PainSA academy is an initiative set up by PainSA to educate professionals from all health care spectrums in the complicated field of pain. Specific focus is on chronic pain and its many faces… The Durban leg saw a number of talks presented by Anaesthetists, Psychiatrists, a Physio and a Chiro.
Dr Carel Cairns mentioned a few cool nemonic to use during a case history. SOCRATES can be used to check that you’ve asked all pertinent questions and stands for Site, Onset, Character, Radiation, Association, Time, Exacerbating/relieving, Severity. TUNAFISH is used as a check for red flags. Trauma, Unexplained weight loss, Neurologic symptoms, Age greater than 50, Fever, IVDU, Steroid use, History of CA. Another interesting note was the definition of acute and chronic pain, chronic pain specifically being long standing, the pathology is typically unclear, and unpredictable and requires a multidisciplinary team to manage.
Dr Velasquez touched on a few stats including the prevalence of chronic pain. It was quite scary to see that the prevalence of chronic pain is sitting at 26% compared to the likes of Diabetes Mellitus (7%), chronic heart disease & stroke (6%) and Cancer at 0.4%. Pretty scary stuff considering how much research, resources and money goes into the big 3… Interdisciplinary communication was also touched on and seemed to run as a theme throughout the day. Its vitally important that professionals communicate with each other and their patients especially when it comes to management of chronic pain! Dr Velasquez shared a quote from a Pontypool CNMP focus group that sums up the impact of chronic pain in peoples lives:
“Chronic pain turns a life into a mere existence. The effects are devastating and often demeaning. It has a negative impact on relationships, inside and outside the home. It involves the loss of independence, dignity and control”
Dr Yashana H made an important point about measuring pain. We need to stop focusing on the quantity of pain reduction and look rather at the quality of reduction and the impact it has on improving a patients quality of life. There are many outcome measures which can be used more effectively depending on the type of pain being measured. For acute pain unidimensional measures such as the VAS and NRS seem to be valid but when it comes to chronic pain more detailed analysis is necessary including the evaluation of yellow flags, which tend to predict poorer outcomes if not addressed adequately. The MPQ, short form MPQ, DN4 (specifically for neuropathic pain), and the brief pain inventory seem to be the best to cover these bases, and are more multidimensional in assessment.
Dr Porter presented a really nice talk on the link between chronic pain and depression and the viscous cycle we all know exists between chronic pain, depression, sleeplessness and anxiety and how we really need to address all the aspects if we hope to have a positive outcome with our patients. Again a multi and ideally interdisciplinary approach is key! We know there is a link between chronic pain and depression but the exact details are vague. Dr Porter touched briefly on the neuroanatomical link i.e. that depression and chronic pain stimulate similar areas in the brain (hypocampus, amygdala and cingulate gyrus). Interestingly there has been shown to be a reduction in grey matter in these areas in patients with chronic pain as well as patients with depression. The good news is that through appropriate management this can be reversed. On a neurochemical basis there are shared neurotransmitters i.e. serotonin and noradrenaline that are reduced in both depression and chronic pain. It makes sense then that based on these anatomical and chemical connections between chronic pain and depression that patients with chronic pain respond to SNRI therapy and tricyclic antidepressants. Less efficiency is seen with SSRI as this targets only one neurotransmitter. Also important to add is the effective management of sleep hygiene, another common denominator that popped up more than once through the day.
Dr Kamalin Govender closed off the day with an ethics talk and put in front of us a quote which i thought was worth sharing and something to really think about…
“…from the age of Hippocrates to the present time, the annals of every civilised people contained abundant evidences of the devotedness of medical men to the relief of their fellow creatures from pain and disease…” -American Medical Association 1847-
The talks in general were really only an introduction to the complexity of the pain epidemic we face and aimed at providing food for thought for health care professionals who continue to struggle to understand this problem. It really isn’t something that can be understood in one day but rather over a long period of time with persistent continued learning and clinical experience. Reference to and familiarisation with the latest research findings is also paramount in being at the forefront in offering hope to patients with chronic pain.
