Multispeciality and multidisciplinary practice: A UK pain medicine perspective

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8.1 Multispeciality and multidisciplinary practice: A UK pain medicine perspective

As discussed in Chapters 1 and 3, several groups have tried to tackle the issue of defining chronic pelvic pain (CPP), and the Pain of Urogenital Origin (PUGO) Special Interest Group of The International Association for the Study of Pain (IASP) are currently proposing the following:

Chronic Pelvic Pain Syndrome (CPPS) is a sub-division of CPP and is the occurrence of CPP where there is no proven infection or other obvious local pathology that may account for the pain. It is often associated with negative cognitive, behavioural, sexual and emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction.

The implications of the above for clinical management are huge. Essentially pain perceived to be both chronic and sited within the pelvis is associated with a wide range of causes and associated symptoms that must be investigated and managed in their own right. For this to occur, patients with CPP must have access to the appropriate resources through multispeciality (e.g. urology, urogynaecology, gynaecology, neurology and pain medicine) and multidisciplinary (e.g. medical doctor, nurse, psychology and physiotherapy) teams (Baranowski et al. 2008).

Multispeciality and multidisciplinary practice (Baranowski et al. 2008)

In this chapter the term speciality refers to the team and the term discipline to the training and background of the individuals within the team. What has to be recognized is that individuals of a discipline working within different specialities will have different skills and experience.

Patients with chronic pain will have to go through two processes:

1. Diagnostic and treatment of specific diseases (Fall et al. 2008);

2. Identification and management of symptoms that are ongoing (Baranowski et al. 2008, Fall et al. 2008).

This chapter focuses primarily on those conditions where we are looking at the second stage: identification of troublesome symptoms and their management. However, it is worthwhile to emphasize the negative prognostic aspect of multiple investigations and inappropriate treatment supposedly aimed at diagnostic and treatment of spurious specific diseases (Abrams et al. 2006).

The medical teams

Very little work has been undertaken looking at the phenotypes of those patients with no specific disease process presenting to different teams because of where the symptoms are perceived/focused. However, it is suggested that there is much overlap in the patient characteristics in those patients seen, for example, by a urologist as compared to a gynaecologist.

At the end of the day many patients will end up in the chronic pain management centre where the medical doctors are experienced in the management of ongoing, persistent pain. The more complex CPP patients may be referred to a specific pelvic pain/urogenital pain management centre.

In our urogenital pain management centre, all patients are initially assessed by a chronic pain consultant with a primary interest in urogenital pain as well as by a clinical nurse specialist. The initial consultation takes the form of a structured history, a range of health questionnaires (psychological and disability based, such as BPI, PSEQ, self-efficacy, DAPOS), clinical examination and review of past investigations. Following an in-depth explanation the patient is triaged to one or more of the following: psychology, physiotherapy or a specific multispeciality clinic as well as receiving medical management.

The multispeciality clinic

Whereas the pain consultant is best able to manage the pain symptoms, input from other specialists, such as urologists (Fall et al. 2008), urogynaecologists, gynaecologists, neurologists, colorectal physicians (Emmanuel & Chatoor 2009), is important for other symptoms.

These joint clinics are invaluable for team education which helps us to manage the simpler non-pain problems and also to identify those issues that may require a more complex work-up and management plan from the joint clinic.

The multidisciplinary team and clinic

Within our pain management centre we have a specific team of urogenital physiotherapists, psychologists, nurses and clinicians. We have regular meetings to discuss our patients as well as access to multidisciplinary clinics where several members of the team may meet up with an individual patient and their significant others. Such an approach ensures a consistent message and reduces the chance of misunderstanding within the team.

The exact role of a team member in managing the patient will depend upon training and experience. Inevitably there will be some overlap.

The role of the pain medicine consultant

1. Diagnosis:

a. To ensure specific disease processes have been identified and managed as appropriate. The medical consultant may consider onward referral if further investigation and medical management appear necessary.

b. Identify the pain mechanisms that are present (Vecchiet et al. 1992, Giamberardino 2005, Baranowski & Curran 2008). Most information will be achieved from a good history and full examination. However, there may be a role for specialist techniques such as differential neural blockade, intravenous drug challenges, imaging, muscle electromyographs and nerve conduction studies.

2. Triage to other team members.

3. Medical management of pain mechanisms (Baranowski et al. 2008):

a. Specialist drugs (Chong & Hester 2008): neuropathic analgesics (e.g. tricyclics and other antidepressants, anticonvulsants, sodium channel blockade, N-methyl-D-aspartate (NMDA) antagonists, α-blockade). Many of these drugs have a limited evidence base for the management of pelvic pain and as such these drugs should only be initiated in pelvic pain by an experienced practitioner in the field.

i. The mainstream simple analgesics are usually prescribed prior to the patient presenting at the pain management centre. These drugs will include simple analgesics such as paracetamol (acetaminophen), the non-steroidal anti-inflammatory drugs and simple opioids such as codeine. The evidence base for these in CPP is limited, though the role of non-steroidal anti-inflammatory drugs in dysmenorrhoea is well established.

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