of a makes producing a textbook that is as these specialities. The fifth section is a particular condition. This ease of finding comprehensive and detailed as the 34 fantastic addition to the textbook. It information is further enhanced by the chapters of Campbell’s Physical Therapy highlights key philosophies of treating colour-coded sections providing an for Children, fifth edition, are, seem even children, encouraging the clinician to aesthetically appealing textbook while more outstanding. treat more holistically and see the child also proving helpful in finding a desired Upon reading the very first sentence of rather than the condition, taking into point of reference quickly and with the Preface, my interest, as a practising account all the biological, social, ease. clinician, was piqued. It became environmental factors that play a key role The five sections are further apparent that this textbook was written in the effectiveness of any paediatric organised into smaller chapters, each and edited with an intended purpose. physical therapy intervention. detailing different areas of interest and The editors set out to produce a Each section of the textbook is specialism within the section heading. textbook with the aim of informing thorough in its explanation, but remains The spacing of paragraphs, different clinicians not only about the different clear, logical and easy to interpret with font sizes and colours used within the

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Book review

chapters make finding a particular topic paediatrics. The textbook authors have modern day practice of paediatric or piece of information very easy. It is understood this fact and pitched it at physical therapy. so well thought out and visually exactly those clinicians. This makes it In summary, it is an outstanding appealing that it does not lose the different from other physical therapy textbook that fulfilled the intentions of the reader despite the level of detail within textbooks, because it describes and editors. It presents a detailed, accurate the text itself. It appears no corners explains using clinical reasoning. It and up-to-date summary of paediatric were cut when writing and producing focuses on key skills such as decision physical therapy for the modern day this textbook. making, service needs, goal and physical therapist. A well thought out The thing I found most enjoyable about outcome-basedHow interventions. do you The get moretextbook people that to recognises read and its readers’ cite your research? Campbell’s Physical Therapy for reasoning and evidence base for clinical existing skills and requirements and Children, fifth edition, is the thought decisions is used throughout the understands the need for all clinicians to behind who the readers are. Most people textbook. It is exactlyHow dothis kindyou of get ability more be people well-rounded to read professionals and cite who knowyour research? reading this textbook will be physical to translate knowledge into practice that the importance of using a much-needed therapists and experienced clinicians is required for clinicians and Campbell’s combination of knowledge, research, who have already worked as physical textbook does exactly that with ease,EXPLAIN evidence and practical skill in the therapists prior to specialising in accuracy and an understanding of the treatment of children. EXPLAINit in plain language SHAREit in plain language it via web, email How do you get moreSHAREand people social media to read and cite your research? it via web, email How do you get more people to read and cite yourGET andresearch? social STARTED media www.growkudos.com How do you get more people to read and cite your research? GET STARTED www.growkudos.com ✓ Free service EXPLAIN ✓ Quick and simple to use ✓ Free service it in plain language ✓ Proven to increase readership ✓ Quick and simple to use ✓ Keeps track of outreach wherever you do it SHARE EXPLAINProven to increase readership ✓ ✓ Centralized reporting of full text downloads, it via web, email ✓ altmetricsKeeps track and of citationsoutreach wherever you do it and social media EXPLAIN AcrossCentralized all publications reporting of with full atext CrossRef downloads, DOI ✓ GET STARTED it altmetricsin andplain citations language www.growkudos.com ✓ Across all publications with a CrossRef DOI it in plain language ✓ Free service ✓ Quick and simple to use ✓ Proven to increase readership Keeps track of outreach wherever you do it ✓ June 2018 Vol 16 No 2 l Pain News 93 Centralized reporting ofGreater full text Research downloads, Impact SHARE ✓ altmetrics and citations Across all publications with a CrossRef DOI 17_PAN773605.indd✓ 93 26/05/2018 3:54:37 PM SHARE Kudos postcard vanilla.inddit 2 via web, email 10/08/2015 14:39 Kudos postcard vanilla.indd 2 10/08/2015 14:39 it via web, email and social media and social media Kudos postcard vanilla.indd 2 GET10/08/2015 14:39 STARTED GET STARTEDwww.growkudos.com www.growkudos.com ✓ Free service ✓ Free service ✓ Quick and simple to use ✓ Quick and simple to use ✓ Proven to increase readership ✓ Proven to increase readership✓ Keeps track of outreach wherever you do it ✓ Keeps track of outreach wherever✓ Centralized you do reporting it of full text downloads, ✓ Centralized reporting of full textaltmetrics downloads, and citations altmetrics and citations ✓ Across all publications with a CrossRef DOI ✓ Across all publications with a CrossRef DOI

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