Chronic pain is often defined as a pain that lasts for more
than 3 months. It is often considered a disease of the brain. Patients of
chronic pain present with a constellation of signs and symptoms with often and ill-defined
pathophysiology. It usually consists of a heterogeneous group of patient
population suffering from various kind of central nervous system disorder. The
disease may lead to a complex presentation involving sensory, emotional,
cognitive, modulatory and autonomic changes.
Managing such a patient and pain clinic requires an overall
care of the patient’s constant pain in question, focusing on successful control
of pain (acute on chronic and chronic) along with consideration of the
distressful symptoms of the disease, prevention of side effects and therapeutic
modalities while keeping the patient comfortable.
Pain management is thus an interdisciplinary subject
requiring health care members working as a team. Each member contributes a
unique blend of knowledge and clinical practice in the care of patient.
Effective pain control results in decreased morbidity and mortality as well as
an improved patient satisfaction with healthcare.
Apart from the disease process itself that initiated the
pain, chronic pain is influenced by a combination of genetics, stress, behavioural,
cultural and emotional factors. A persistent pain of long duration can cause
changes in the nervous system thus making the pain a distinct chronic disease
by itself. It can then lead to certain other symptoms like depression, anxiety
as well as decreased physical activity.
Management of a chronic pain patient should start at Primary
health care level. Primary health care forms the first point of contact of an
individual with the healthcare system. The need of the hour is to train the
staff, to make them better educated in understanding pain and its various
causes and to collaborate with pain specialists in case of persistence of pain
despite treatment.
Setting up a pain
clinic
Bonica has been credited with the development of modern
multidisciplinary pain clinic. He was an anaesthetist working at an army
Hospital in the USA following World War II and is considered as father of
modern pain management. He observed that patients with causalgia responded well
to nerve blocks whereas, others with more chronic pain problems did not. Bonica
discussed about his patients with other specialists in related fields to arrive
at a diagnosis and a treatment plan was charted out thus, making his efforts a
multidisciplinary approach which was later found to be more effective and
efficient.
Pain clinic
Pain clinic is usually an OPD based service where patients
with pain who are not incapacitated and do not need continuous assessment on a
daily basis are seen. The basic aim here is to treat the patient’s pain and not
the underlying disease. Therefore a thorough evaluation from various
specialities is a prerequisite before referral to a pain clinic.
there are different types of pain clinics like single
modalities clinic using ‘nerve block’; acupuncture; electrical nerve
stimulation; physiotherapy’ counselling etc. In this case specialists from a
single stream man the clinic.
Pain clinic can be syndrome oriented like ‘low back pain’ or
‘headache’ clinic.
Multidisciplinary pain clinics treat various pain syndromes
when they present. They often have facility for keeping a patient admitted for a procedure. They play a more active role in patient management as
compared to procedure based clinics.
A pain Clinic can function on its own or it may be a part of a larger Institution like a Medical College or a Hospital.
Members of the pain
management team
Being an interdisciplinary subject professionals from
various streams are part of the team which include anaesthesiologist,
rheumatologist, physiatrist, orthopedician, neurologist, neurosurgeon and
psychiatrist. The team should be headed by a team leader.
An anaesthesiologist is in a unique position to coordinate
with other specialities. The ability and skill to interact with members of the
team, expertise in the technical skill to administer sedation and pain relief
propels him to be a leader. In practice the success of continuing the program
is usually based on anaesthesiologist and psychiatrist whereas other medical
specialists contribute as required.
Auditing
It is mandatory to audit the efficacy of the service
frequently depending on the policy of the institution. It can be used as a tool
for learning in addition to improving the quality of service.
Some chronic
conditions presenting to the pain clinic
Non malignant
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Acute herpes zoster
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Post herpetic neuralgia
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CRPS 1 and 2
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Sympathetic mediated pain
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Diabetic neuropathy
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Phantom pain
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Vasomotor rhinitis
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Myofascial pain syndrome
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Fibromyalgia
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Low back pain
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Failed back syndrome
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Headache
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Lumbago
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Frozen shoulder
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Plantar fasciitis
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Urogenital pain
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Chronic pelvic pain
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Post-surgical pain
Malignant pain
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Cancer pain with or without bony secondaries
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Terminally ill cancer patients
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AIDS patient
