Management of chronic pain in adults

Best Practice Statement ~ February 2006

Management of chronic pain in adults

© NHS Quality Improvement Scotland 2006

ISBN 1-84404-385-1

First published February 2006

You can copy or reproduce the information in this document for use within NHSScotland and foreducational purposes. You must not make a profit using information in this document.Commercial organisations must get our written permission before reproducing this document.

www.nhshealthquality.org

i

Foreword

Chronic pain is a major health and social care challenge affecting asignificant number of people in Scotland, many of whom are cared bynurses and Allied Health Professionals (AHPs) working in primary careand in the community. In order to support these healthcare professionalsin their work, NHS Quality Improvement Scotland has, in partnershipwith patients, carers and clinical experts, developed a Best PracticeStatement for the Management of Chronic Pain in Adults.

This best practice statement is aimed at general nursing and AHP staffand does not cover Specialist Pain Services although it is acknowledgedthat they are a key element in the patient pathway for those withchronic pain.

We hope you find it of use and would welcome any comments you mayhave.

David R SteelChief ExecutiveNHS Quality Improvement Scotland


Acknowledgements

This best practice statement was developed in partnership with a numberof people who live with chronic pain, carers and clinical experts. A listof those involved can be found in Appendix 2.

There are also a number of individuals whose guidance and support hasbeen greatly appreciated. These include:

Dr. M. Basler, Consultant anaesthetistDr. Robin McKinlay, Consultant in anaesthesia and pain managementMr. Mick McMenemy, Physiotherapist, lead clinicianDr Mick Serpell, Consultant and senior lecturer in anaesthesiaMrs Rosemary Showell, District nurse and team leaderDr Nicola Stuckey, Consultant psychologist

We would also like to thank those who sent letters of inspiration andsupport throughout the development process.

ii

Contents

Foreword i

Acknowledgments ii

Introduction v

What is Chronic Pain? ix

Background x

Section 1: Initial assessment 1

Section 2: Pharmacological management of chronic pain 3

Section 3: Unconventional analgesics (Adjuvants) 5

Section 4: The use of opioids 7

Section 5: The multidisciplinary approach in primary care 8

Section 6: Pain management programmes 15

Section 7: Self management/support groups 16

Section 8: Chronic pain "flare-ups" 17

Section 9: Specific challenges 18

Section 10: The use of complementary therapies 24

Section 11: Culture and chronic pain 25

Section 12: Education for health professionals 26

Additional Information 27

Integration of pain services 27

Palliative care and chronic pain 28

Determining pain in people who have difficulty 29communicating

Examples of unconventional analgesics 30

The use of opioids in the management of chronic pain 31

Specialist Services: Pain management clinic 33

Common interventional procedures 34


Appendix 1: Examples of Assessment Tools 35

Doloplus-2 Scale 35

NoPain – Non-Communicative Patient’s Pain 38Assessment instrument

McCaffery & Pasero initial assessment 39

Patient comfort assessment guide 42

Short form McGill pain questionnaire 44

Brief pain inventory 45

Oswestry disability questionnaire 47

Appendix 2: Who was involved in developing the statement? 49

Glossary 52

References 54

iv

v

Introduction

NHS Quality Improvement Scotland (NHS QIS) was set up by the ScottishParliament in 2003 to take the lead in improving the quality of care andtreatment delivered by NHSScotland.

The purpose of NHS QIS is to improve the quality of healthcare inScotland by setting standards and monitoring performance, and byproviding NHSScotland with advice, guidance and support on effectiveclinical practice and service improvements.

A series of best practice statements has been produced within thePractice Development Unit of NHS QIS, designed to offer guidance onbest and achievable practice in a specific area of care. These statementsreflect the current emphasis on delivering care that is patient-centred,cost-effective and fair. They reflect the commitment of NHS QIS tosharing local excellence at a national level.

Best practice statements are produced by a systematic process, outlinedoverleaf, and underpinned by a number of key principles:

• They are intended to guide practice and promote a consistent,cohesive and achievable approach to care. Their aims are realistic butchallenging.

• They are primarily intended for use by registered nurses, midwives,allied health professionals, and the staff who support them.

• They are developed where variation in practice exists and seek toestablish an agreed approach for practitioners.

• Responsibility for implementation of these statements rests at locallevel.

Best practice statements are reviewed, and, if necessary, updated after 3years in order to ensure the statements continue to reflect currentthinking with regard to best practice.


vi

Key Stages in the development of best practice statements

Topic selection and Scoping Process

Establish working group.Review literature on topic.

Source grey literature.

Ascertain current policy and legislation.

Seek information from manufacturers,

voluntary groups and other relevant

sources.

Establish reference group to

advise on consultation drafts.

Determine focus and content

of statement.

Review evidence for

relevance to practice.

Determine process for

incorporating patients’ views.

Draft document sent to

reference group.

Wide consultation process.

Review and update process. Identify

new research/ findings affecting topic.

Consider challenges of using

statement in practice.

Review and revise statement

in light of consultation

comments.

Publish and disseminate

statement.

Feedback on impact

of statement is

sought/impact

evaluation.

▲

▲

▲

▲

▲

▲

▲

▲

▲

▲

▲

vii

Best practice statement on the management of chronicpain in adults

This best practice statement has been developed by a multidisciplinaryworking group of relevant specialists, which included people living withchronic pain and carers. A multi-professional reference group has advisedon and overseen the work of the working group.

Chronic pain is one of the most common reasons people seek medicalhelp and depending on the severity of their pain are thought to usehealth services up to five times more often than the rest of thepopulation (Von Korff 1991).

Pain is defined as an unpleasant sensory and emotional experienceassociated with actual or potential tissue damage, or described in terms ofsuch damage (IASP 1986). This definition suggests that chronic pain islinked with severe psychological, social and economic consequenceswhich impact upon the sufferer, their families and healthcare resources(Smith 2001).

Patients and families struggling with chronic pain have different needsthan those with acute healthcare problems (Matthews 2002). These needsare unlikely to be met within an acute care culture.

Traditionally chronic pain has been viewed as a symptom orcomplication of another condition rather than a medical problem in itsown right. Consequently, many approaches to pain management havebeen short-sighted reinforcing the problem of chronicity (Bonica andLoeser 2001).

Chronic pain varies in aetiology (the cause of a disease or condition) andpresentation therefore the effects on individuals are often particular tothem and can include disruption of employment, family and socialfunctioning. This can lead to depression, withdrawal from socialactivities, inability to cope and increasing disability. The Pain in EuropeSurvey (2004) suggested that the prevalence of chronic pain in Scotland islikely to be around 18.1% of the population, with only 3% of peopleaccessing specialist pain services.

Considering the number of people who live with chronic pain, this Bestpractice statement is intended as a resource to guide the practice ofnurses and allied health professionals (AHPs) in acute care and primarycare who will undoubtedly care for people with chronic pain.


This Best practice statement refers to the management of chronic pain in

adults; it does not address the needs of children who suffer chronic pain.

The IASP (International Association for the Study of Pain) taxonomy on

chronic pain lists over 600 individual clinical syndromes related to

chronic pain. It would be impractical to attempt to produce guidelines

on all these individual syndromes. Instead a more generalised approach

is taken. Further reference to individual disorders can and should be

sought elsewhere.

The analgesic medications referred to in this document are onlyillustrative examples. The prescription of medicines for the relief of painshould be carried out in accordance with information provided withinthe British National Formulary (BNF) and according to the Nursing andMidwifery Council (NMC) Guidelines for the Administration of Medicines(2004).

viii

ix

What is chronic pain?

Pain can be defined as "an unpleasant sensory and emotional experienceassociated with actual or potential tissue damage, or described in terms ofsuch damage" (International Association for the Study of Pain 1986). TheIASP further define Chronic Pain as "pain without apparent biologicalvalue that has persisted beyond normal tissue healing time" (usually takento be 3 months). When pain lasts longer than 3 months or beyond thetime when an acute injury would be expected to have healed, theperson’s presentation becomes more complex. There may bepsychological features, including complaints of poor or non-refreshingsleep, tiredness, depression and poor concentration.Apart from the time characteristics (acute or persistent), pain can beclassified clinically as either nociceptive or neuropathic, although inpractice these can co-exist. Psychosocial features may play a significantrole in the persistence of symptoms.Because of the complexity of persistent pain, it is essential to make abiopsychosocial assessment (Dysvik et al 2004). By viewing chronic painin a biopsychosocial manner it enables the practitioner to focus on theindividual area which is having the largest impact on the patient’ssymptoms.

Figure 1 Biopsychosocial model for pain courtesy of Medical IllustrationsDepartment, Glasgow Royal Infirmary, adapted from Waddell et al (1993)


x

The Scope of the Problem

Chronic pain is a complex, devastating and widespread problem affectingapproximately 18.1% of people in Scotland (Breivik et al 2005). It hasharmful effects on health, employment and daily life (Smith et al 2001). Itis often described as persistent and may not totally resolve even withtreatment (Elliott et al 2002).

Nevertheless, management is worth pursuing.

Resources:

www.neuropathy-trust.org/www.arc.org.uk/about-arth/astats.htm

Key points

• Chronic pain is most prevalent in middle aged people. It is more prevalent in women than men (Rustoen et al 2005, Verhaaket al 1998).

• At least 7 million adults in the UK have long-term health problemsdue to arthritis and related conditions (Arthritis ResearchCampaign).

• In the UK the prevalence of neuropathic pain is 2.4%-8% of thepopulation (Neuropathy Trust).

• Chronic pain is one of the most common reasons why peopleseek medical care (Haetzman et al 2003).

• Chronic pain is a major public health problem.

• Chronic pain inflicts tremendous personal suffering.

• Chronic pain can reduce quality of life.

• Chronic pain does not always lead to disability – different peoplewith the same condition or injury often respond differently.

• There are significant health and social economic consequencesassociated with chronic pain (Pizzi et al 2005, Thomsen 2002).

xi

Key Principles

The key to successful management is identification of chronic pain,accurate assessment, adequate intervention and frequent evaluation(McCaffery 1999). This will allow the professional to:

• explain the process to the patient

• offer empathy and support having clearly explained the possiblelimitations of the physical relief of symptoms

• support the patient in a holistic way, in terms of the social andenvironmental impact

• improve quality of life, where possible

• encourage continuance at work, or return to work, where appropriateand possible

• foster an understanding of these patients within their families andwithin the general population, including employers.

Factors to consider in patient assessment:

• clinical history

• general personality traits and dispositions

• current level of somatic concern, depression, anger

• report of pain and functional limitations

• preliminary behavioural analysis

• pain coping strategies

• beliefs about injury, pain and treatment outcome

• social, economic and occupational influences on symptom presentation(Keefe and Bonk 1999).

What are the most common causes of chronic pain?

For many people the source of pain is musculoskeletal. Commondiagnoses are back pain, arthritis and widespread joint pain. Headache,angina and neuropathic pain are other common causes of pain. It isimportant to recognise that a significant number of individuals (5-10%)will have chronic pain with no formal diagnosis. This does not mean theirpain is imaginary. Pain is what the person says it is and exists wheneverthe person says it does (McCaffery 1980).

Table 1 Common diagnostic subgroups of chronic pain in the community

(based on Elliott et al 1999)

Table 2 Anatomical Site of Pain (based on Gureje et al 1998)

Diagnosis Male (%) Female (%)

Back Pain 14.9 17

Arthritis 13.7 17.8

After Injury 7.6 4.3

Angina 4.9 4.1

Gynaecological 0 7.5

Unknown Cause 5.2 3.4


xii

Anatomical site Subjects reporting pain (%)

Backpain 47.8

Headache 45.2

Joint Pain 41.7

Arm or leg pain 34.3

Chest Pain 28.9

Abdominal Pain 24.9

Pain Elsewhere 11.7

Number of sites

1 32.1

2 27.5

3 22.8

>4 17.5

Working Model

In relation to Back Pain a set of "flags" have been produced to reflect thebiopsychosocial phenomenon.

Figure 2 Adapted from Main CJ, Spanswick CC. 2000

A number of psychosocial "yellow flags" can be used during acuteepisodes and have been found to be useful in predicting failure to returnto work after back injury, and also prove useful in predicting whichpatients will develop prolonged pain in other situations.

These include:

• presence of a belief that the pain is harmful or potentially severelydisabling

• fear-avoidance behaviour (avoiding a movement or activity because ofa misplaced anticipation of pain), and reduced activity levels

• tendency to low mood and withdrawal from social interaction

• an expectation that passive treatments rather than active participationwill help Kendall et al (1997).

Resource: www.nzgg.org.nz

xiii

Organic pathology

Concurrent medical problems

latrogenic factors

Beliefs

Coping strategies

Distress

Illness behaviour

Willingness to change

Family reinforcement

Work Status

Health benefits and insurance

Litigation

Work satisfaction

Working conditions

Work characteristics

Social Policy

Occupational blue flags

Socio-occupational

black Flags

Clinical yellow Flags

Clinical red Flags

Biomedical factors

Psychological or

behavioural factors

(predictors)

Social and Economical

factors

Occupational factors


Types of Pain

Nociceptive pain (tissue damage pain) arises from mechanical, chemicalor thermal stimulation of nociceptors (eg after surgery, trauma orassociated with degenerative processes such as osteoarthritis). It isimportant to realise that pain may persist long after the nociceptiveprocess has ended and that other factors eg psychosocial features mayneed to be considered.

Neuropathic pain (nerve damage pain) is initiated or caused by aprimary lesion or dysfunction in the nervous system (eg in conditionssuch as diabetic neuropathy or spinal cord injury). It has quite differentclinical features from nociceptive pain. It is less well localised and often isdescribed as burning or shooting. It can occur in areas that are numb andwhere there is no tissue damage.

Table 3 Types of pain adapted from Nicholson (2003)

xiv

Nociceptive (tissue damage) pain

• Well localised

• May be more diffuse ifvisceral structures involved

• Sharp

• Stabbing

• Ache

• Gripping

Examples of nociceptive pain

• Arthritis

• Trauma

• Acute Post Operative

Neuropathic (nerve damage) pain

• Persistent

• Burning

• Paroxsysmal/spontaneous

• "Electric Shocks"

• Pain in the absence ofongoing tissue damage

• Allodynia – painful responseto stimuli that would notnormally cause pain

• Hyperalgesia – increased painin response to pain stimulus

• Dysaesthesia – unpleasantabnormal sensations

Examples of neuropathic pain

• Trigeminal neuralgia

• Diabetic neuropathy

• Post-herpetic neuralgia

• Complex regional painsyndromes I & II

• Peripheral Neuropathy

xv

Key points

• The above characteristics are typical rather than definitive

• Not all the above characteristics will be present

• Both nociceptive and neuropathic pain may co-exist

Psychosocial Features have been shown to be predictors of incidence andduration of chronic pain. It is important to realise that this does not implythat the pain has a psychological basis, only that psychological and socialfactors may have an implication in the severity and maintenance of pain.This relationship has been firmly established by research.

Patients' fear of pain, their interpretation of what the pain means and itslikely effect on their lives, have become important targets for therapy.

Patient Assessment

Comprehensive assessment of pain requires protected time with the personand consideration of the following domains:

• Physical effects/manifestations

• Functional effects

• Interference with activities of daily living

o Weight gain/losso Sit from standing and vice versao Dress and undress unaidedo Walk with easeo Employment/unemploymento Unresolved litigation issues

• Psychosocial factors

o Level of anxietyo Moodo Cultural influenceso Fearso Effects on interpersonal relationshipso Factors affecting pain thresholds

• Spiritual aspects

o This relates to the meaning of purpose ie "why am I experiencingsuch pain"? It does not always include a religious component.(SIGN Guideline 44, 2000)


1

Sect

ion

1:

Init

ial A

sses

smen

t

Key

Po

ints

~

1Peo

ple

wit

h ch

ron

ic p

ain

nee

d t

o ha

ve u

nder

gon

e a c

ompre

hen

sive

med

ical

ass

essm

ent

to e

nsu

re n

o u

nkn

own

un

der

lyin

g path

olog

ical

pro

cess

acc

oun

ts f

or t

heir

sym

pto

ms.

Thi

s is

ess

enti

al.

2Com

pre

hen

sive

ass

essm

ent

of t

he p

erso

n a

nd t

heir

pain

is

nec

essa

ry t

o in

crea

se t

he l

ikel

ihoo

d o

f su

cces

sfu

l m

an

age

men

t.

3Chr

onic

pain

is

a m

ultid

imen

sion

al

phe

nom

enon

an

d m

an

age

men

t m

ust

addre

ss a

ll a

spec

ts (

Ru

cker

et

al

1996).

4The

per

son

’s se

lf-r

epor

t of

pain

will

be c

onsi

der

ed a

n a

ccu

rate

acc

oun

t of

the

ir p

ain

(So

lom

on 2

001)

.

Nur

ses

& A

HPs

und

erst

and

the

mul

tidim

ensi

onal

nat

ure

ofch

roni

c p

ain

and

its c

omp

onen

t fe

atur

es.

Form

alis

ed a

sses

smen

t to

ols

that

are

ap

pro

pria

te f

or t

hein

divi

dual

are

use

d to

ass

ess

the

per

son

and

thei

r p

ain

(Bou

rbon

nais

et

al 2

004)

.

Onc

e p

ain

is r

epor

ted,

a c

omp

rehe

nsiv

e as

sess

men

t of

the

imp

act

of p

ain

on t

he p

erso

n is

und

erta

ken

and

am

anag

emen

t p

lan

deve

lop

ed.

Ther

e is

evi

denc

e of

loca

lly a

gree

d m

ulti

- di

men

sion

al p

ain

asse

ssm

ent

tool

s be

ing

used

to

dete

rmin

e m

anag

emen

tst

rate

gies

. To

ols

shou

ld b

e ap

pro

pria

te f

or e

ach

indi

vidu

alp

erso

n.

See

Ap

pen

dix

1 f

or

exam

ple

of

asse

ssm

ent

do

mai

ns

and

too

ls.

A p

ain

man

agem

ent

pla

n is

for

mul

ated

in p

artn

ersh

ip w

ithth

e p

erso

n.

A c

opy

of t

his

pla

n is

hel

d w

ithin

the

per

son’

sre

cord

s.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Acc

urat

e as

sess

men

t an

d in

divi

dual

man

agem

ent

of t

hep

erso

n w

ith c

hron

ic p

ain

(Tw

ycro

ss 2

000)

.

Mul

tidim

ensi

onal

ass

essm

ent

tool

s m

ust

refle

ct t

he h

olis

ticp

heno

men

on o

f ch

roni

c p

ain

(Dav

ies

& M

cVic

ar 2

000)

.

Ong

oing

ass

essm

ent

will

hel

p e

valu

ate

trea

tmen

tin

terv

entio

ns (

Turk

& B

urw

inkl

e 20

05).

Peop

le w

ith c

hron

ic p

ain

may

hav

e m

ultip

le n

eeds

.Su

cces

sful

man

agem

ent

dep

ends

on

com

pre

hens

ive

and

accu

rate

ass

essm

ent

and

reas

sess

men

t (d

eWit

et a

l 199

9).

Poin

ts t

o c

on

sid

er w

hen

tak

ing

a p

atie

nt’

s p

ain

his

tory

•Th

e si

te o

f p

ain

– W

here

do

you

feel

the

pai

n?

•W

here

doe

s it

radi

ate

to?

•N

atur

e of

pai

n –

Spee

d of

ons

et,

is it

inte

rmitt

ent

orp

ersi

sten

t?•

Cha

ract

eris

tics

of p

ain

– D

escr

ibe

wha

t th

e p

ain

feel

slik

e, e

g, is

the

pai

n bu

rnin

g, s

hoot

ing,

dul

l?•

His

tory

of

pai

n –

Ons

et a

nd d

urat

ion,

how

long

hav

eyo

u ha

d th

is p

ain?

•A

llevi

atin

g/ex

acer

batin

g fa

ctor

s –

Wha

t do

you

do

that

mak

es it

bet

ter

or w

orse

?

2

Nur

ses

& A

HPs

can

diff

eren

tiate

bet

wee

n no

cice

ptiv

e an

dne

urop

athi

c p

ain

Doc

umen

tatio

n de

mon

stra

tes

app

rop

riate

man

agem

ent

stra

tegi

es h

ave

been

ado

pte

d.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

•A

ssoc

iate

d fa

ctor

s? F

or e

xam

ple

, na

usea

, vi

scer

alsy

mp

tom

s, s

igns

of

sym

pat

hetic

dys

func

tion?

•Se

verit

y of

sle

ep d

istu

rban

ce –

Doe

s th

e p

ain

wak

e yo

uup

?•

Imp

act

on a

ctiv

ities

of

daily

livi

ng –

Doe

s th

e p

ain

stop

you

from

doi

ng a

nyth

ing?

•Pr

evio

us t

reat

men

ts –

Wha

t ha

ve y

ou a

lread

y tr

ied

tore

lieve

you

r p

ain,

why

did

you

sto

p a

ny p

revi

ous

trea

tmen

t?

The

ph

ysic

al a

spec

ts o

f a

per

son

’s

pai

n m

ust

be

trea

ted

in c

on

jun

ctio

n w

ith

th

e p

sych

olo

gic

al,

emo

tio

nal

an

dso

cial

asp

ects

.

Chr

onic

pai

n ca

n be

cha

ract

eris

ed a

s no

cice

ptiv

e or

neur

opat

hic.

How

ever

, it

is o

ften

a m

ixtu

re o

f th

e tw

o(N

icho

lson

200

3).

Key

Ch

alle

ng

es ~

1Con

sider

ing

the

fact

tha

t an

y n

ew

com

pla

int

of p

ain

cou

ld b

e a r

esu

lt o

f an

un

der

lyin

g path

olog

ical

pro

cess

, whi

ch m

ay

nee

d u

rgen

tatten

tion

.

2 D

isti

ngu

ishi

ng

neu

ropath

ic p

ain

fro

m n

ocic

epti

ve p

ain

as

trea

tmen

t st

rate

gies

oft

en d

iffe

r.

3 R

ecog

nis

ing

that

chro

nic

pain

aff

ects

man

y act

ivit

ies

of d

aily

livi

ng

– tr

eat

the

who

le p

erso

n n

ot ju

st t

he p

hysi

cal

sym

pto

ms

of p

ain

.

4

Appro

pri

ate

ass

essm

ent

of p

sych

osoc

ial

fact

ors

infl

uen

cin

g patter

n o

f pain

, pre

sen

tati

on, a

nd i

mpact

of

pain

on

psy

chos

ocia

l fu

nct

ion

ing, e

g,fa

mily,

cu

ltu

ral,

sexu

al

issu

es, D

isabi

lity

Liv

ing

Allow

an

ce (

DLA

) an

d o

ngo

ing

liti

gati

on.

5 A

sses

sin

g th

e abo

ve f

act

ors

in a

sen

siti

ve m

an

ner

.

Re

sou

rce

: w

ww

.jr2

.ox

.ac

.uk

/b

an

do

lie

r/b

oo

th/

pa

inp

ag

/


3

Sect

ion

2:

Phar

mac

olo

gic

al m

anag

emen

t o

f ch

ron

ic p

ain

Key

Po

ints

~

1A

ltho

ugh

nu

rses

may

or m

ay

not

be

pre

scri

bin

g, i

t is

vit

al

that

they

are

aw

are

of

the

pri

nci

ple

s of

the

adm

inis

trati

on o

f m

edic

ines

(N

MC 2

004).

The

y sh

ould

be

aw

are

of

whe

n i

t w

ould

be

appro

pri

ate

to

init

iate

or

dis

con

tin

ue

a d

rug, k

now

the

dos

e ra

nge

an

d p

oten

tial

side

effe

cts.

2The

use

of

pha

rmaco

logi

cal

age

nts

in

the

man

age

men

t of

pain

sho

uld

be

tailor

ed t

o ea

ch i

ndiv

idu

al.

3Pha

rmaco

logi

cal

man

age

men

t is

on

ly o

ne

com

pon

ent

of t

he p

erso

n’s

man

age

men

t pla

n.

4The

Wor

ld H

ealth

Org

an

isati

on (

WH

O)

an

alg

esic

ladder

is

ofte

n u

sed a

s a t

heor

etic

al

fram

ewor

k to

su

ppor

t th

e pha

rmaco

logi

cal

man

age

men

t of

chr

onic

pain

.

The

pha

rmac

olog

ical

man

agem

ent

of c

hron

ic p

ain

will

be

indi

vidu

alis

ed t

o m

eet

the

need

s of

the

per

son,

the

ir he

alth

and

conc

urre

nt m

edic

atio

ns.

The

prin

cip

les

of t

he W

HO

ana

lges

ic la

dder

are

ap

plie

d to

the

man

agem

ent

of p

eop

le w

ith c

hron

ic p

ain.

Peop

le w

ho h

ave

diffi

culty

man

agin

g p

ain

will

be

refe

rred

to a

sp

ecia

list

pai

n cl

inic

.

Op

timal

pai

n re

lief

is r

epor

ted

by t

he p

erso

n in

bal

ance

with

tol

erab

le s

ide-

effe

cts.

Con

cord

ance

with

mut

ually

agre

ed t

reat

men

ts e

xist

s.

Side

effe

cts

to a

nalg

esic

med

icin

es a

re r

ecor

ded,

man

aged

and

mon

itore

d.

Doc

umen

tatio

n re

flect

s th

at t

he p

rinci

ple

s of

the

WH

Oan

alge

sic

step

ladd

er h

ave

been

ap

plie

d an

d th

at p

ain

med

icat

ion

has

been

dis

cuss

ed a

nd a

gree

d w

ith t

he p

erso

n.

Evid

ence

exi

sts

in t

he p

erso

n’s

reco

rds

that

ap

pro

pria

tere

ferr

al t

o a

spec

ialis

t p

ain

clin

ic h

as b

een

mad

e.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Phar

mac

olog

ical

man

agem

ent

of c

hron

ic p

ain

is a

nim

por

tant

ele

men

t in

mul

timod

al t

reat

men

t (O

xfor

d Pa

inRe

sear

ch T

rust

200

2).

Nur

ses

& A

HPs

mus

t be

aw

are

of d

rug-

drug

inte

ract

ions

/dr

ug-n

utrie

nt in

tera

ctio

ns (

Kaye

et

al 2

002)

.

The

WH

O a

nalg

esic

ladd

er w

as d

evel

oped

and

has

bee

nva

lidat

ed f

or c

ance

r p

ain.

(W

HO

199

6).

How

ever

, its

prin

cip

les

are

wid

ely

imp

lem

ente

d in

man

agem

ent

ofch

roni

c no

n-ca

ncer

pai

n.

The

redu

ctio

n of

pai

n af

ter

trea

tmen

t at

a m

ultid

isci

plin

ary

pai

n ce

ntre

is r

epor

ted

to b

e st

atis

tical

ly s

igni

fican

t (F

lor

et a

l 199

2).

4

Key

Ch

alle

ng

es ~

1M

isco

nce

pti

ons

exis

t re

gard

ing

the

pha

rmaco

logi

cal

trea

tmen

ts o

f ch

ron

ic p

ain

, whi

ch c

an

be

a b

arr

ier

to s

ucc

essf

ul

man

age

men

t.

2In

form

ing

peo

ple

of

the

indic

ati

ons,

side

effe

cts

an

d b

enef

its

of t

heir

med

icati

on i

n a

way

that

is c

learl

y u

nder

stoo

d.

3A

na

lges

ic m

edic

ines

are

oft

en u

sed

ou

twit

h l

icen

sed

in

dic

ati

on

san

d a

ppro

pri

ate

in

form

ati

on a

bou

t ri

sks

an

d b

enef

its

for

pati

ents

an

dhe

althc

are

pro

fess

ion

als

req

uir

es t

o be

made

ava

ilabl

e.

Lice

nse

d p

rodu

cts

shou

ld b

e u

sed w

here

pos

sibl

e.

4To

en

sure

the

pati

ent

pro

gres

ses

up t

he l

adder

to

the

appro

pri

ate

lev

el. (

Bri

tish

Pain

Soc

iety

2004).

5R

ecog

nis

ing

that

othe

r in

terv

enti

ons

may

cau

se a

red

uct

ion

in

an

alg

esic

s n

eeded

.

INC

RE

AS

ING

PA

IN

No

no

pio

id

Ad

juva

nt

1

2

Op

ioid

fo

r M

od

era

te t

o S

eve

re P

ain

No

no

pio

id A

dju

va

nt

3

No

no

pio

id A

dju

va

nt

Op

ioid

fo

r M

ild t

o M

od

era

te P

ain

Figu

re 3

Adap

ted f

rom

WH

O 1

996


5

Sect

ion

3:

Un

con

ven

tio

nal

an

alg

esic

s (A

dju

van

ts)

Thes

e ar

e dr

ugs,

whi

ch a

re n

ot n

orm

ally

con

side

red

anal

gesi

cs,

but

they

hav

e a

prim

ary

role

in o

ther

con

ditio

ns.

The

y ar

e us

ed a

s ad

juva

nt t

reat

men

ts in

the

man

agem

ent

of p

ain

(McQ

uay

et a

l 199

6).

Key

Po

ints

~

1A

tri

al

of u

nco

nve

nti

onal

an

alg

esic

s sh

ould

be

con

sider

ed i

f th

e pati

ent

des

crib

es d

iffi

culty

in m

an

agi

ng

pain

.

2N

euro

path

ic p

ain

can

be

trea

ted b

y u

nco

nve

nti

onal

an

alg

esic

s eg

an

tidep

ress

an

ts, a

nti

con

vuls

an

ts a

s w

ell

as

con

ven

tion

al

med

icati

ons

egop

ioid

s.

3Tri

cycl

ic a

nti

dep

ress

an

ts a

re t

he p

refe

rred

in

itia

l th

erapy

in n

euro

path

ic p

ain

.

4U

nco

nve

nti

onal

an

alg

esic

s m

ay

be e

ffec

tive

at

dos

es w

hich

may

be l

ower

tha

n t

hose

use

d f

or t

heir

pri

mary

in

dic

ati

on.

Ta

ble

1

Fir

st-l

ine

me

dic

ati

on

s fo

r n

eu

rop

ath

ic p

ain

ad

ap

ted

fro

m D

wo

rkin

et

al

20

03

Tric

yclic

an

tid

epre

ssan

tssh

ould

be

cons

ider

ed f

orne

urop

athi

c p

ain.

An

tico

nvu

lsan

tssh

ould

be

cons

ider

ed f

or n

euro

pat

hic

pai

n.

Tram

ado

lsho

uld

be c

onsi

dere

d fo

r ne

urop

athi

c p

ain.

Star

ting

dose

10

– 25

mgs

eve

ry n

ight

.D

urat

ion

of a

deq

uate

tra

il 6

– 8

wee

ks a

t m

axim

umto

lera

ted

dosa

ge (

Dw

orki

n et

al 2

003)

.

Star

ting

dose

100

– 3

00m

gs e

very

nig

ht o

r 10

0 –

300m

gs 3

tim

es a

day

.In

crea

se b

y 10

0 –

300m

gs e

very

1 –

7 d

ays

as t

oler

ated

.D

urat

ion

of a

deq

uate

tria

l 3 –

8 w

eeks

for

titr

atio

n p

lus

1 –

2 w

eeks

at

max

imum

tol

erat

ed d

osag

e (D

wor

kin

et a

l 200

3).

Star

ting

dose

50m

gs o

nce

or t

wic

e da

ily.

Incr

ease

d by

50

– 1

00m

gs in

div

ided

dos

es e

very

3 –

7 d

ays

as t

oler

ated

.

Dur

atio

n of

ade

qua

te t

rial 4

wee

ks (

Dw

orki

n et

al 2

003)

.

Med

icat

ion

Evid

ence

Co

mm

ents

Tric

yclic

an

tid

epre

ssan

tsar

eth

ough

t to

be

effe

ctiv

etr

eatm

ent

for

neur

opat

hic

pai

n. T

he b

est

avai

labl

eev

iden

ce is

for

am

itrip

tylin

e (S

aart

o &

Wiff

en 2

005)

.

Gab

apen

tin

is t

houg

ht t

o be

effe

ctiv

e in

chr

onic

neur

opat

hic

pai

n (W

iffen

et

al 2

005)

.

Tram

ado

lis

thou

ght

to h

ave

a th

erap

eutic

effe

ct o

np

arae

sthe

siae

, al

lody

nia

and

touc

h ev

oked

pai

n.

It is

cons

ider

ed a

n ef

fect

ive

trea

tmen

t fo

r ne

urop

athi

c p

ain

(Duh

mke

et

al 2

005)

.

6

Un

con

ven

tio

nal

an

alg

esic

s (A

dju

van

ts)

Nur

ses

and

AH

Ps u

nder

stan

d th

e re

ason

s fo

r us

ing

unco

nven

tiona

l ana

lges

ic in

pai

n st

ates

eg

neur

opat

hic

pai

n.

Ther

e is

evi

denc

e in

the

per

son’

s re

cord

to

show

tha

t th

ese

unco

nven

tiona

l ana

lges

ics

have

bee

n co

nsid

ered

in a

syst

emat

ic w

ay.

Op

timal

pai

n re

lief

is r

epor

ted

by t

he p

erso

n in

bal

ance

with

tol

erab

le s

ide-

effe

cts.

Con

cord

ance

with

mut

ually

agre

ed t

reat

men

ts e

xist

s.

Side

effe

cts

to a

nalg

esic

med

icin

es a

re r

ecor

ded,

man

aged

and

mon

itore

d.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Ther

e is

str

ong

evid

ence

tha

t bo

th a

ntid

epre

ssan

ts a

ndan

ticon

vuls

ants

are

effe

ctiv

e in

pai

n st

ates

(Sa

arto

& W

iffen

2005

, W

iffen

et

al 2

005)

.

Key

Ch

alle

ng

es ~

1In

form

ing

pati

ents

of

the

indic

ati

ons,

side

effe

cts

an

d b

enef

its

of t

heir

med

icati

on i

n a

n a

cces

sibl

e fo

rmat.

2U

nder

stan

din

g th

e ri

sks

ben

efit

rati

os a

ssoc

iate

d w

ith

med

icati

ons

eg a

nti

con

vuls

an

ts.

3U

nco

nve

nti

onal

an

alg

esic

med

icin

es a

re o

ften

use

d o

utw

ith

lice

nse

d i

ndic

ati

ons,

an

d a

ppro

pri

ate

in

form

ati

on a

bou

t ri

sks

an

d b

enef

its

for

pati

ents

an

d h

ealthc

are

pro

fess

ion

als

req

uir

es t

o be

made

ava

ilabl

e.

Lice

nse

d p

rodu

cts

shou

ld b

e u

sed w

here

pos

sibl

e.

4

Chr

onic

pain

may

be a

n u

nlice

nse

d i

ndic

ati

on f

or m

ost

of t

hese

med

icin

es a

nd t

he p

ati

ent

info

rmati

on l

eafl

et, w

hich

is

issu

ed a

t th

e poi

nt

ofdis

pen

sin

g, m

ay

not

con

tain

rel

evan

t in

form

ati

on f

or t

he c

ondit

ion

bei

ng

trea

ted.

Th

e in

form

ati

on

pro

vid

ed m

ay

be

con

fusi

ng

.


7

Sect

ion

4:

The

use

of

op

ioid

s in

th

e m

anag

emen

t o

f ch

ron

ic n

on

-mal

ign

ant

pai

n

Key

Po

ints

~

1O

pio

id m

edic

ati

on m

ay

not

be

suit

abl

e or

eff

ecti

ve f

or s

ome

peo

ple

wit

h ch

ron

ic p

ain

.

2The

cho

ice

of o

pio

id m

edic

ati

on d

epen

ds

on c

lin

ical

circ

um

stan

ces.

A p

hysi

cal,

psy

chol

ogic

al a

nd s

ocia

l ass

essm

ent

isun

dert

aken

bef

ore

star

ting

the

per

son

on lo

ng-t

erm

op

ioid

med

icat

ion.

The

per

son

with

chr

onic

pai

n w

ill b

e fu

lly in

form

ed o

f th

eir

trea

tmen

t p

lan

befo

re c

omm

enci

ng o

pio

id t

hera

py.

Peop

le w

ith c

hron

ic p

ain

rece

ivin

g op

ioid

med

icat

ion

are

clos

ely

mon

itore

d du

ring

dose

titr

atio

n.

Doc

umen

tatio

n re

flect

s ap

pro

pria

te p

resc

ribin

g an

dev

alua

tion

of t

reat

men

t.

The

per

son

is c

onco

rdan

t w

ith t

reat

men

t.

Ther

e is

evi

denc

e th

at t

he u

se o

f op

ioid

s an

d p

oten

tial s

ide-

effe

cts

have

bee

n di

scus

sed

and

agre

ed b

etw

een

the

per

son

and

the

heat

h p

rofe

ssio

nal.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Som

e p

eop

le w

ith c

hron

ic p

ain

can

atta

in f

avou

rabl

eou

tcom

es f

or p

rolo

nged

per

iods

usi

ng o

pio

id m

edic

ines

(Por

teno

y 19

96).

To a

ssis

t th

e p

atie

nt t

o m

ake

as in

form

ed a

cho

ice

aspo

ssib

le a

bout

ben

efits

and

ris

ks (

Briti

sh P

ain

soci

ety

2005

).

Plea

se r

efer

to

th

e R

eco

mm

end

atio

ns

for

the

app

rop

riat

e us

e o

f o

pio

ids

for

per

sist

ent

no

n-c

ance

rp

ain

. T

he

Bri

tish

Pai

n S

oci

ety

2004

ww

w.b

riti

shp

ain

soci

ety.

org

/pd

f/Pu

b_F

inal

_op

ioid

_mar

ch

%20

2005

.pd

f

Key

Ch

alle

ng

es ~

1En

suri

ng

pati

ents

are

in

form

ed t

hat

inje

ctabl

e op

ioid

s are

rare

ly a

ppro

pri

ate

for

per

sist

ent

non

-can

cer

pain

(B

riti

sh P

ain

Soc

iety

2004).

8

Sect

ion

5:

The

mul

tid

isci

plin

ary

app

roac

h t

o p

ain

man

agem

ent

in p

rim

ary

care

Key

Po

ints

~

1Peo

ple

wit

h ch

ron

ic p

ain

oft

en h

ave

mu

ltip

le f

act

ors

that

con

trib

ute

to

pain

.

2A

mu

ltid

isci

plin

ary

appro

ach

may

be n

eces

sary

for

peo

ple

wit

h co

mple

x n

eeds.

3N

ot a

ll p

ati

ents

wit

h ch

ron

ic p

ain

req

uir

e fu

ll m

ultid

isci

plin

ary

care

.

Med

ical

Pra

ctiti

oner

Nur

se

Phys

ioth

erap

ist

Psyc

holo

gist

Phar

mac

ist

Occ

upat

iona

l The

rap

ist

Psyc

hiat

ric S

ervi

ces

The

role

invo

lves

tak

ing

a de

taile

d hi

stor

y, m

edic

al e

xam

inat

ion,

ass

essi

ng,

co-o

rdin

atin

g th

e ap

pro

pria

te m

anag

emen

t st

rate

gy f

or p

atie

nts

with

ref

erra

l to

othe

r m

embe

rs o

f th

e te

am o

r ot

her

spec

ialis

ts;

agre

eing

and

rev

iew

ing

clin

ical

man

agem

ent

pla

ns.

The

nurs

e’s

role

invo

lves

a n

ursi

ng a

sses

smen

t, r

unni

ng n

urse

led

clin

ics,

TEN

S, a

cup

unct

ure,

sle

ep m

anag

emen

t, f

ollo

win

g up

on

med

icat

ion

regi

men

s, e

duca

tion,

cou

nsel

ling,

col

lect

ing

and

orga

nisi

ng p

atie

nt d

ata.

The

man

agem

ent

pla

n in

clud

es r

eass

essm

ent

and

educ

atio

n; a

dvic

e on

pac

ing

and

goal

set

ting;

and

fac

ilita

tion

of m

ovem

ent

and

exer

cise

with

the

aim

of

optim

isin

g p

hysi

cal f

itnes

s, a

ctiv

ity a

nd p

artic

ipat

ion.

Poor

ly m

anag

ed c

hron

ic p

ain

can

gene

rate

fee

lings

of

dist

ress

, ho

pel

essn

ess

and

desp

air,

psy

chol

ogic

al in

terv

entio

ns h

ave

been

dem

onst

rate

dto

be

effe

ctiv

e (M

orel

y et

al 1

999)

.

As

par

t of

the

mul

tidis

cip

linar

y te

am p

harm

acis

ts c

an e

valu

ate

med

icat

ion

regi

men

s to

gua

rd a

gain

st d

rug

inte

ract

ions

, ad

vers

e ef

fect

s an

ddu

plic

atio

n in

the

rap

y.

Phar

mac

ists

can

als

o di

scus

s p

reco

ncei

ved

fear

s as

soci

ated

with

ana

lges

ic,

asse

ssin

g co

mp

lianc

e an

d ad

visi

ng o

nap

pro

pria

te c

omp

lianc

e ai

ds.

Ass

essm

ent

and

trea

tmen

t is

foc

used

on

enab

ling

occu

pat

ion,

whi

ch in

tur

n ca

n le

ad t

o an

imp

rove

men

t in

qua

lity

of li

fe.

Anx

iety

and

dep

ress

ion

is c

omm

on in

chr

onic

pai

n p

atie

nts,

and

can

be

deal

t w

ith b

y p

sych

olog

y.

Psyc

hiat

ric o

pin

ion

shou

ld b

e so

ught

par

ticul

arly

in r

elat

ion

to m

anag

emen

t of

sui

cide

ris

k an

d re

sist

ant

seve

re m

edic

al d

epre

ssio

n.

Key

Ch

alle

ng

es ~

1The

re i

s n

o co

mm

only

acc

epte

d s

tan

dard

mu

ltid

isci

plin

ary

appro

ach

to

chro

nic

pain

.

2A

ll p

ract

ices

may

not

have

acc

ess

to a

ll d

isci

plin

es, t

here

fore

, altho

ugh

not

idea

l, so

me

role

s m

ay

be i

nte

rcha

nge

abl

e.

3En

suri

ng

a u

nif

ied a

ppro

ach

.

4U

nder

stan

din

g th

e lim

itati

ons

of e

ach

rol

e in

the

tea

m.


9

Sect

ion

5 (

i) R

ole

of

the

Nur

se

Key

Po

ints

~

1N

urs

es u

nder

take

a v

ari

ety

of r

oles

whi

ch s

hou

ld b

e vi

ewed

wit

hin

the

con

text

of t

he m

ultid

isci

plin

ary

tea

m. T

hese

can

vary

fro

m r

un

nin

g a

Tra

nsc

uta

neo

us

elec

tric

al

ner

ve s

tim

ula

tor

(TEN

S) c

lin

ic t

o cl

inic

al

ass

essm

ent,

med

icati

on r

evie

w a

nd c

ogn

itiv

e be

havi

oura

l th

erapy.

2N

urs

es r

equ

ire

know

ledge

of

both

pha

rmaco

logi

c an

d n

on-p

harm

aco

logi

c in

terv

enti

ons

an

d t

he a

pplica

tion

of

this

kn

owle

dge

thr

ough

su

chact

ivit

ies

as

ass

essm

ent,

teach

ing, m

onit

orin

g, p

ati

ent

self

–man

age

men

t an

d c

o-or

din

ati

ng

care

am

ong

health

care

pro

vider

s.

3N

urs

es a

re i

n a

n i

dea

l pos

itio

n t

o fo

cus

on i

nte

rven

tion

s th

at

help

the

per

son

take

an

act

ive

role

in

the

ir c

are

an

d m

ain

tain

as

mu

chin

dep

enden

ce a

s pos

sibl

e.

Nur

ses

unde

rsta

nd t

he n

eed

for

regu

lar

pai

n as

sess

men

tan

d re

asse

ssm

ent,

and

hav

e an

aw

aren

ess

of t

hep

rofe

ssio

nal/

lega

l res

pon

sibi

litie

s re

late

d to

pai

nm

anag

emen

t.

Nur

ses

can

imp

lem

ent

a cl

inic

al m

anag

emen

t p

lan/

care

pla

n fo

r th

e re

lief

of p

ain

in p

artn

ersh

ip w

ith t

he p

atie

ntan

d w

ithin

the

con

text

of

the

mul

tidis

cip

linar

y te

am.

Nur

ses

dem

onst

rate

an

abili

ty t

o lia

ise

succ

essf

ully

with

othe

r ag

enci

es.

The

nurs

e de

mon

stra

tes

clin

ical

and

inte

rper

sona

l ski

lls t

oas

sess

and

rel

ieve

pai

n an

d m

easu

res

outc

omes

by

clin

ical

audi

t.

Ther

e is

evi

denc

e th

at a

n ac

tion

pla

n/ca

re p

lan

has

been

form

ulat

ed,

imp

lem

ente

d an

d ev

alua

ted.

The

docu

men

tatio

n re

flect

s th

at t

he n

eces

sary

age

ncie

sha

ve b

een

invo

lved

.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Nur

ses

rout

inel

y p

erfo

rm a

sses

smen

t of

pai

n in

tens

ity a

ndad

min

istr

atio

n of

ana

lges

ics.

(M

cCaf

fery

et

al 2

000,

NM

C20

04).

Effe

ctiv

e p

ain

man

agem

ent

is in

extr

icab

ly li

nked

to

deci

sion

s nu

rses

are

req

uire

d to

mak

e in

dai

ly p

ract

ice

(Van

Nie

kerk

and

Mar

tin 2

003,

Pel

lino

et a

l 200

2).

Com

mun

icat

ion,

col

labo

ratio

n an

d p

atie

nt a

dvoc

acy

are

fund

amen

tal n

ursi

ng a

ctiv

ities

(N

MC

200

4).

Key

Ch

alle

ng

es ~

1U

nder

stan

din

g th

e br

eadth

an

d l

imit

ati

ons

of t

he s

kills

requ

ired

to

be a

n e

ffec

tive

pra

ctit

ion

er.

2Pro

vidin

g su

ffic

ien

t ti

me

to s

pen

d w

ith

the

per

son

to

un

der

take

com

pre

hen

sive

ass

essm

ent.

10

Sect

ion

5 (

ii) R

ole

of

ph

ysio

ther

apy

Key

Po

ints

~

1Peo

ple

wit

h ch

ron

ic p

ain

oft

en h

ave

pro

blem

s w

ith

phy

sica

l fi

tnes

s.

2A

ctiv

ity

lim

itati

on (

pro

blem

s w

ith

the

capaci

ty t

o ca

rry

out

task

s or

act

ion

s), i

s of

ten

a p

robl

em f

or p

eople

wit

h ch

ron

ic p

ain

.

3Part

icip

ati

on r

estr

icti

on (

pro

blem

s w

ith

per

form

an

ce o

r in

volv

emen

t in

soc

ial

situ

ati

ons)

, is

ofte

n a

pro

blem

for

peo

ple

wit

h ch

ron

ic p

ain

.

4Pro

mot

ion

of

mov

emen

t an

d e

xer

cise

can

main

tain

an

d i

mpro

ve p

hysi

cal

fitn

ess,

act

ivit

y an

d p

art

icip

ati

on f

or p

eople

wit

h ch

ron

ic p

ain

.

5A

s in

dep

enden

t pra

ctit

ion

ers,

phy

siot

hera

pis

ts h

ave

an

im

por

tan

t ro

le i

n a

sses

sin

g an

d m

an

agi

ng

pati

ents

wit

h pain

.

6Peo

ple

wit

h acu

te p

ain

or

chro

nic

pain

will

rou

tin

ely

be r

efer

red t

o ou

tpati

ent

phy

siot

hera

py

serv

ices

in

acu

te s

ites

an

d c

omm

un

ity

settin

gs.

Ass

essm

ent

of t

he im

pac

t of

pai

n on

fun

ctio

n (p

hysi

cal

fitne

ss,

activ

ity a

nd p

artic

ipat

ion)

is u

nder

take

n to

ass

ist

with

for

mul

atio

n of

a m

anag

emen

t p

lan.

The

man

agem

ent

pla

n in

clud

es r

eass

essm

ent

and

educ

atio

n; a

dvic

e on

pac

ing

and

goal

set

ting;

and

faci

litat

ion

of m

ovem

ent

and

exer

cise

with

the

aim

of

optim

isin

g p

hysi

cal f

itnes

s, a

ctiv

ity a

nd p

artic

ipat

ion.

The

per

son

with

chr

onic

pai

n is

invo

lved

in f

orm

ulat

ing

the

man

agem

ent

pla

n to

ens

ure

that

it is

rel

evan

t to

the

irne

eds.

Doc

umen

tatio

n re

flect

s th

at p

ain-

rela

ted

phy

sica

l dis

abili

tyha

s be

en m

easu

red

and

used

to

influ

ence

the

tre

atm

ent

pla

n.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Ass

essm

ent

of p

hysi

cal f

unct

ion

is a

cru

cial

ele

men

t in

the

form

ulat

ion

of a

n ac

cura

te d

iagn

osis

and

effe

ctiv

etr

eatm

ent

pla

n (S

trou

d et

al 2

004)

.

Key

Ch

alle

ng

es ~

1Phy

siot

hera

pis

ts n

eed t

o apply

a b

iopsy

chos

ocia

l appro

ach

to

the

man

age

men

t of

chr

onic

pain

.

"Incr

easi

ngl

y in S

cotlan

d, p

atie

nts

can

sel

f-re

fer

dir

ectly t

o p

hysi

oth

erap

y w

ithout

GP

refe

rral

. Se

lf-r

efer

ral bri

ngs

with it

a re

sponsi

bili

ty t

o t

riag

epat

ients

saf

ely a

nd e

ffic

iently.

A

key

res

ponsi

bili

ty is

to c

lass

ify t

he

nat

ure

of

the

pat

ient’s

pai

n a

nd inst

igat

e im

med

iate

appro

pri

ate

man

agem

ent.

For

exam

ple

, in G

lasg

ow, 7

00 n

ew p

atie

nts

pre

sent

to p

hysi

oth

erap

y e

ach m

onth

with low

bac

k p

ain.

Som

e of

thes

e pat

ients

will

hav

e neu

ropat

hic

pai

n w

hic

h r

equir

es s

pec

ific

med

icat

ion a

nd m

anag

emen

t. P

hysi

oth

erap

ists

can

iden

tify

this

conditio

n a

nd a

rran

geap

pro

pri

ate

med

icat

ion v

ia t

he

GP

oft

en r

esultin

g in

dra

mat

ic r

educt

ion in p

ain s

ym

pto

ms

and m

inim

isin

g th

e ch

ance

of

chro

nic

pai

ndev

elopin

g".

Mr.

M. M

cMen

emy,

Gla

sgow

Bac

kpai

n S

ervic

e


11

Sect

ion

5 (

iii):

Ro

le o

f p

sych

olo

gy

in t

he

man

agem

ent

of

chro

nic

pai

n

Key

Po

ints

~

1Psy

chol

ogic

al

fact

ors

aff

ect

the

neu

rophy

siol

ogic

al

an

d b

ioch

emic

al

asp

ects

of

the

pain

exper

ien

ce (

Pri

ce 1

999)

an

d c

an

adve

rsel

y aff

ect

the

effi

cacy

of

esta

blis

hed t

reatm

ents

(W

asa

n e

t al

2005)

.

2 Psy

chol

ogic

al

appro

ach

es t

o th

e m

an

age

men

t of

chr

onic

pain

in

clu

de

dif

fere

nt

inte

rven

tion

s aim

ed a

t en

abl

ing

an

in

div

idu

al

to d

evel

opst

rate

gies

to

man

age

the

ir t

hin

kin

g, b

ehavi

our

an

d e

mot

ion

in

res

pon

se t

o pain

.

3 Psy

chol

ogic

al

appro

ach

es c

an

be

on t

hree

lev

els

(Mow

bray

1989).

Lev

el o

ne

– (a

ll c

lin

icia

ns)

basi

c u

nder

stan

din

g of

psy

chol

ogic

al

pri

nci

ple

s, sk

ills

eg

good

the

rapeu

tic

rela

tion

ship

, lis

ten

ing

skills

.

Lev

el t

wo

(sp

ecif

ica

lly

tra

ined

cli

nic

ian

s)

applica

tion

of

psy

chol

ogic

al

tech

niq

ues

des

crib

ed b

y pro

toco

l (c

an

be

to h

igh

leve

l) e

g re

laxati

on, C

ogn

itiv

e B

ehavi

oura

l The

rapy

(CB

T)

pri

nci

ple

s, Pain

Man

age

men

t Pro

gram

me

(PM

P)

train

ing

to a

gree

d c

ompet

ency

ess

enti

al

an

d o

ngo

ing

super

visi

on f

rom

psy

chol

ogis

t to

en

sure

con

tin

uin

g co

mpet

ence

.

Lev

el t

hre

e (c

lin

ica

l a

nd

ap

pli

ed p

sych

olo

gis

ts)

applica

tion

of

psy

chol

ogic

al

pri

nci

ple

s an

d t

heor

ies.

Dis

cret

ion

ary

com

pon

ent

in d

ecis

ion

s as

to w

hat

to u

se a

nd w

hen

.Com

ple

x c

ase

s, in

div

idu

al,

grou

p a

nd g

rou

p p

roce

sses

, tra

inin

g ot

hers

.

Com

ple

x i

ssu

es s

uch

as

seve

re d

epre

ssio

n, p

ost-tr

au

mati

c st

ress

res

pon

se, v

uln

erabi

lity

du

e to

pre

viou

s life

exper

ien

ces,

will

infl

uen

ce p

ain

exper

ien

ce a

nd s

hou

ld o

nly

be

dea

lt w

ith

by

som

eon

e w

orki

ng

at

leve

l 3.

Psyc

holo

gica

l int

erve

ntio

ns c

an b

e p

rovi

ded

by in

divi

dual

sat

sp

ecifi

ed le

vels

of

com

pet

ence

with

ap

pro

pria

tesu

per

visi

on,

to e

nabl

e an

indi

vidu

al t

o de

velo

p t

heir

thin

king

, be

havi

our

and

emot

ion

in r

esp

onse

to

chro

nic

pai

n.

Patie

nts

rece

ive

cogn

itive

beh

avio

ural

tre

atm

ents

to

help

them

cop

e w

ith p

ain-

rela

ted

psy

chos

ocia

l pro

blem

s.

Ther

e is

doc

umen

ted

evid

ence

tha

t th

e p

atie

nt h

as b

een

offe

red

evid

ence

-bas

ed p

sych

olog

ical

inte

rven

tion.

Doc

umen

ted

evid

ence

sug

gest

s co

gniti

ve b

ehav

iour

alst

rate

gies

hav

e be

en c

onsi

dere

d.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Poor

ly m

anag

ed c

hron

ic p

ain

can

gene

rate

fee

lings

of

dist

ress

, ho

pel

essn

ess

and

desp

air,

psy

chol

ogic

alin

terv

entio

ns h

ave

been

dem

onst

rate

d to

be

effe

ctiv

e(M

orel

y et

al 1

999)

.

Cog

nitiv

e be

havi

oura

l str

ateg

ies

can

rest

ore

a se

nse

ofco

ntro

l and

imp

rove

cop

ing

abili

ty f

or p

eop

le w

ith c

hron

icp

ain

(Vla

eyen

& M

orle

y 20

05,

Mor

ley

et a

l 199

9).

12

Com

ple

x p

sych

olog

ical

pre

sent

atio

ns e

g su

icid

al id

eatio

n,p

ost

trau

mat

ic s

tres

s di

sord

er,

influ

ence

of

pre

viou

s ab

use,

is m

anag

ed b

y cl

inic

al p

sych

olog

ist

with

in p

ain

team

, or

refe

rred

to

app

rop

riate

men

tal h

ealth

ser

vice

.

Doc

umen

ted

evid

ence

of

refe

rral

to

app

rop

riate

ly q

ualif

ied

per

son/

serv

ice.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Thes

e fa

ctor

s w

ill h

ave

a si

gnifi

cant

imp

act

on o

utco

mes

and

pai

n ex

per

ienc

e, a

nd r

equi

re a

pp

rop

riate

tra

inin

g in

orde

r to

pro

vide

saf

e tr

eatm

ent.

(D

.O.H

. 20

01,

Trea

tmen

tch

oice

in p

sych

olog

ical

the

rap

ies

and

coun

selli

ng)

Key

Ch

alle

ng

es ~

1Pro

vidin

g appro

pri

ate

tra

inin

g an

d s

uper

visi

on f

or t

hose

wor

kin

g w

ith

psy

chol

ogic

al

pri

nci

ple

s (l

evel

2).

2A

cces

sin

g adeq

uate

res

ourc

es f

or p

sych

olog

ical

serv

ices

loc

ally

an

d t

imeo

usl

y (l

evel

3).

3A

dapti

ng

cogn

itiv

e be

havi

oura

l st

rate

gies

to

mee

t th

e n

eeds

of p

eople

wit

h co

gnit

ive

impair

men

ts.

4D

ealin

g w

ith

pati

ents

who

are

not

rea

dy

to e

mbr

ace

a p

sych

olog

ical

appro

ach

to

pain

man

age

men

t.


13

Sect

ion

5 (

iv):

Ro

le o

f O

ccup

atio

nal

Th

erap

y

Key

Po

ints

~

1The

foc

us

of i

nte

rven

tion

is

the

pro

mot

ion

of

occu

pati

on.

Occ

upati

on i

s def

ined

as

"daily

act

ivit

ies

that

refl

ect

cultu

ral

valu

es, p

rovi

de

stru

ctu

re t

o livi

ng

an

d m

ean

ing

to i

ndiv

idu

als

; the

se a

ctiv

itie

s m

eet

hum

an

nee

ds

for

self

-care

, en

joym

ent

an

d p

art

icip

ati

on i

n s

ocie

ty" (C

OT2

2004).

2A

sses

smen

t of

the

per

son

’s oc

cupati

onal

per

form

an

ce s

hou

ld b

e u

nder

take

n w

ithi

n a

ny

ass

essm

ent.

3A

tre

atm

ent

pla

n s

hou

ld b

e id

enti

fied

wit

h jo

int

goal-s

etti

ng.

4The

per

son

sho

uld

be

edu

cate

d o

n g

oal-s

etti

ng

pri

nci

ple

s an

d p

aci

ng

tech

niq

ues

as

tool

s to

part

icip

ati

on i

n o

ccu

pati

ons

rele

van

t to

his

/her

lif

e.

Ass

essm

ent

and

trea

tmen

t is

foc

used

on

enab

ling

occu

pat

ion,

whi

ch c

an le

ad t

o an

imp

rove

men

t in

qua

lity

of li

fe.

Inte

rven

tion

is u

nder

take

n w

ithin

the

fra

mew

ork

of a

mul

tidis

cip

linar

y ap

pro

ach

to p

ain

man

agem

ent.

The

per

son’

s p

rogr

ess

is d

ocum

ente

d an

d p

erfo

rman

cem

onito

red

with

reg

ular

rev

iew

.

Ap

pro

pria

te o

utco

me

mea

sure

s ar

e co

mp

lete

d be

fore

and

afte

r oc

cup

atio

nal t

hera

py

(Law

et

al 1

991)

.

The

occu

pat

iona

l the

rap

ist

has

read

and

com

plie

s w

ith t

heN

atio

nal O

ccup

atio

nal T

hera

py

Pain

Ass

ocia

tion

Gui

delin

eson

the

Rol

e of

Occ

upat

iona

l The

rap

y an

d M

inim

umRe

qui

rem

ents

for

Pra

ctic

e (P

ain

Soci

ety,

200

1).

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

An

occu

pat

iona

l beh

avio

ural

mod

el p

rovi

des

a ho

listic

pic

ture

of

the

per

son

with

chr

onic

pai

n. A

reh

abili

tativ

eap

pro

ach

to b

e ta

ken

with

em

pha

sis

on r

e-es

tabl

ishi

ngor

der

in t

he o

ccup

atio

nal f

unct

ioni

ng o

f th

e in

divi

dual

pat

ient

(St

rong

199

6).

A m

ultid

isci

plin

ary

team

ap

pro

ach

to c

hron

ic p

ain

is c

ost

effe

ctiv

e (W

adde

ll 19

96).

Key

Ch

alle

ng

es ~

1The

pro

visi

on o

f eq

uip

men

t an

d a

dapta

tion

s m

ust

pro

mot

e fu

nct

ion

al

abi

lity

an

d n

ot r

ein

forc

e fu

nct

ion

al

dis

abi

lity

.

2A

ddre

ssin

g so

cial

barr

iers

(phy

sica

l, or

gan

isati

onal,

cultu

ral

an

d a

ttit

udin

al)

to

occu

pati

onal

per

form

an

ce.

3Con

sider

ing

the

man

age

men

t of

ris

k w

hen

pro

mot

ing

occu

pati

onal

per

form

an

ce.

14

Sect

ion

5 (

v):

Psyc

hia

tric

Ser

vice

s

Key

Po

ints

~

1A

nxie

ty a

nd d

epre

ssio

n a

re c

omm

on i

n c

hron

ic p

ain

pati

ents

, an

d c

an

be

addre

ssed

by

psy

chol

ogy

serv

ices

. Psy

chia

tric

opin

ion

sho

uld

be

sou

ght,

part

icu

larl

y, i

n r

elati

on t

o m

an

age

men

t of

su

icid

e ri

sk a

nd r

esis

tan

t se

vere

med

ical

dep

ress

ion

.

2Illn

ess

beha

viou

r ca

n a

ffec

t pain

pati

ents

’ clin

ical

pre

sen

tati

on.

3So

mato

form

Dis

order

can

pre

sen

t in

a p

ain

clin

ic.

Key

Ch

alle

ng

es ~

1A

sses

sin

g pati

ents

in

a s

ensi

tive

an

d n

on-c

onfr

onta

tion

al

man

ner

whe

re p

ati

ents

may

be d

efen

sive

abo

ut

psy

chia

tric

con

tact

.


15

Sect

ion

6:

Pain

man

agem

ent

pro

gra

mm

es

Key

Po

ints

~

1Peo

ple

wit

h ch

ron

ic p

ain

nee

d t

he k

now

ledge

an

d s

kills

to b

e act

ivel

y in

volv

ed i

n s

elf-

man

age

men

t of

the

ir c

ondit

ion

.

2Fa

mily

suppor

t ca

n b

e an

im

por

tan

t fa

ctor

in

the

reh

abi

lita

tion

of

peo

ple

wit

h ch

ron

ic p

ain

.

3Pain

man

age

men

t pro

gram

mes

req

uir

e cl

ose

inte

rdis

ciplin

ary

wor

kin

g w

ith

all s

taff

en

gagi

ng

the

pri

nci

ple

s of

cog

nit

ive

beha

viou

ral

ther

apy.

4The

aim

s of

pain

man

age

men

t pro

gram

mes

are

to:

•im

pro

ve p

eople

’s u

nder

stan

din

g of

chr

onic

pain

an

d t

he r

elati

onsh

ip b

etw

een

pain

, em

otio

n a

nd b

ehavi

our

•im

pro

ve p

eople

’s le

vel

of p

hysi

cal,

soci

al,

pra

ctic

al

an

d e

mot

ion

al

fun

ctio

nin

g an

d c

onfi

den

ce

•re

du

ce f

ear

of m

ovem

ent

•pro

vide

copin

g st

rate

gies

for

dea

lin

g w

ith

thei

r dis

abi

lity

an

d d

istr

ess

•pro

mot

e au

ton

omy

an

d i

ndep

enden

ce

•re

du

ce o

r m

odif

y th

e per

son

’s fu

ture

use

of

healthc

are

res

ourc

es e

g, G

P a

ppoi

ntm

ents

, med

icati

on.

Pain

man

agem

ent

pro

gram

mes

incl

ude

all a

spec

ts o

f p

ain,

the

trea

tmen

t of

pai

n, p

ain

per

cep

tion,

psy

chol

ogic

al a

ndso

cial

fac

tors

.

Car

ers

or f

amily

mem

bers

are

act

ivel

y in

volv

ed in

the

man

agem

ent

of c

hron

ic p

ain

and

the

per

son’

sre

habi

litat

ion.

Pre

and

pos

t-p

rogr

amm

e as

sess

men

ts a

re c

omp

lete

d.

The

pat

ient

and

the

fam

ily/c

arer

rep

ort

imp

rove

d q

ualit

y of

life.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Pain

man

agem

ent

educ

atio

n p

rogr

amm

es h

ave

been

show

n to

red

uce

pai

n, a

nxie

ty,

dep

ress

ion,

imp

rove

trea

tmen

t ad

here

nce

and

faci

litat

e re

turn

to

wor

k (O

laso

n20

04).

Chr

onic

pai

n af

fect

s im

por

tant

bas

ic r

elat

ions

hip

s in

clud

ing

emot

iona

l and

phy

sica

l int

imac

y (S

mith

200

3).

Key

Ch

alle

ng

es ~

1En

suri

ng

pain

man

age

men

t pro

gram

mes

mee

t th

e des

irabl

e cr

iter

ia s

et b

y th

e B

riti

sh P

ain

Soc

iety

, (19

97,

cu

rren

tly

un

der

rev

iew

), in

clu

din

gm

inim

um

sta

ffin

g.

2En

suri

ng

pain

man

age

men

t pro

gram

mes

are

acc

essi

ble

to a

ll w

ho r

equ

ire

them

via

ref

erra

l to

spec

ialist

pain

man

age

men

t cl

inic

(M

cEw

enR

epor

t 20

04).

3En

suri

ng

appro

pri

ate

pati

ent

sele

ctio

n.

4A

cces

sin

g pain

man

age

men

t pro

gram

mes

.

Re

sou

rce

: ww

w.b

riti

shp

ain

soc

iety

.org

/p

df/

de

sira

ble

.pd

f

16

Sect

ion

7:

Self

-man

agem

ent/

sup

po

rt g

roup

s

Key

Po

ints

~

1So

me

self

-man

age

men

t gr

oups

offe

rin

g se

lf-m

an

age

men

t an

d t

rain

ing

can

pro

mot

e w

ays

of

copin

g w

ith

chro

nic

pain

an

d i

mpro

ve s

elf-

effi

cacy

(Lo

rig

et a

l 19

99).

2M

utu

al

suppor

t an

d g

rou

p e

nco

ura

gem

ent

can

im

pro

ve t

he p

erso

n’s

copin

g abi

liti

es.

3Se

lf-m

an

age

men

t/su

ppor

t gr

oups

can

red

uce

soc

ial

isol

ati

on.

4Se

lf-m

an

age

men

t/su

ppor

t gr

oups

can

com

ple

men

t st

atu

tory

ser

vice

s by

offe

rin

g su

ppor

t be

twee

n a

ppoi

ntm

ents

an

d b

y of

feri

ng

lon

g-te

rmfo

llow

-up s

uppor

t.

Peop

le w

ith c

hron

ic p

ain

will

be

info

rmed

of

any

loca

l sel

f-m

anag

emen

t/su

pp

ort

grou

ps

or o

rgan

isat

ions

to

faci

litat

eth

eir

cop

ing

skill

s an

d ac

cess

ong

oing

sup

por

t.

Ther

e is

evi

denc

e th

at t

he p

atie

nt a

nd t

he c

arer

hav

ere

ceiv

ed in

form

atio

n on

how

to

acce

ss s

elf-

man

agem

ent

/sup

por

t gr

oup

s.

Ther

e is

evi

denc

e of

an

up t

o da

te d

irect

ory

of s

elf

man

agem

ent

grou

ps/

sup

por

t gr

oup

s av

aila

ble

in t

he a

rea.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Peop

le w

ith c

hron

ic p

ain

who

cho

ose

to jo

in

self-

man

agem

ent/

sup

por

t gr

oup

s re

por

t th

e be

nefit

s as

: •

an o

pp

ortu

nity

to

rece

ive

info

rmat

ion

•an

op

por

tuni

ty t

o ge

t a

deep

er,

diffe

rent

sor

t of

unde

rsta

ndin

g th

at c

an b

e ob

tain

ed f

rom

frie

nds,

fam

ilyan

d he

alth

pro

fess

iona

ls•

over

com

ing

a se

nse

of is

olat

ion

•le

arni

ng f

rom

oth

ers

with

chr

onic

pai

n•

help

ing

othe

rs a

nd s

ocia

lisin

g (S

ubra

man

iam

et

al 1

999)

.

Key

Ch

alle

ng

es ~

1Se

lf-m

an

age

men

t/su

ppor

t gr

oups

requ

ire

act

ive

leader

ship

.

2H

ealth

pro

fess

ion

al

invo

lvem

ent

in s

elf-

man

age

men

t/su

ppor

t gr

oups

can

in

flu

ence

the

dir

ecti

on o

f th

e gr

oup.

3En

suri

ng

succ

essf

ul

inte

grati

on w

ith

the

health

care

tea

m.

Re

sou

rce

s:

ww

w.p

ain

ass

oc

iati

on

.co

m

ww

w.p

ain

co

nc

ern

.org

.uk


17

Sect

ion

8:

Ch

ron

ic p

ain

‘fla

re-u

ps’

/exa

cerb

atio

ns

Key

Po

ints

~

1Peo

ple

wit

h ch

ron

ic p

ain

will

exper

ien

ce f

luct

uati

ons

in t

heir

pain

in

ten

sity

.

2Chr

onic

pain

‘fla

re-u

ps’

can

last

for

vary

ing

per

iods

of t

ime

from

a f

ew s

econ

ds

to s

ever

al

hou

rs.

Peop

le w

ith c

hron

ic p

ain

are

awar

e th

at t

hey

may

exp

erie

nce

occa

sion

al p

erio

ds o

f flu

ctua

tion

in p

ain

inte

nsity

.

The

pos

sibi

lity

of’ ‘

flare

-up

s’ is

incl

uded

in p

atie

nted

ucat

ion

sess

ions

.

Peop

le w

ith c

hron

ic p

ain

have

suf

ficie

nt k

now

ledg

e to

man

age

thei

r an

alge

sic

med

icin

es a

nd e

mp

loy

per

sona

lco

pin

g st

rate

gies

to

man

age

fluct

uatio

ns o

f p

ain

inte

nsity

.

Peop

le w

ith c

hron

ic p

ain

dem

onst

rate

effe

ctiv

e co

pin

gm

echa

nism

s du

ring

fluct

uatio

ns in

pai

n in

tens

ity.

Peop

le w

ith c

hron

ic p

ain

are

awar

e of

the

ir ow

n p

ain-

activ

atin

g tr

igge

rs.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Patie

nts

with

per

sist

ent

non-

canc

er p

ain

may

pre

sent

with

acut

e ex

acer

batio

ns o

f p

ain

(Brit

ish

Pain

Soc

iety

200

4).

Perip

hera

l and

/or

cent

ral s

ensi

tisat

ion

may

pla

y a

role

inm

any

case

s of

bre

akth

roug

h p

ain

in c

hron

ic

non-

mal

igna

nt p

ain

(Sve

ndse

n et

al 2

005)

.

Key

Ch

alle

ng

es ~

1R

ecog

nis

ing

an

d d

iagn

osis

of

an

epis

ode

of ‘f

lare

-up’.

2Peo

ple

wit

h ch

ron

ic p

ain

who

exper

ien

ce a

‘fla

re-u

p’ m

ay

avo

id p

hysi

cal

act

ivit

y.

3Peo

ple

who

are

exper

ien

cin

g a ‘f

lare

-up’ m

ay

adop

t n

egati

ve t

hou

ghts

.

4En

suri

ng

aw

are

nes

s th

at

‘fla

re-u

ps’

may

be i

nfl

uen

ced b

y be

havi

oura

l act

ivit

y patter

ns.

5The

re i

s pati

ent-le

d d

eman

d f

or a

n a

ctio

n p

lan

for

the

man

age

men

t of

‘fla

re-u

ps’.

6The

re i

s a n

eed f

or r

esea

rch

into

the

valu

e of

an

act

ion

pla

n i

n t

he m

an

age

men

t of

‘fla

re-u

ps’

of p

ain

.

18

Sect

ion

9:

Spec

ific

ch

alle

ng

es (

i):

chro

nic

pai

n a

nd

th

e o

lder

ad

ult

Key

Po

ints

~

1 Chr

onic

pain

is

high

ly p

reva

len

t in

old

er p

eople

(G

agl

iese

& M

elza

ck 2

003,

Ellio

tt e

t al

1999).

2 Pain

is

poo

rly

man

age

d i

n o

lder

peo

ple

(Pro

ctor

& H

irdes

2001,

Ber

nabe

i et

al

1998, C

loss

1994).

3Pain

is

ofte

n a

part

of

a c

omple

x p

ictu

re i

ncl

udin

g co

ncu

rren

t m

edic

al

con

dit

ion

s.

Old

er p

eop

le w

ho r

epor

t p

ain

are

rout

inel

y as

sess

ed u

sing

a fo

rmal

ised

pai

n as

sess

men

t to

ol a

s p

art

of in

itial

eval

uatio

n fo

llow

ing

refe

rral

to

any

heal

thca

re p

rofe

ssio

nal.

Any

pai

n re

por

ted

is r

ecog

nise

d as

a p

robl

em.

Form

alis

ed p

ain

asse

ssm

ent

tool

s ar

e av

aila

ble

for

use

by a

llhe

alth

pro

fess

iona

ls.

Ther

e is

evi

denc

e of

pai

n as

sess

men

t w

ithin

the

pat

ient

s’re

cord

s.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Chr

onic

pai

n is

not

an

inev

itabl

e co

nseq

uenc

e of

age

ing,

how

ever

, p

ain

may

be

a co

nseq

uenc

e of

oth

er c

hron

icco

nditi

ons

(Am

eric

an G

eria

tric

Soc

iety

199

8).

Pain

in t

he o

lder

adu

lt is

poo

rly a

sses

sed

and

man

aged

(Pro

ctor

& H

irdes

200

1, C

loss

199

4).

Key

Ch

alle

ng

es ~

1En

suri

ng

suff

icie

nt

tim

e to

un

der

take

acc

ura

te a

sses

smen

t.

2A

n o

lder

per

son

may

be u

nw

illin

g to

ack

now

ledge

pain

du

e to

mis

con

cepti

ons

that

pain

is

a p

art

of

age

ing

(Clo

ss 2

004).

3O

verc

omin

g co

mm

un

icati

on d

iffi

cultie

s. R

epea

tin

g or

rep

hrasi

ng

ques

tion

s ca

n i

mpro

ve r

espon

se (

Clo

ss e

t al

2004).

4U

nqu

alifi

ed s

taff

pro

vide

dir

ect

care

to

elder

ly r

esid

ents

in

nu

rsin

g ho

mes

. The

y m

ay

not

be

edu

cati

onally

pre

pare

d t

o u

nder

take

man

yco

mple

x t

ask

s in

clu

din

g th

ose

invo

lved

in

pain

man

age

men

t (H

orga

s &

Du

nn

2001, H

iggi

ns

et a

l 20

04).


19

Spec

ific

chal

len

ges

(ii)

: ch

ron

ic p

ain

an

d t

he

per

son

wit

h le

arn

ing

dis

abili

ties

incl

udin

g c

ogn

itiv

e im

pai

rmen

t

Key

Po

ints

~

1Peo

ple

wit

h pro

fou

nd l

earn

ing

dis

abi

liti

es m

ay

be u

nabl

e to

com

mu

nic

ate

ver

bally

ther

efor

e pain

ass

essm

ent

tool

s th

at

rely

on

sel

f-re

por

t u

sin

gla

ngu

age

are

in

adeq

uate

(D

avi

s &

Eva

ns

2001)

.

2Psy

chol

ogic

al

dis

tres

s ca

n o

ccu

r if

pain

is

not

ack

now

ledge

d.

3The

cari

ng

rela

tion

ship

wit

h th

e cl

ien

t is

im

por

tan

t fo

r th

e id

enti

fica

tion

of

beha

viou

ral

chan

ges

ass

ocia

ted w

ith

pain

(D

onov

an

2002)

.

4U

se o

f n

on-v

erba

l co

mm

un

icati

on m

etho

ds

an

d n

on-tra

dit

ion

al

met

hods

requ

ire

spec

ialist

ski

lls,

pati

ence

an

d i

nte

rpre

tati

on.

Peop

le w

ith le

arni

ng d

isab

ilitie

s ha

ve t

he r

ight

to

have

thei

r p

ain

man

aged

.

Loca

lly a

gree

d to

ols

to a

ssis

t in

the

ass

essm

ent

of p

ain

inp

eop

le w

ith le

arni

ng d

isab

ilitie

s ar

e av

aila

ble

and

used

.

Loca

l pra

ctic

e gu

idel

ines

for

the

man

agem

ent

of p

ain

inp

eop

le w

ith le

arni

ng d

isab

ilitie

s ex

ist.

Ther

e is

evi

denc

e th

at r

efer

ral a

dvic

e ha

s be

en s

ough

t fr

omle

arni

ng d

isab

ilitie

s se

rvic

es.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Def

icie

ncie

s ha

ve b

een

high

light

ed in

the

tre

atm

ent

ofp

ain

in p

eop

le w

ith le

arni

ng d

isab

ilitie

s (C

SAG

199

9).

Pain

ass

essm

ent

for

this

car

e gr

oup

rel

ies

on b

ehav

iour

alin

dica

tors

and

fac

ial e

xpre

ssio

n (M

cGra

th e

t al

199

8).

Key

Ch

alle

ng

es ~

1B

ehavi

our

that

indic

ate

s pain

in

the

gen

eral

pop

ula

tion

may

be i

nco

nsi

sten

t an

d d

iffi

cult t

o in

terp

ret

in t

hose

wit

h pro

fou

nd l

earn

ing

dis

abi

liti

es (

McG

rath

et

al

1998).

2En

suri

ng

pra

ctit

ion

ers

do

not

make

ass

um

pti

ons

abo

ut

the

cau

ses

of p

ain

.

3A

ckn

owle

dgi

ng

that

peo

ple

wit

h le

arn

ing

dis

abi

liti

es o

ften

exper

ien

ce o

ngo

ing

pain

fro

m a

vari

ety

of o

ther

dis

abi

liti

es.

20

Spec

ific

ch

alle

ng

es (

iii):

man

agem

ent

of

slee

p in

peo

ple

wit

h c

hro

nic

pai

n

Key

Po

ints

~

170

% o

f peo

ple

wit

h ch

ron

ic p

ain

rep

ort

impair

ed s

leep

(M

orin

et

al

1998).

2Pain

cau

ses

ligh

ter/

dis

turb

ed s

leep

an

d c

an

in

terf

ere

wit

h th

e abi

lity

to

init

iate

or

main

tain

sle

ep.

3Poo

r sl

eep m

ay

be a

con

trib

uti

ng

fact

or t

o th

e per

cepti

on o

f pain

in

ten

sity

.

Patie

nts

with

chr

onic

pai

n w

ho r

epor

t sl

eep

dis

turb

ance

unde

rgo

accu

rate

eva

luat

ion

of t

he r

epor

ted

sym

pto

ms.

Adv

ice

is g

iven

to

peo

ple

with

chr

onic

pai

n on

how

to

addr

ess

pro

blem

s w

ith s

leep

dis

turb

ance

.

The

pat

ient

dem

onst

rate

s sk

ill in

tec

hniq

ues

that

enh

ance

rest

ful s

leep

.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

25%

of

peo

ple

with

chr

onic

pai

n re

por

t th

at p

ain

disr

upts

thei

r sl

eep

at

leas

t 10

nig

hts

per

mon

th (

Lam

berg

199

9).

Key

Ch

alle

ng

es ~

1M

an

agi

ng

slee

p d

istu

rban

ce w

hich

may

be a

con

sequ

ence

of

an

d a

con

trib

uti

ng

fact

or t

o ch

ron

ic p

ain

.

2Tre

ati

ng

dep

ress

ion

whi

ch c

an

be

ass

ocia

ted w

ith

slee

p d

istu

rban

ce.

3O

pti

mis

ing

an

alg

esic

med

icati

on a

nd m

an

agi

ng

side-

effe

cts

that

can

in

terf

ere

wit

h sl

eep.

4A

cces

sin

g co

gnit

ive

beha

viou

ral

inte

rven

tion

s th

at

spec

ific

ally

targ

et i

nso

mn

ia (

Smit

h et

al

2000).


21

Spec

ific

ch

alle

ng

es (

iv):

sp

irit

ual n

eed

s as

soci

ated

wit

h c

hro

nic

pai

n

Key

Po

ints

~

1Sp

irit

uality

is

a b

asi

c hu

man

phe

nom

enon

tha

t allow

s th

e cr

eati

on o

f a m

ean

ing

an

d p

urp

ose

in l

ife.

2Chr

onic

pain

may

be a

ssoc

iate

d w

ith

endle

ss, m

ean

ingl

ess

suff

erin

g.

3The

per

son

’s sp

irit

ual

belief

s ca

n i

nfl

uen

ce t

heir

hea

lth

belief

s an

d s

ense

of

wel

l-bei

ng.

Emot

iona

l, p

sych

olog

ical

, so

cial

and

sp

iritu

al a

spec

ts o

fch

roni

c p

ain

are

addr

esse

d.

Spiri

tual

car

e is

giv

en in

a o

ne-t

o-on

e re

latio

nshi

p,

isco

mp

lete

ly p

erso

n-ce

ntre

d an

d m

akes

no

assu

mp

tions

abou

t p

erso

nal c

onvi

ctio

n or

life

orie

ntat

ion

(NH

S H

DL

2002

76)

.

The

per

son’

s sp

iritu

al n

eeds

for

m p

art

of t

he o

vera

llm

anag

emen

t p

lan

and

are

asse

ssed

sen

sitiv

ely.

Loca

l res

ourc

es f

or s

piri

tual

sup

por

t ar

e ac

cess

ed w

ith t

hep

erso

n’s

per

mis

sion

.

The

pers

on d

ispl

ays

the

desi

re a

nd a

bilit

y to

get

on

with

life

.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Unc

ontr

olle

d p

ain

can

caus

e su

fferin

g an

d lo

ss o

f se

lf-es

teem

(C

hap

man

& G

avrin

199

9, B

ullin

gton

et

al 2

003)

.

Spiri

tual

issu

es r

elat

ed t

o th

e su

fferin

g of

chr

onic

pai

n ca

nin

volv

e a

reac

tion

betw

een

emot

ions

suc

h as

fea

r, gu

ilt,

ange

r, lo

ss a

nd d

esp

air.

It m

ay a

pp

ear

inse

par

able

fro

mp

hysi

cal p

ain

and

can

influ

ence

the

way

pai

n is

exp

ress

ed.

The

NH

S m

ust

offe

r bo

th s

piri

tual

and

rel

igio

us c

are

with

equa

l ski

ll an

d en

thus

iasm

(N

HS

HD

L 20

02 7

6).

Key

Ch

alle

ng

es ~

1The

con

cept

of s

pir

itu

al

pain

req

uir

es p

ract

itio

ner

s to

go

beyo

nd t

he b

oun

ds

of c

lin

ical

trea

tmen

ts a

nd b

e pre

pare

d t

o dev

ote

the

tim

ere

quir

ed t

o gi

ve s

uppor

tive

an

d u

nder

stan

din

g ca

re.

2In

clu

din

g th

e sp

irit

ual

asp

ects

of

pain

in

the

hol

isti

c ass

essm

ent.

3 Sp

irit

ual

care

is

not

nec

essa

rily

rel

igio

us.

Rel

igio

us

care

, at

its

best

, sho

uld

alw

ays

be

spir

itu

al

(NH

S H

DL

2002

76).

Re

sou

rce

: htt

p:/

/w

ww

.sh

ow

.sc

ot.

nh

s.u

k/

seh

d/

me

ls/

HD

L2

00

2_

76

.pd

f

22

Spec

ific

Ch

alle

ng

es (

v):

chro

nic

pai

n a

nd

sex

ualit

y

Key

Po

ints

~

1Peo

ple

who

exper

ien

ce c

hron

ic p

ain

may

repor

t a d

eter

iora

tion

or

cess

ati

on o

f se

xu

al

act

ivit

y.

2Peo

ple

wit

h ch

ron

ic p

ain

may

fear

an

exace

rbati

on o

f pain

du

rin

g se

xu

al

act

ivit

y.

3Pha

rmaco

logi

cal

age

nts

com

mon

ly u

sed i

n t

he t

reatm

ent

of p

ain

can

dim

inis

h libi

do

an

d i

nhi

bit

sexu

al

fun

ctio

n.

4D

epre

ssio

n c

omm

only

lin

ked w

ith

chro

nic

pain

can

con

trib

ute

to

loss

of

libi

do.

5Tim

e sh

ould

be

alloc

ate

d t

o dis

cuss

thi

s asp

ect

of c

are

in

pri

vate

.

Ass

essm

ent

of s

exua

l fun

ctio

n is

incl

uded

in t

hem

ultid

imen

sion

al a

sses

smen

t of

peo

ple

with

chr

onic

pai

n.

Whe

n st

artin

g ne

w p

harm

acol

ogic

al a

gent

s fo

r th

etr

eatm

ent

of c

hron

ic p

ain

the

pat

ient

is in

form

ed o

fp

oten

tial e

ffect

s of

the

med

icin

es.

Mul

tidim

ensi

onal

ass

essm

ent

incl

udin

g se

xual

fun

ctio

n ha

sbe

en c

arrie

d ou

t if

nece

ssar

y.

Peop

le w

ith c

hron

ic p

ain

rece

ive

info

rmat

ion

on t

he d

rug

trea

tmen

ts in

itiat

ed a

nd a

re e

duca

ted

on t

he p

oten

tial s

ide-

effe

cts.

Ther

e is

evi

denc

e to

sho

w t

hat

any

sexu

al d

ysfu

nctio

n ha

sbe

en a

ddre

ssed

.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Ther

e is

a h

igh

inci

denc

e of

sex

ual d

ysfu

nctio

n re

por

ted

byp

eop

le li

ving

with

chr

onic

pai

n (A

mbl

er e

t al

200

1).

Man

y m

edic

ines

use

d to

tre

at c

hron

ic p

ain

are

know

n to

inhi

bit

sexu

al f

unct

ion

(Pai

ce 2

003)

.

Key

Ch

alle

ng

es ~

1A

void

ing

the

ass

um

pti

on t

hat

the

iden

tifi

cati

on o

f se

xu

al

dif

ficu

ltie

s m

ean

s th

at

the

indiv

idu

al

wis

hes

to a

cces

s he

lp.

2R

ecog

nis

ing

that

phy

siol

ogic

al

chan

ges

can

alter

sex

uality

in

peo

ple

wit

h ch

ron

ic p

ain

.

3A

ckn

owle

dgi

ng

pati

ents

an

d p

rofe

ssio

nals

are

oft

en u

nco

mfo

rtabl

e dis

cuss

ing

sexu

al

issu

es.


23

Spec

ific

Ch

alle

ng

es (

vi):

ch

ron

ic p

ain

an

d t

he

wo

rkp

lace

Key

Po

ints

~

1Peo

ple

wit

h ch

ron

ic p

ain

are

at

incr

ease

d r

isk

of w

ork

loss

an

d d

isabi

lity

, an

d t

he l

onge

r th

ey a

re a

bsen

t fr

om w

ork,

the

les

s like

ly t

hey

are

to

retu

rn (

Waddel

l 19

98).

2Peo

ple

liv

ing

in a

reas

of s

ocia

l dep

riva

tion

, whe

re u

nem

plo

ymen

t m

ay

be h

ighe

r, a

re m

ore

like

ly t

o su

ffer

chr

onic

pain

.

3In

form

ati

on o

n t

he D

isabi

lity

Dis

crim

inati

on A

ct (

2005)

can

be

obta

ined

fro

m h

ttp://

ww

w.d

isabi

lity

.gov

.uk/

dda/e

mplo

yers

/em

plo

yers

.asp

Key

Ch

alle

ng

es ~

1If

chr

onic

pain

is

lin

ked t

o a w

ork-

rela

ted i

nju

ry t

here

may

be o

ngo

ing

com

pen

sati

on i

ssu

es.

2Peo

ple

may

be r

elu

ctan

t to

ret

urn

to

wor

k as

they

may

lose

fin

an

cial

suppor

t.

3A

sta

ged a

ppro

ach

for

ret

urn

to

wor

k m

ay

nee

d t

o be

neg

otia

ted w

ith

the

emplo

yer.

4To

lia

ise

wit

h oc

cupati

onal

health

dep

art

men

ts t

o fa

cilita

te r

etu

rn t

o w

ork.

24

Sect

ion

10:

Use

of

com

ple

men

tary

th

erap

ies

in t

he

man

agem

ent

of

chro

nic

pai

n

Key

Po

ints

~

1M

an

y peo

ple

wit

h ch

ron

ic p

ain

sou

rce

com

ple

men

tary

the

rapie

s.

2Vari

ous

def

init

ion

s of

com

ple

men

tary

the

rapie

s ex

ist.

3The

re h

as

been

an

in

crea

se i

n t

he u

se o

f co

mple

men

tary

the

rapie

s fo

r pain

-rel

ate

d p

robl

ems

(Rao

et a

l 19

99, H

aet

zman

n e

t al

2003)

.

4N

on-p

harm

aco

logi

cal

inte

rven

tion

s m

ust

not

be

seen

as

a s

ubs

titu

te f

or p

harm

aco

logi

cal

age

nts

.

5The

in

tera

ctio

n b

etw

een

the

pati

ent

an

d h

ealthc

are

pro

fess

ion

al

may

be a

n i

mpor

tan

t m

edia

tor

in t

reatm

ent

outc

ome.

6Tra

nsc

uta

neo

us

Ele

ctri

cal

Ner

ve S

tim

ula

tion

(TEN

S) a

nd a

cupu

nct

ure

are

com

mon

ly u

sed f

or t

he r

elie

f of

chr

onic

pain

.

Ass

essm

ent

of p

atie

nts’

use

of

com

ple

men

tary

the

rap

ies

isin

clud

ed in

the

com

pre

hens

ive

asse

ssm

ent.

Ass

essm

ent

of t

he p

atie

nt’s

sui

tabi

lity

and

a tr

ial o

f TE

NS

shou

ld b

e co

nsid

ered

in m

anag

ing

chro

nic

pai

n.

Doc

umen

tatio

n re

flect

s th

at c

onsi

dera

tion

ofco

mp

lem

enta

ry t

hera

pie

s ha

s be

en in

clud

ed in

the

pat

ient

’sas

sess

men

t.

A t

rial o

f TE

NS

is o

ffere

d to

the

pat

ient

.

The

pat

ient

dem

onst

rate

s an

und

erst

andi

ng o

f th

e TE

NS

mac

hine

.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Ther

e is

evi

denc

e to

sug

gest

tha

t so

me

com

ple

men

tary

ther

apie

s ha

ve a

pos

itive

effe

ct o

n ch

roni

c p

ain

(Sny

der

&W

iela

nd 2

003,

Ste

phe

nson

& D

alto

n 20

03).

The

use

of T

ENS

has

been

sho

wn

to b

e ef

fect

ive

in t

hem

anag

emen

t of

chr

onic

pai

n if

used

cor

rect

ly a

nd f

or a

suffi

cien

t du

ratio

n (J

ohns

on 2

000)

.

Patie

nt e

duca

tion

can

influ

ence

the

suc

cess

of

TEN

Sth

erap

y (M

itche

ll &

Kaf

ai 1

997)

.

Key

Ch

alle

ng

es ~

1En

suri

ng

a b

ala

nce

d a

ttit

ude

tow

ard

s th

e u

se o

f co

mple

men

tary

the

rapie

s is

con

veye

d.

2R

ecog

nis

ing

that

som

e co

mple

men

tary

the

rapie

s m

ay

be u

nsu

itabl

e fo

r peo

ple

wit

h ch

ron

ic p

ain

who

are

con

sider

ed p

sych

olog

ically

un

stabl

e.

3En

suri

ng

pati

ents

un

der

stan

d h

ow a

TEN

S m

ach

ine

wor

ks t

o m

axim

ise

the

ben

efit

.

NB

: TE

NS

an

d a

cu

pu

nc

ture

ca

n b

e p

rov

ide

d b

y h

ea

lth

ca

re p

rofe

ssio

na

ls b

ut

it m

ust

be

ac

kn

ow

led

ge

d t

ha

t p

eo

ple

ma

y a

cc

ess

th

ese

tre

atm

en

ts f

rom

oth

er

sou

rce

s.


25

Sect

ion

11:

Ch

ron

ic p

ain

an

d c

ultu

re

Key

Po

ints

~

1Pain

has

both

per

son

al

an

d c

ultu

ral

inte

rpre

tati

ons.

2Ver

bal

an

d n

on-v

erba

l co

mm

un

icati

ons

dif

fer

betw

een

cu

ltu

res.

Hea

lth p

rofe

ssio

nals

dem

onst

rate

sen

sitiv

ity t

o th

ein

fluen

ce o

f cu

lture

on

pai

n p

erce

ptio

ns a

nd p

ain

beha

viou

rs.

Patie

nt a

sses

smen

t an

d m

anag

emen

t re

flect

s cu

ltura

llyap

pro

pria

te c

are.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Cro

ss-c

ultu

ral d

iffer

ence

s in

the

mea

ning

of

and

cop

ing

with

pai

n ha

ve b

een

rep

orte

d (C

lela

nd e

t al

200

5, C

allis

ter

2003

, L

asch

200

0).

Key

Ch

alle

ng

es ~

1En

suri

ng

health

pro

fess

ion

als

are

sen

siti

ve t

o th

e in

flu

ence

of

a p

erso

n’s

cultu

ral

back

grou

nd o

n p

ain

per

cepti

ons

an

d b

ehavi

ours

, an

d a

reaw

are

tha

t th

ere

are

dif

fere

nce

s in

the

pain

exper

ien

ce b

etw

een

in

div

idu

als

in

cu

ltu

ral

grou

ps.

26

Sect

ion

12:

Ed

ucat

ion

fo

r H

ealt

hca

re P

rofe

ssio

nal

s

Key

Po

ints

~

1H

ealthc

are

pro

fess

ion

als

sho

uld

be

pre

pare

d t

o m

eet

pati

ents

’ des

ire

for

info

rmati

on a

bou

t ch

ron

ic p

ain

an

d i

ts m

an

age

men

t.

2La

ck o

f kn

owle

dge

by

healthc

are

pro

fess

ion

als

is

one

reaso

n f

or t

he i

nappro

pri

ate

tre

atm

ent

of c

hron

ic p

ain

.

3Edu

cati

on s

hou

ld r

efle

ct t

hat

chro

nic

pain

is

a m

ultid

imen

sion

al

phe

nom

enon

, whi

ch c

uts

acr

oss

pro

fess

ion

al

bou

ndari

es.

The

prin

cip

les

of c

hron

ic p

ain

asse

ssm

ent

and

man

agem

ent

are

incl

uded

in e

duca

tiona

l pro

gram

mes

for

heal

th p

rofe

ssio

nals

at

pre

and

pos

t re

gist

ratio

n le

vels

.

Educ

atio

n p

rogr

amm

es r

efle

ct t

he m

ultid

imen

sion

al n

atur

eof

chr

onic

pai

n.

A r

ecor

d of

hea

lthca

re p

rofe

ssio

nals

who

att

end

pai

nm

anag

emen

t ed

ucat

ion

is a

vaila

ble.

Hea

lthca

re p

rofe

ssio

nals

are

eq

uip

ped

with

the

kno

wle

dge

to c

are

for

peo

ple

with

chr

onic

pai

n.

As

a m

inim

um r

equi

rem

ent

chan

ges

in k

now

ledg

e an

d/or

skill

s ar

e as

sess

ed;

atte

mp

ts a

re m

ade

to a

sses

s ch

ange

s in

attit

udes

and

bel

iefs

; id

eally

cha

nges

in p

atie

nt/c

lient

outc

omes

are

add

ress

ed.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Chr

onic

pai

n is

a m

ultid

imen

sion

al p

heno

men

on,

whi

chcu

ts a

cros

s al

l pro

fess

iona

l bou

ndar

ies.

Ther

e is

an

educ

atio

nal g

ap r

elat

ing

to c

are

for

peo

ple

with

chr

onic

pai

n (J

ones

et

al 2

001)

.

Hea

lthca

re p

rofe

ssio

nals

mus

t be

pre

par

ed f

or p

ract

ice

(Soh

n &

Coo

k 20

02).

Key

Ch

alle

ng

es ~

1En

suri

ng

edu

cati

on a

ddre

sses

the

kn

owle

dge

, ski

lls

an

d c

onfi

den

ce r

equ

ired

to

del

iver

eff

ecti

ve p

ain

man

age

men

t in

a m

ultip

rofe

ssio

nal

envi

ron

men

t.

2Pro

fess

ion

als

’ attit

udes

an

d b

elie

fs, a

nd o

rgan

isati

onal

barr

iers

may

ham

per

pain

man

age

men

t pra

ctic

e in

dep

enden

tly

of p

rofe

ssio

nals

’kn

owle

dge

.

3En

suri

ng

the

edu

cati

onal

nee

ds

of s

ocia

l ca

re p

rofe

ssio

nals

who

com

e in

to c

onta

ct w

ith

peo

ple

wit

h ch

ron

ic p

ain

are

addre

ssed

.


27

Ad

dit

ion

al I

nfo

rmat

ion

Inte

gra

tio

n o

f Pa

in S

ervi

ces

Situ

ati

ons

whe

re a

cute

pa

in s

erv

ices

an

d c

hro

nic

pa

in m

an

ag

emen

t se

rvic

esw

ill

over

lap

Key

Po

ints

~

1Sp

ecif

ic a

nalg

esic

in

terv

enti

ons

may

redu

ce t

he i

nci

den

ts o

f ch

ron

ic p

ain

aft

er s

urg

ery.

2Chr

onic

pos

t–su

rgic

al

pain

is

com

mon

, may

be s

ever

e an

d l

ead t

o si

gnif

ican

t dis

abi

lity

.

3R

isk

fact

ors

whi

ch a

re p

redis

pos

ed t

o ch

ron

ic p

ost-su

rgic

al

pain

in

clu

de

the

seve

rity

of

pre

or

pos

t-op

erati

ve p

ain

, in

traop

erati

ve n

erve

in

jury

an

d p

sych

olog

ical

vuln

erabi

lity

.

4M

an

y pati

ents

su

ffer

ing

from

chr

onic

pain

rel

ate

thi

s to

an

acu

te i

nci

den

t.

5Chr

onic

sev

ere

pain

is

com

mon

aft

er s

urg

ery

(Macr

ae

2001)

. Su

ch p

ain

may

have

a n

euro

path

ic e

lem

ent

whi

ch m

ay

appea

r ea

rly

in t

hepos

t–op

erati

ve p

erio

d.

6Chr

onic

pain

pati

ents

req

uir

ing

trea

tmen

t fo

r acu

te p

ain

pre

sen

t a s

pec

ial

challen

ge.

Inci

den

ce o

f C

hro

nic

Pai

n a

fter

Surg

ery

Typ

e o

f o

per

atio

nIn

cid

ence

%

Am

puta

tion

30 - 8

5

Thora

coto

my

5 - 67

Mas

tect

om

y11

- 5

7

Chole

cyst

ecto

my

3 - 56

Ingu

inal

her

nia

0

- 63

Vas

ecto

my

0 - 37

Adap

ted f

rom

Mac

rae

2001

, Per

kin

s an

d K

ehle

t 20

00

28

Palli

ativ

e ca

re a

nd

ch

ron

ic p

ain

Situ

ati

ons

whe

re c

hro

nic

pa

in a

nd

pa

llia

tiv

e ca

re w

ill

over

lap

Key

Po

ints

~

1The

pri

nci

ple

s u

nder

lyin

g th

e m

an

age

men

t of

chr

onic

pain

an

d t

he p

allia

tive

care

of

pati

ents

wit

h ca

nce

r ha

ve m

uch

in

com

mon

(S

IGN

Gu

idel

ine

44, N

HS

QIS

2000).

2Thi

s in

clu

des

the

pallia

tive

man

age

men

t of

non

-malign

an

t dis

ease

whe

re p

ain

may

be a

majo

r is

sue

eg

HIV

, mu

ltip

le s

cler

osis

.

3The

bes

t re

sults

are

lik

ely

to b

e ach

ieve

d w

here

the

re a

re g

ood l

ocal

lin

ks b

etw

een

pallia

tive

care

, pain

man

age

men

t se

rvic

es a

nd t

he l

ocal

com

mu

nit

y.

4A

sig

nif

ican

t n

um

ber

of c

an

cer

pati

ents

will

not

ach

ieve

opti

mal

pain

rel

ief

wit

h th

e W

HO

gu

idel

ines

eit

her

du

e to

the

dru

g or

un

acc

epta

ble

side-

effe

cts.

5Fo

r pati

ents

whe

re s

tan

dard

tre

atm

ents

have

failed

, in

terv

enti

onal

tech

niq

ues

may

be r

equ

ired

an

d r

efer

ral

to a

pain

man

age

men

t se

rvic

efo

r advi

ce w

ould

be

appro

pri

ate

(SI

GN

Gu

idel

ine

44).

Key

Ch

alle

ng

es ~

1To

en

sure

tha

t he

alth

pro

fess

ion

als

loo

kin

g aft

er s

uch

pati

ents

are

aw

are

of

the

ran

ge o

f te

chn

iqu

es a

vailabl

e an

d w

hen

the

se a

re a

ppro

pri

ate

.

2To

ach

ieve

adeq

uate

rapid

acc

ess

to s

pec

ialist

pain

ser

vice

s (M

cEw

en 2

004).


29

Det

erm

inin

g p

ain

in p

eop

le w

ho

hav

e d

iffi

cult

y co

mm

unic

atin

g a

nd

may

be

cog

nit

ivel

y im

pai

red

:b

ehav

iour

al s

ign

s

Voca

l sig

ns

Eatin

g/sl

eep

ing

Soci

al/p

erso

nalit

y

Faci

al e

xpre

ssio

ns

Act

ivity

Body

and

lim

bs

Phys

iolo

gica

l

Cat

ego

ries

Beh

avio

ural

sig

ns

Beha

viou

rs a

re u

niqu

e to

eac

h in

divi

dual

; kno

wle

dge

of t

he p

erso

n’s

‘bas

elin

e’ b

ehav

iour

is h

elpf

ul a

nd c

an a

ssis

t in

reco

gnis

ing

beha

viou

r w

hich

indi

cate

s th

e pe

rson

is e

xper

ienc

ing

pain

.

A s

pec

ific

soun

d or

voc

alis

atio

n fo

r p

ain

– a

cry

or w

ord,

eg

moa

ning

, w

hini

ng,

whi

mp

erin

g, c

ryin

g, s

crea

min

g.

Eats

less

. N

ot in

tere

sted

in f

ood.

Incr

ease

in s

leep

. D

ecre

ase

in s

leep

.

Not

co-

oper

atin

g. Ir

ritab

le.

Unh

app

y. L

ess

inte

ract

ion.

With

draw

n. S

eeks

com

fort

. Se

eks

phy

sica

l clo

sene

ss.

Diff

icul

t to

dis

trac

t.C

anno

t be

sat

isfie

d or

pac

ified

.

Cry

ing,

grim

acin

g ha

s fu

rrow

ed b

row

. Ey

es c

lose

d tig

ht,

eyes

op

en w

ide,

fro

wni

ng.

Mou

th t

urne

d do

wn,

not

sm

iling

, tig

ht p

out

or q

uive

r, cl

ench

es t

eeth

, gr

inds

tee

th,

chew

s, t

hrus

ts t

ongu

e.

Not

mov

ing,

less

act

ive,

qui

et,

jum

pin

g ar

ound

, fid

gety

, ag

itate

d.

Flop

py,

stif

f, te

nse,

has

sp

astic

ity o

r rig

idity

, ge

stur

es t

o or

tou

ches

par

t of

bod

y th

at h

urts

, p

roje

cts,

fav

ours

or

guar

ds p

art

of b

ody

that

hurt

s, f

linch

es o

r m

oves

bod

y p

art

away

, se

nsiti

ve t

o to

uch,

mov

es b

ody

in a

sp

ecifi

c w

ay –

cur

ls u

p,

head

bac

k or

arm

s m

ay b

e do

wn.

Shiv

erin

g, c

hang

es in

col

our,

pal

lor,

swea

ting,

tea

rs,

shar

p in

take

of

brea

th,

gasp

ing,

bre

ath–

hold

ing.

Adap

ted f

rom

McG

rath

et

al (

1998

).

30

Exam

ple

s o

f un

con

ven

tio

nal

an

alg

esic

s (

Ad

juva

nts

)

Tric

yclic

ant

idep

ress

ants

shou

ld b

e co

nsid

ered

for

Neu

rop

athi

c p

ain.

Sele

ctiv

e Se

roto

nin

Re-u

pta

ke in

hibi

tors

(SS

RIs)

Sero

toni

n N

orad

rena

line

Re-u

pta

ke in

hibi

tors

(SN

RIs)

Ant

icon

vuls

ants

sho

uld

be c

onsi

dere

d fo

rne

urop

athi

c p

ain.

Am

itryp

tylin

eIm

ipra

min

eN

ortr

ypty

line

Cita

lop

ram

Venl

afax

ine

Car

bam

azep

ine

Gab

apen

tin

Ther

e m

ay b

e a

redu

ctio

n in

op

ioid

req

uire

men

tre

por

ted.

Whe

n th

e p

atie

nt h

as s

usta

ined

pai

n re

lief

for

3 m

onth

s, a

slo

w d

ose

redu

ctio

n sh

ould

be

atte

mp

ted

to s

ee if

the

ant

icon

vuls

ant

coul

d be

disc

ontin

ued.

Live

r fu

nctio

n sh

ould

rem

ain

with

in n

orm

al li

mits

whi

lst

rece

ivin

g an

ticon

vuls

ant

ther

apy.

Typ

e o

f D

rug

Pres

crib

ing

no

tes/

Pati

ent

info

rmat

ion

Mo

nit

ori

ng

no

tes

❏St

art

with

a lo

w d

ose

and

grad

ually

incr

ease

.

❏Th

e an

alge

sic

effe

ct a

pp

ears

with

in t

he f

irst

few

day

s of

the

rap

y.

❏Th

ere

is a

dos

e-re

spon

se c

urve

to

anal

gesi

c ef

fect

s of

tric

yclic

antid

epre

ssan

ts.

❏C

hron

ic p

ain

may

be

an u

nlic

ense

d in

dica

tion

for

mos

t of

the

sem

edic

ines

and

the

pat

ient

info

rmat

ion

leaf

let,

whi

ch is

issu

ed a

tth

e p

oint

of

disp

ensi

ng,

may

not

con

tain

rel

evan

t in

form

atio

nfo

r th

e co

nditi

on b

eing

tre

ated

.

The

info

rmat

ion

pro

vid

ed m

ay b

e co

nfu

sin

g.

❏A

ntid

epre

ssan

ts a

nd a

ntic

onvu

lsan

ts h

ave

a si

mila

r ef

ficac

y in

the

trea

tmen

t of

neu

rop

athi

c p

ain.

C

hoic

e is

bas

ed o

n p

atie

ntfa

ctor

s an

d co

ncur

rent

med

icat

ion.

❏D

iffer

ent

antic

onvu

lsan

ts h

ave

diffe

rent

mec

hani

sms

of a

ctio

n.

If on

e is

inef

fect

ive

it m

ay b

e w

orth

con

side

ring

tria

l of

anot

her.

Exam

ple

SSR

Is a

re t

hough

t to

be

less

eff

ective

for

the

relie

f of

neu

ropat

hic

pai

n t

han

tri

cycl

ic a

ntidep

ress

ants

or

SNR

Is

(Sin

dru

p e

t al

200

5).


31

Use

of

op

ioid

s in

th

e m

anag

emen

t o

f ch

ron

ic n

on

-mal

ign

ant

pai

n

Key

Iss

ues

~

1St

ron

g op

ioid

s sh

ould

no

tbe

con

sider

ed a

s fi

rst

lin

e tr

eatm

ents

for

chr

onic

pain

.

2So

me

peo

ple

wit

h ch

ron

ic n

on-m

align

an

t pain

can

ben

efit

fro

m t

he u

se o

f or

al

opio

ids.

3Tho

rou

gh a

tten

tion

to

dia

gnos

is a

nd p

ati

ent

hist

ory

mu

st p

rece

de

an

y dec

isio

n t

o pre

scri

be o

pio

ids.

4Pati

ents

sho

uld

be

dee

med

psy

chol

ogic

ally

stabl

e w

ith

spec

ific

reg

ard

to

addic

tion

iss

ues

.

5The

per

son

wit

h ch

ron

ic p

ain

an

d t

heir

doc

tor

shou

ld a

gree

bef

oreh

an

d o

n h

ow t

o ass

ess

the

outc

ome

of t

hera

py.

6Su

stain

ed r

elea

se o

pio

id p

repara

tion

s are

the

dru

g of

cho

ice

7A

n i

mm

edia

te r

elea

se p

repara

tion

may

be r

equ

ired

to

man

age

bre

akt

hrou

gh/’f

lare

-up’ p

ain

.

8A

tri

al

of t

hera

py,

wit

h go

als

an

d e

ndpoi

nt

agr

eed b

etw

een

the

per

son

wit

h ch

ron

ic p

ain

an

d t

heir

doc

tor, s

hou

ld p

rece

de

an

y dec

isio

n t

opre

scri

be o

pio

ids

in t

he l

ong

term

.

Info

rmed

co

nse

nt

sho

uld

:

•st

ress

tha

t or

al

opio

ids

are

on

ly o

ne

part

of

the

trea

tmen

t pla

n, a

nd t

hat

data

is

lack

ing

on t

he l

ong-

term

eff

ects

of

med

ically

pre

scri

bed

opio

ids.

•cl

earl

y def

ine

spec

ific

goa

ls o

f th

e tr

eatm

ent

pro

gram

.

•w

arn

of

the

pot

enti

al

for

cogn

itiv

e im

pair

men

t w

hich

may

aff

ect

dri

vin

g abi

lity

, esp

ecia

lly

whi

le c

omm

enci

ng

opio

id t

hera

py

an

d a

rou

nd

the

tim

e of

dos

e es

cala

tion

.

•poi

nt

out

the

incr

ease

d l

ikel

ihoo

d o

f se

dati

on i

f be

nzo

dia

zepin

es a

nd/o

r alc

ohol

are

use

d i

n c

onju

nct

ion

wit

h op

ioid

the

rapy.

•st

ress

tha

t pati

ents

mu

st a

ccep

t re

spon

sibi

lity

for

:

oen

suri

ng

thei

r su

pply

of

med

icati

on d

oes

not

ru

n o

ut

aft

er h

ours

;

ose

curi

ty o

f th

eir

med

icati

on;

oke

epin

g re

view

appoi

ntm

ents

;

ou

sin

g on

ly o

ne

doc

tor

to s

upply

thi

s m

edic

ati

on.

32

•ex

pla

inth

e co

nse

quen

ces

of a

berr

an

t be

havi

our

as

clea

rly

as

pos

sibl

e.

•ex

pla

in t

he i

ndic

ati

ons

for

ceasi

ng

trea

tmen

t w

ith

opio

ids:

ola

ck o

f im

pro

vem

ent

in f

un

ctio

n, o

r ev

iden

ce o

f det

erio

rati

on i

n f

un

ctio

n;

ou

nsa

nct

ion

ed d

ose

esca

lati

on a

nd r

equ

ests

for

earl

y re

pea

t pre

scri

pti

ons;

olo

sin

g pre

scri

pti

ons;

ou

nappro

ved u

se o

f th

e dru

g to

tre

at

othe

r sy

mpto

ms.

•dis

cuss

sid

e-ef

fect

s an

d t

heir

man

age

men

t (e

g, c

onst

ipati

on, n

au

sea, s

edati

on, d

ry m

outh

, uri

nary

hes

itan

cy, a

nd d

epre

ssio

n o

f se

xho

rmon

es, w

ith

ass

ocia

ted r

isk

of o

steo

por

osis

wit

h lo

ng-

term

use

).

•th

e pos

sibi

lity

(fo

r w

omen

) of

phy

sica

l dep

enden

ce i

n c

hild

ren

bor

n t

o th

em i

f th

ey c

onti

nu

e to

take

opio

ids

in l

ate

pre

gnan

cy.


33

Spec

ialis

t Se

rvic

es:

The

Pain

Man

agem

ent

Clin

ic

Key

Po

ints

~

1R

efer

ral

to a

pain

clin

ic s

hou

ld b

e co

nsi

der

ed a

fter

appro

pri

ate

tre

atm

ent

stra

tegi

es h

ave

pro

ved u

nsu

cces

sfu

l.

2W

hen

the

pati

ent

has

dif

ficu

lt-to-

con

trol

pain

.

3W

hen

the

re a

re c

omple

x p

sych

osoc

ial

infl

uen

ces

in t

he p

ain

pre

sen

tati

on.

4Pro

fess

ion

al

role

s in

pain

man

age

men

t cl

inic

s m

ay

vary

.

At

a pai

n c

linic

, pat

ients

will

usu

ally

be

seen

by a

pai

n m

edic

ine

spec

ialis

t an

d b

e off

ered

a m

ore

com

pre

hen

sive

and s

pec

ialis

ed a

sses

smen

t th

at is

likel

y t

o b

e m

ulti-d

isci

plin

ary.

Dis

ciplin

es r

epre

sente

d v

ary,

but

may

incl

ude

spec

ialis

t nurs

ing,

spec

ialis

t pai

n p

hysi

oth

erap

ist,

pai

n m

edic

ine

spec

ialis

t, occ

upat

ional

ther

apis

t, phar

mac

ist

and c

linic

al p

ain p

sych

olo

gist

(le

vel 3)

. Pr

ofe

ssio

nal

role

s in

thes

e cl

inic

s m

ay v

ary.

The

key

to e

ffec

tive

man

agem

ent,

nam

ely a

ppro

pri

ate

asse

ssm

ent,

funct

ional

res

tora

tion a

nd a

bio

psy

choso

cial

appro

ach, u

nder

pin

any

phar

mac

olo

gica

l or

inva

sive

ther

apie

s under

taken

. T

he

ke

y t

o s

uc

ce

ss i

s p

ati

en

t in

vo

lve

me

nt.

A m

ultid

isci

plin

ary m

anag

emen

t pla

n s

hould

be

dev

eloped

for

appro

pri

ate

pat

ients

. M

edic

atio

n r

evie

w is

an im

port

ant

par

t, co

nsi

der

ing

the

appro

pri

aten

ess

of

exis

ting

med

icin

es, w

ithdra

win

g or

reduci

ng

or

intr

oduci

ng

new

med

icin

es.

This

may

be

com

ple

men

ted w

ith n

on-in

vasi

veth

erap

ies.

The

man

agem

ent

pla

n m

ay incl

ude

inte

rven

tional

ther

apie

s, but

rare

ly in iso

lation.

Good r

esourc

es f

or

info

rmat

ion a

bout

thes

e in

clude:

•A

n e

vid

ence

bas

ed r

esourc

e fo

r in

terv

entional

pai

n m

anag

emen

t w

ww

.acc

.co.n

z/ip

m

•T

he

Bri

tish

Pai

n S

oci

ety

ww

w.b

ritish

pai

nso

ciet

y.org

Key

Ch

alle

ng

es ~

1The

pati

ent

un

der

stan

ds

why

the

y are

bei

ng

refe

rred

to

the

pain

clin

ic.

2A

n a

ppro

pri

ate

med

ical

ass

essm

ent

shou

ld h

ave

take

n p

lace

.

3A

co

mp

lete

refe

rral

letter

sho

uld

be

sen

t (S

IGN

Gu

idel

ine

31).

4R

ealist

ic e

xpec

tati

ons

shou

ld b

e en

cou

rage

d.

5Tre

atm

ent

at

a p

ain

clin

ic s

hou

ld b

e lim

ited

wit

h dis

charg

e ba

ck t

o pri

mary

care

wit

h co

mm

un

ity

suppor

t w

here

appro

pri

ate

.

34

Co

mm

on

inte

rven

tio

nal

pro

ced

ures

Su

mm

ary

of

com

mo

n in

terv

enti

on

al p

roce

dur

es in

sp

ecia

list

pai

n m

anag

emen

t cl

inic

s

Mus

cle

trig

ger

sp

ots

Loca

lised

intr

amus

cula

r in

ject

ion

Neu

rom

a o

r sc

ar in

filt

rati

on

Peri

ph

eral

ner

ve b

lock

s

Join

t in

ject

ion

s

Reg

ion

al b

lock

s

Sym

pat

het

ic b

lock

s

Loca

l ana

esth

etic

with

or

with

out

ster

oid.

Botu

linum

tox

in is

som

etim

es u

sed

Loca

l ana

esth

etic

with

or

with

out

ster

oid.

Rar

ely

cryo

-an

alge

sia

Loca

l ana

esth

etic

with

or

with

out

ster

oid

Loca

l ana

esth

etic

with

or

with

out

ster

oid

With

or

with

out

opio

id

Loca

l ana

esth

etic

with

or

with

out

ster

oid

Loca

l ana

esth

etic

Loca

l ana

esth

etic

with

or

with

out

guan

ethi

dine

Pro

ced

ure

Ind

icat

ion

Co

mm

ent

For

loca

lised

myo

fasc

ial p

ain

Pain

ful m

uscl

e sp

asm

Post

-op

erat

ive

or p

ost

trau

ma

pai

n

Gre

ater

occ

ipita

l ner

ve f

or h

eada

ches

Inte

rcos

tal n

erve

for

che

st w

all p

ain

Num

erou

s ot

her

limb

and

trun

k bl

ocks

Face

t jo

ints

for

bac

kpai

nIn

tra

artic

ular

hip

inje

ctio

ns f

or o

steo

arth

ritis

Epid

ural

ste

roid

inje

ctio

ns f

or r

adic

ular

ref

erre

d p

ain,

usua

lly le

g p

ain

Stel

late

gan

glio

n in

ject

ion

for

angi

na,

Coe

liac

Plex

us B

lock

for

abd

omin

al p

ain,

eg

pan

crea

ticm

alig

nanc

y

Bloc

ks f

or C

omp

lex

Regi

onal

Pai

n Sy

ndro

me

Less

co

mm

on

pro

ced

ures

:

Epid

ural

or

intr

athe

cal d

rug

deliv

ery

syst

ems

via

sho

rt o

rlo

ng-t

erm

cat

hete

r. T

hese

can

be

adm

inis

tere

d vi

aex

tern

al p

ump

s or

by

inte

rnal

ised

res

ervo

irs.

Loca

l ana

esth

etic

O

pio

idLi

ores

al

Pro

ced

ure

Ind

icat

ion

Co

mm

ent

Mor

e co

mm

only

use

d in

the

man

agem

ent

of c

ance

r p

ain

or s

ever

e m

uscl

e sp

asm


35

COPYRIGHT

DOLOPLUS-2 SCALE BEHAVIOURAL PAIN ASSESSMENT IN THE ELDERLY

Behavioural RecordsNAME : Christian Name : Unit :

1• Somatic complaints

2• Protective body posturesadopted at rest

3• Protection ofsore areas

4• Expression

5• Sleep pattern

6• washing &/or dressing

7• Mobility

8• Communication

9• Social life

10• Problems ofbehaviour

SCORE

DATES

SOMATIC REACTIONS

PSYCHOMOTOR REACTIONS

PSYCHOSOCIAL REACTIONS

• no complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0• complaints expressed upon inquiry only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 1• occasionnal involuntary complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 2 2• continuous involontary complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3 3 3

• no protective body posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0• the patient occasionally avoids certain positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 1• protective postures continuously and effectively sought . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 2 2• protective postures continuously sought, without success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3 3 3

• no protective action taken . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0• protective actions attempted without interfering against any investigation or nursing . . . . . . . . . . . . . . 1 1 1 1• protective actions against any investigation or nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 2 2• protective actions taken at rest, even when not approached . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3 3 3

• usual expression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0• expression showing pain when approached . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 1• expression showing pain even without being approached . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 2 2• permanent and unusually blank look (voiceless,staring, looking blank) . . . . . . . . . . . . . . . . . . . . . . . 3 3 3 3

• normal sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0• difficult to go to sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 1• frequent waking (restlessness) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 2 2• insomnia affecting waking times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3 3 3

• usual abilities unaffected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0• usual abilities slightly affected (careful but thorough) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 1• usual abilities highly impaired, washing &/or dressing is laborious and incomplete . . . . . . . . . . . . . . 2 2 2 2• washing &/or dressing rendered impossible as the patient resists any attempt . . . . . . . . . . . . . . . . . . 3 3 3 3

• usual abilities & activities remain unaffected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0• usual activities are reduced (the patient avoids certain movements and reduces his/her walking distance) . 1 1 1 1• usual activities and abilities reduced (even with help, the patient cuts down on his/her movements) . . . . 2 2 2 2• any movement is impossible, the patient resists all persuasion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3 3 3

• unchanged . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0• heightened (the patient demands attention in an unusual manner) . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 1• lessened (the patient cuts him/herself off) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 2 2• absence or refusal of any form of communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3 3 3

• participates normally in every activity (meals, entertainment, therapy workshop) . . . . . . . . . . . . . . . . . 0 0 0 0• participates in activities when asked to do so only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 1• sometimes refuses to participate in any activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 2 2• refuses to participate in anything . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3 3 3

• normal behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0• problems of repetitive reactive behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 1• problems of permanent reactive behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 2 2• permanent behaviour problems (without any external stimulus) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3 3 3

Appendix 1 Examples of tools and assessment domains

Sample 1: Doloplus-2 Scale

36

Somatic complaintsThe patients expresses pain by word, gesture, cries, tears or moans.

Protective body postures adopted at restUnusual body positions intended to avoid or relieve pain.

Protection of sore areasThe patient protects one or several areas of his/her body by a defensive attitude or gestures.

ExpressionThe facial expression appears to express pain (grimaces, drawn, atonic) as does the gaze (fixedgaze, empty gaze, absent, tears).

InvestigationAny investigation whatsoever (approach of a caregiver, mobilization, care procedure, etc.).

Washing/dressingPain assessment during washing and/or dressing, alone or with assistance.

MobilityEvaluation of pain in movement: change of position, transfer, walking alone or with assistance.

CommunicationVerbal or non-verbal.

Social lifeMeals, events, activities, therapeutic workshops, visits, etc.

Problems of behaviourAggressiveness, agitation, confusion, indifference, lapsing, regression, asking for euthanasia, etc.

DOLOPLUS-2 SCALE : LEXICON


37

1 • Scale use requires learningAs is the case with any new instrument, it is judicious to test it before circulating it. Scale scoring timedecreases with experience (at most a few minutes). Where possible, it is of value to appoint a referenceperson in a given care structure.

2 • Pluridisciplinary team scoringIrrespective of the health-care, social-care or home structure, scoring by several caregivers is preferable(physician, nurse, nursing assistant, etc.). At home, the family and other persons can contribute using a liaison notebook, telephone or even a bedside meeting. The scale should be included in the 'care' or 'liaison notebook' file.

3 • Do not score if the item is inappropriateIt is not necessary to have a response for all the items on the scale, particularly given an unknown patienton whom one does not yet have all the data, particularly at psychosocial level. Similarly, in the event ofcoma, scoring will be mainly based on the somatic items.

4 • Compile score kineticsRe-assessment should be twice daily until the pain is sedated, then at longer intervals, depending on thesituation. Compile score kinetics and show the kinetics on the care chart (like temperature or blood pressure).The scale will thus become an essential argument in the management of the symptom and in treatment initiation.

5 • Do not compare scores on different patientsPain is a subjective and personal sensation and emotion. It is therefore of no value to compare scoresbetween patients. Only the time course of the scores in a given patient is of interest.

6 • If in doubt, do not hesitate to conduct a test treatment with an appropriate analgesicIt is now accepted that a score greater than or equal to 5/30 is a sign of pain. However, for borderlinescores, the patient should be given the benefit of the doubt. If the patient's behavior changes followinganalgesic administration, pain is indeed involved.

7 • The scale scores pain and not depression, dependence or cognitive functionsNumerous instruments are available for each situation. It is of primary importance to understand that thescale is used to detect changes in behavior related to potential pain.Thus, for items 6 and 7, we are not evaluating dependence or independence but pain.

8 • Do not use the DOLOPLUS 2 scale systematicallyWhen the elderly patient is communicative and cooperative, it is logical to use the self-assessment instruments.When pain is patent, it is more urgent to relieve it than to assess it ... However, if there is the slightestdoubt, hetero-assessment will avoid underestimation.

DOLOPLUS-2 SCALE : INSTRUCTIONS FOR USE

Reproduced with permission

http://www.doloplus.com

38

Sample 2: NoPain - Non-Communicative Patient’s Pain Assessment Instrument

Snow et al 2003


39

Initial Pain Assessment Tool

Date: _________________________________

Patient's name: ____________________________________________ Age: ________

Diagnosis: ____________________________________________________________________

____________________________________________________________________

Physician: _______________________________________________

Nurse: __________________________________________________

I. Location: Patient or nurse marks drawing

II. Intensity: Patient rates the pain. Scale used: ___________

Present:__________________________________________________

Worst pain gets:___________________________________________

Best pain gets:____________________________________________

Acceptable level of pain:_____________________________________

Sample 3: McCaffery and Pasero Initial Assessment Tool

40

III. Quality: (Use patient's own words, e.g., prick, ache, burn, throb, pull, sharp)

____________________________________________________________________________

____________________________________________________________________________

IV. Onset, duration, variations, rhythms:

____________________________________________________________________________

____________________________________________________________________________

V. Manner of expressing pain:

____________________________________________________________________________

___________________________________________________________________________

VI. What relieves the pain?

____________________________________________________________________________

____________________________________________________________________________

VII. What causes or increases the pain?

____________________________________________________________________________

____________________________________________________________________________

VIII. Effects of pain: (Note decreased function, decreased quality of life.)

Accompanying symptoms (e.g., nausea)_____________________________________________

Sleep_________________________________________________________________________

Appetite_______________________________________________________________________

Physical activity________________________________________________________________

Relationship with others (e.g., irritability)_____________________________________________

Emotions (e.g., anger, suididal, crying)______________________________________________

Concentration__________________________________________________________________

Other_________________________________________________________________________


41

IX. Other comments: _________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

X. Plan:_____________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

___________________________________________________________________________

____________________________________________________________________________

Note: May be duplicated and used in clinical practice Source: McCaffery and Beebe, 1989. Usedwith permission.

42

Sample 4: Patient Comfort Assessment Guide


43

44

Appendix IV (i)

SHORT FORM McGILL PAIN QUESTIONNAIRE and PAINDIAGRAM

(Reproduced with permission of author © Dr. Ron Melzack, for publication and

distribution)

Date: ______________________________________

Name: _____________________________________

Check the column to indicate the level of yourpain for each word, or leave blank if it does notapply to you.

Mild Moderate Severe

1 Throbbing _____ _____ _____

2 Shooting _____ _____ _____

3 Stabbing _____ _____ _____

4 Sharp _____ _____ _____

5 Cramping _____ _____ _____

6 Gnawing _____ _____ _____

7 Hot-burning _____ _____ _____

8 Aching _____ _____ _____

9 Heavy _____ _____ _____

10 Tender _____ _____ _____

11 Splitting _____ _____ _____

12 Tiring-Exhausting_____ _____ _____

13 Sickening _____ _____ _____

14 Fearful _____ _____ _____

15 Cruel-Punishing _____ _____

Indicate on this line how bad your pain is—at the left end of line means no pain at all, at right endmeans worst pain possible.

No ________________________________________________ Worst PossiblePain Pain

S /33 A /12 VAS /10

Sample 5: Short Form McGill Pain Questionnaire


45

Brief pain inventory goes here

��

��

� � ! " # $ % & ' ��(� )�� *�� )��

��+� ��(�

��

��

��

�� ,�� -��)��.��

� � ! " # $ % & ' ��(� )�� *�� )��

� � ! " # $ % & ' ��(� )�� *�� )��

� � ! " # $ % & ' ��(� )�� *�� )��

�� )�� *��*��*� �� *� �� -�� "��

�� )�� *��*��*� �� *� ��

�� )�� *��*��*� �� *� �� "��

�� )�� *��*�� -��-�

��

Sample 6: Brief Pain Inventory

46

%� /��

��

�0 ��0 �0 !�0 "�0 #�0 $�0 %�0 &�0 '�0 ��0(� ��1��2�� 2��

� � ! " # $ % & ' ��3�� 1��4�� 4��

5� 6��5��

� � ! " # $ % & ' ��3�� 1��4�� 4��

7� 8��

� � ! " # $ % & ' ��3�� 1��4�� 4��

1� /��5*��

� � ! " # $ % & ' ��3�� 1��4�� 4��

3� (��/�� *��-�� -��

� � ! " # $ % & ' ��3�� 1��4�� 4��

9� 2�� -��

� � ! " # $ % & ' ��3�� 1��4�� 4��

:� ;��

� � ! " # $ % & ' ��3�� 1��4�� 4��

6� 9�<��

'� 1��*�� *� ��-�� "�� -��=

&� 4�� "�� -�� )�� - ��-��

Used by permission.


47

Oswestry Disability Questionnaire This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by checking one box in each section for the statement which best applies to you. We realise you may consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem.

Section 1: Pain Intensity

� I have no pain at the moment

� The pain is very mild at the moment � The pain is moderate at the moment � The pain is fairly severe at the moment � The pain is very severe at the moment � The pain is the worst imaginable at the moment

Section 2: Personal Care (eg. washing, dressing)

� I can look after myself normally without causing extra pain

� I can look after myself normally but it causes extra pain

� It is painful to look after myself and I am slow and careful

� I need some help but can manage most of my personal care

� I need help every day in most aspects of self-care

� I do not get dressed, wash with difficulty and stay in bed

Section 3: Lifting

� I can lift heavy weights without extra pain

� I can lift heavy weights but it gives me extra pain

� Pain prevents me lifting heavy weights off the floor but I can manage if they are conveniently placed eg. on a table

� Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned

� I can only lift very light weights

� I cannot lift or carry anything

Section 4: Walking*

� Pain does not prevent me walking any distance � Pain prevents me from walking more than 2 kilometres � Pain prevents me from walking more than 1 kilometre � Pain prevents me from walking more than 500 metres � I can only walk using a stick or crutches

� I am in bed most of the time

Section 5: Sitting

� I can sit in any chair as long as I like

� I can only sit in my favourite chair as long as I like � Pain prevents me sitting more than one hour � Pain prevents me from sitting more than 30 minutes � Pain prevents me from sitting more than 10 minutes � Pain prevents me from sitting at all

Section 6: Standing

� I can stand as long as I want without extra pain

� I can stand as long as I want but it gives me extra pain � Pain prevents me from standing for more than 1 hour � Pain prevents me from standing for more than 30

minutes

� Pain prevents me from standing for more than 10 minutes

� Pain prevents me from standing at all

Section 7: Sleeping

� My sleep is never disturbed by pain

� My sleep is occasionally disturbed by pain

� Because of pain I have less than 6 hours sleep � Because of pain I have less than 4 hours sleep

� Because of pain I have less than 2 hours sleep

� Pain prevents me from sleeping at all

Section 8: Sex Life (if applicable)

� My sex life is normal and causes no extra pain

� My sex life is normal but causes some extra pain

� My sex life is nearly normal but is very painful

� My sex life is severely restricted by pain

� My sex life is nearly absent because of pain

� Pain prevents any sex life at all

Section 9: Social Life

� My social life is normal and gives me no extra pain

� My social life is normal but increases the degree of pain

� Pain has no significant effect on my social l ife apart from limiting my more energetic interests e.g. sport

� Pain has restricted my social life and I do not go out as often

� Pain has restricted my social life to my home

� I have no social life because of pain

Section 10: Travelling

� I can travel anywhere without pain

� I can travel anywhere but it gives me extra pain

� Pain is bad but I manage journeys over two hours

� Pain restricts me to journeys of less than one hour

� Pain restricts me to short necessary journeys under 30 minutes

� Pain prevents me from travelling except to receive treatment

Sample 7: Oswestry Disability Questionnaire

48

Score: / x 100 = % Scoring: For each section the total possible score is 5: if the first statement is marked the section score = 0, if the last statement is marked it = 5. If all ten sections are completed the score is calculated as follows: Example: 16 (total scored) 50 (total possible score) x 100 = 32% If one section is missed or not applicable the score is calculated: 16 (total scored) 45 (total possible score) x 100 = 35.5% Minimum Detectable Change (90% confidence): 10%points (Change of less than this may be attributable to error in the measurement) Source: Fairbank JCT & Pynsent, PB (2000) The Oswestry Disability Index. Spine, 25(22):2940-2953.

Davidson M & Keating J (2001) A comparison of five low back disability questionnaires: reliability and responsiveness. Physical Therapy 2002;82:8-24.

*Note: Distances of 1mile, ½ mile and 100 yards have been replaced by metric distances in the Walking section.


Appendix 2

Who was Involved in Developing the Statement?

Working Group

Janette Barrie Practice Development NHS QISProject Co-ordinator

Helen Cadden Lay Representative Glasgow

David Carroll General Practitioner NHS Grampian

David Craig Psychologist NHS Glasgow

Sandra Fyfe Lay Representative Pain Association Scotland

Mairi Harvey Lay Representative Argyll

Kathleen Henderson Occupational Therapist NHS Borders

Jennifer Hogg District Nurse NHS Ayrshire & Arran

Rhona Hotchkiss Head of Practice Development NHS QISChair of Working Group

Derek Jones Lecturer in Occupational Therapy Queen Margaret University College

Alison MacRobbie Pharmacist Inverness

Robin McKinlay Consultant in Anaesthesia NHS Forth Valleyand Pain Management

Fiona McPherson Clinical Nurse Specialist NHS Lothian

Mary Maghee Care Home Manager Glasgow

Gail Monteith Lay Representative Pain Association Scotland

Blair Robertson Hospital Chaplain NHS Glasgow

Mick Serpell Consultant and Senior Lecturer University of Glasgow,in Anaesthesia NHS Glasgow

Rosemary Showell District Nurse NHS Lanarkshire

Michael Souter Lay Representative Pain Association Scotland

Drummond Taylor Carer Pain Association Scotland

Jenny Williamson Clinical Nurse Specialist NHS LothianPain Management

49

50

Reference Group

Ms Dorothy Armstrong Programme Director NHS Education ScotlandDr. Clare Blackburn Chairperson National Occupational

Therapist Pain AssociationMs Ruth Clark Operations Manager Princess Royal Trust for

CarersDr. Beverly Collett President The British Pain Society

Consultant AnaesthetistMr. David Falconer Director Pain Association ScotlandMrs Aileen Hamilton Lecturer in Holistic Therapies Telford College, EdinburghMr Brian Jappy Chief Pharmacist NHS GrampianDr Pete Mackenzie Consultant Anaesthetist Royal College of

AnaesthetistsDr. Bill Macrae Consultant in Pain Medicine NHS TaysideDr. John McGarrity General Practitioner NHS LanarkshireDr. Danny McGhee General Practitioner NHS GlasgowDr. Denis Martin Research Fellow with special Sheffield Hallum

interest in Chronic Pain University Chairman, Pain Association, Scotland

Ms Tracey Nairn Dietician Care CommissionMr John Norden Lecturer in Nursing Studies Bell College, LanarkshireProfessor Ian Power Head of Anaesthesia, Critical Care The University of Edinburgh

and Pain Medicine NHS LothianDr David Reilly Medical Director Homeopathic Hospital,

GlasgowDr. Blair Smith General Practitioner The University of Aberdeen

Senior LecturerDr. Nicola Stuckey Head of Clinical Psychology NHS LothianDr Tun Than Consultant Anaesthetist NHS Western Isles Mrs. Heather Wallace National Organiser Pain ConcernDr Asad Zoma Consultant in Rheumatology NHS Lanarkshire


NHS Quality Improvement Scotland Support Team

Paula Carson Unit Secretary

Louise Foster Information Scientist

Rosemary Hector Practice Development Project Coordinator

Annie Wright Communication and Publication Officer

Further Information

For further information about NHS QIS, or to obtain additional copies ofthis best practice statement, please contact:

NHS Quality Improvement Scotland

Edinburgh Office

Elliott House

8-10 Hillside Crescent

Edinburgh

EH7 5EA

Tel: 0131 623 4300

Fax: 0131 623 4299

[email protected]@nhshealthquality.org

Copies of all NHS QIS publications can also be downloaded from the

website (www.nhshealthquality.org).

51

52

Glossary of Terms

AHP Allied Health Professions

acute pain Related to injury and resolves during an appropriate

healing period.

addiction The compulsive use of opioids or other agent to the

detriment of the user’s physical and/or psychological

health and/or social function. Signs of compulsive use

include preoccupation with obtaining opioids,

apparently impaired control over their use, and reports

of craving. These signs of compulsive use are well

established where opioids are taken not primarily for

pain relief but for effects on mood and thinking (The

Pain Society 2004).

allodynia Pain due to a stimulus which does not normally

provoke pain (IASP)

analgesia Absence of pain or suppression of pain

analgesic Substance or technique that reduces pain

BNF British National Formulary

chronic pain Pain that persists for more than 3 months or that

outlasts the healing process.

complementary Any range of medical treatments that fall beyond the

therapy scope of scientific medicine

dysaesthesia An unpleasant abnormal sensation, whether

spontaneous or evoked (IASP)

hyperalgeisa Increased sensitivity to pain or noxious stimulation

hyperaesthesia Increased sensitivity to stimulation

IASP International Association for the Study of Pain

NMC Nursing and Midwifery Council

neuralgia Pain in the distribution of a nerve

neuropathic pain Pain initiated or caused by a primary lesion or

dysfunction in the nervous system (IASP)

NHS QIS NHS Quality Improvement Scotland

nociceptive Pain Pain due to tissue damage i.e. skin, muscle, bone,

viscera

opioid A broad term that applies to any substance which

produces its effects by binding opioid receptors and

which is stereospecifically antagonised by naloxone

(Shug & Cardwell 2003)


pain An unpleasant sensory and emotional experience

associated with actual or potential tissue damage or

described in terms of such damage (IASP 1994)

paraesthesia An abnormal sensation, whether spontaneous or

evoked.

physical Is the physiological adaptation of the body to the

dependence presence of an opioid

pruritis Where irritation of sensory nerve endings leads to

localised or more general itching

sensitisation Elevated spontaneous activity in neurones, lowered

activation thresholds, and increased response to stimuli

tolerance State of adaptation in which exposure to a drug

induces changes that result in a diminution of one or

more of the drug’s effects over time. Increased doses

are then needed to get the same effect.

unconventional/ Diverse group of drugs that have a primary indication

adjuvant other than pain, but are used to enhance analgesia in

analgesics specific circumstances (WHO 2002)

WHO World Health Organization

withdrawal usually occurs when pharmacological agents eg opioids

are stopped suddenly, or an antagonist such as

naloxone or naltrexone is administered. Withdrawal is

easily avoided by gradual reduction of opioid dose

(The Pain Society 2004).

53

54

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Management of chronic pain in adults

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