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.

ii. Antidepressant drugs, especially the tricyclic antidepressant amitriptyline, have a long history of use for neuropathic pain. Amitriptyline has a number needed to treat in the range of 2–3. That is one patient in two or three will have a 30–50% reduction in pain depending upon the study. It has been shown to be superior to placebo for neuropathic pain of diabetic painful neuropathy and postherpetic neuralgia and it is thought that would be the case for all neuropathic pains. As you might expect, the drug may produce significant benefit for an individual, but be of no help for many others. The fact that drugs are not cures but often only take the edge off the pain, needs to be emphasized. Selective serotonin reuptake inhibitors are thought not to be as effective as the tricyclics but may be considered when side effects from the tricyclics are a problem. Citalopram may be a consideration if there is anxiety. The selective noradrenaline reuptake inhibitor duloxetine is said to be effective for neuropathic pain and is gaining widespread acceptance in various guidelines. As it may have a role in stress incontinence it may also be useful for pelvic pain with a significant bladder irritability. However, duloxetine is an example of the difficulties we may face with prescribing complex drugs. Duloxetine has National Institute for Health and Clinical Excellence, England, UK (NICE) guidelines approval for diabetic neuropathic pain and formulary approval for stress urinary incontinence (SUI) in Europe and Canada. It did not gain FDA approval for SUI because of concerns about suicidal thoughts as well as lack of concerns about efficacy. Suicidal ideation has been associated with other drugs as well (Patorno et al. 2010).

iii. Antiepileptic drugs. Gabapentin and pregabalin are the two most commonly prescribed for pelvic pain, though oxycarbazepine, carbamazepine, topiramate and phenytoin may be considered. The dose of gabapentin in one study was 3.6 g a day, well above the recommendation within the British National Formulary. Whether pregabalin has any advantage over gabapentin is debated. However, it is often prescribed as a trial if side effects are seen with gabapentin. See above with respect to suicidal ideation.

iv. Strong opioids. There is a big move towards using stronger opioids in chronic pain conditions. However, the risks of doing so are still not fully evaluated. There are certain rules that must be adhered to and these can be found at several websites such as the British Pain Society http://www.britishpainsociety.org/book_opioid_patient.pdf. The salient features are that:

Opioid prescription should involve two professionals, usually a pain medicine consultant and the patient’s family doctor.

The drugs should only come from one source, usually the family doctor supported by the specialist.

Slow- or modified-release preparations should be used in preference to rapid-onset of action drugs as the slow or modified drugs are less likely to be associated with addiction (though dependence will always be an issue). Slow-release morphine is the gold standard, though this has been debated and some specialists prefer oxycodone or fentanyl.

A contract should be drawn up with the patient and if the patient exhibits evidence of drug-seeking behaviour consideration to discontinuing the prescription or involving the advice of a drug dependency team should be given. Pseudo addiction is where the patient exhibits addictive behaviour because of a lack of analgesic effect and this must be considered.

The prescription must be reviewed on a regular basis and it is considered prudent to consider a therapeutic trial of effect (possibly an intravenous drug trial) before considering long-term prescription.

v. Other drugs that may be considered in a pain management centre: NMDA antagonists (ketamine and amantadine), cannabinoids (Sativex) and sodium channel blockade (intravenous lidocaine, mexiletine). Intravenous phentolamine may be considered as a trial of sympathetic blockade.

b. Injection type therapy (Dickson & Humphrey 2008): somatic and autonomic nerve blockade. Rarely if ever is there justification for neurolytic blockade. Injection therapy appears to be best when combined with a holistic approach involving physiotherapy and psychology. Somatic nerves that may be blocked include those supplying the anterior part of the pelvis (ilioinguinal, iliohypgastric and genitofemoral) and those arising in the posterior pelvis (pudendal, perineal branches of the posterior femoral and cluneal nerves). These may be blocked at multiple sites from their source in the spine to the peripheral branches. Appropriate imaging and neurotracing technology should be considered. National Institute of Health and Clinical Excellence (NICE) guidelines suggest that ultrasound guidance should be used for peripheral blocks where appropriate. Otherwise fluoroscopy/X-ray guidance and in certain cases computed tomography should be considered. The evidence base that injections cure is limited; however, injections can reverse certain pathologies (such as local inflammation or reduce scar tissue). They can have a role in the management of muscle trigger points. Here, as with any hands-on treatment, maintenance of the positive effect can be an issue. It has been suggested that botulinum toxin may prolong the effect. Similarly, peripheral injections may transiently reduce central sensitization, and a technique of pulsed radiofrequency neuromodulation may prolong the effect. (For further details see Chapter 8.2.)

c. Neuromodulation such as the use of implanted neurostimulators (British Pain Society 2005). NICE has published guidelines on the use of spinal cord stimulation for neuropathic pain: http://www.nice.org.uk/nicemedia/pdf/TA159Guidance.pdf. The problem with conventional spinal cord stimulation and CPP is successfully stimulating the right area so that the neuromodulation stimulus is perceived in the painful area. One way to achieve this is by retrograde stimulation where the stimulating electrode is passed in a retrograde direction from the entry point. Usually spinal cord stimulation is said to have its effect by stimulation of the dorsal horn, the retrograde electrode being adjacent to the preganglionic roots. The effect of this difference is not known. What is known is that transforaminal sacral root stimulation (usually S3) can have an effect on bladder and bowel function. S3 stimulation is recommended by NICE for both faecal and urinary incontinence under specific circumstances: http://www.nice.org.uk/nicemedia/pdf/ip/IPG099guidance.pdf; http://www.nice.org.uk/nicemedia/pdf/ip/IPG064guidance.pdf. Sacral root stimulation probably acts at the dorsal root ganglion level or possibly on the peripheral nerve. Work in patients with pelvic functional disorders and coincidental pain suggests that S3 neuromodulation may reduce the pain. A trial of peripheral nerve evaluation is easy to undertake with a simple unipolar electrode being available for S3 stimulation. This is our unit’s preferred way of exploring neuromodulation in a patient and then considering either a full S3 implant with a tined lead (a lead with flanges to reduce the chance of movement and 4 electrodes to allow maximum chance of maintaining stimulation) or going on to the more complex retrograde trial and possibly full implant with that technology. The systems are essentially like a pacemaker with the electrode being attached to an internalized pulse generator. The more sophisticated pulse generators can be programmed by an external hand-held device and some may even be recharged externally. (Refer to Chapter 8.2 for further information regarding neuromodulation.)

d. Explanation and support. Often the patient will have been given a lot of misinformation and the most influential person in the team who can address this is the medical consultant.

The role of the psychologist

As with any discipline, psychologists may have different training. Pain management psychologists have specific training in the management of those aspects of psychology most likely to require attention in a pain patient. A urogenital pain psychologist, as well as dealing with mood and other emotional disorders associated with pain such as anger and catastrophizing (Rabin et al. 2000, Sullivan et al. 2006, Nickel et al. 2008), will manage sexual disorders (Binik & Bergeron 2001) and help with socializing, work issues and functional problems (Drossman et al. 2003). They may refer on for specific problems such as post-traumatic stress associated with rape or torture. A referral to a psychiatrist may be necessary. The main emphasis is on quality of life rather than pain reduction – simplified, the patient may either be in pain and distressed or in pain and have fewer emotional problems and an increased quality of life. There is no doubt that access to psychology must be a priority for the complex pelvic pain patient (see Chapter 4).

The role of the clinical nurse specialist or nurse consultant (Cambitzi & Baranowski 2009)

Senior nursing staff play a key role in co-ordinating care as well as running their own specialist clinics (e.g. TENS, neuromodulation programming and follow-up, sleep hygiene, education, drug reduction). They are often the cornerstone of any pain clinic team.

The role of the physiotherapist

Different physiotherapy approache include: hands-on manipulation including patient self-management (Weiss 2001), stretching, pacing and exercise programmes (with and without pelvic floor electromyography) (Hetrick et al. 2006). Physiotherapists have an important role in the behavioural aspects of management (Hetrick et al. 2003, Nederhand et al. 2006). Much of this will be covered in Chapters 9, 11, 12 and 13.

The pain management programme

A cognitive-behavioural approach to pain management has some of the strongest evidence base for improving quality of life but less of an effect on pain (Eccleston et al. 2009). This approach is usually run by physiotherapy and psychology with contributions from nursing and medical doctors. There is little evidence to suggest whether individual or group programmes are better; however, the latter are more cost-effective. Similarly, there is little evidence to support a specific group urogenital programme as being better than a generic programme but that would be logical and is what we run at our centre. In general, pain management programmes appear to be the most helpful for those patients for whom physical treatment options have been tried and little progress made. As a consequence, traditionally the role of the chronic pain physiotherapist and psychologist has been to manage those patients who are no longer receiving medical interventions. However, it is generally accepted that earlier intervention by these specialists may help to prevent many of the problems associated with the chronicity that the chronic pain patient has to face. It has therefore been the main aim of our group to introduce patients at an early stage to our psychologists and chronic pain physiotherapists to provide individualized one-to-one programmes where possible.