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Hot topic tutorial with Huw Evans. F Machado August 2003.

Why? Huw identified this a possible Hot Topic.

Pre tutorial Cases 

1. Case. Mrs P, a 60 year old lady comes to see you as the kapake tablets are no longer controlling her arthritis in her back, knees and hands. Investigaitons in the past have not indicated an inflammatory cause and x-rays have suggested “mild degenerative” changes in her back and knees” She has tried numerous analgesics which either have side effects or do not cure the pain.

What is your approach here.

2. Ouline the management of a patient with chronic back pain.

Reading.

Click on links to read original articles.

BJGP 2001 Editorial Chronic pain: a challenge for primary care.

Main messages:  

• Problem: Morbidity high, difficult to treat, patients often achieve sub therapeutic response to management.
• Frustrating for both patients and doctors
• CP defined as “pain which has persisted beyond normal tissue healing time” > 3 months?
• CP seen as a maladaptive response, which is often subjective and influenced by physical, psychological, social and emotional factors that need to be considered in the management of patients.
• Management of acute pain deals with cause while management of chronic pain must also focus on effects of pain
• Specific cause often difficult to find and classifications often labelled by site, Chronic pelvic pain may have a number of aetiologies which often overlap.

Prevalence

• Underestimated as few studies in community
• More common in women, in older age and low income groups
• Community studies have suggested a prevalence of 5-40% depending on country.
• 21% in Manchester in England.
• Many have mild symptoms but 16% of cases reported severe pain and 28% had sought advice recently

Impact of Chronic pain.

• CP associated with poor general health, depression, disability, unemployment and family stress
• These will interact and augment disability
• CP leads to depression, makes pain worse, e.t.c.
• Need to consider economic costs to:
• Individuals
• NHS
• Society

  Implications for management in primary care

• Need to develop a holistic view
• Need to look at treatment goals
• Treat pain?
• Improve quality of life
• Analgesia is only one of the options for GPs
• Often need a multidisciplinary approach
• PAMS
• Social services
• Employers

  Chronic Pain. A Primary Care Condition. ARC. 2002.

  Same author as editorial in BJGP.

  Reinforces the information from the editorial and in addition has the following messages:

• Prognosis is poor. Once a pain has chronic pain, likely to keep it. Therefore need to be realistic with treatment goals and also try and prevent it.

  Diagnosis and assessment

• Need to exclude and treat “treatable conditions”
• But there is evidence that patients who accept their pains chronicity, rather than seek a cure, fair better with therapeutic interventions.
• Need to assess degree of pain ? using formal pain score that can provide some indication of how successful treatment is.
• Need multidimensional assessment and treatment. May require assessment in hopsitla pain clinics but too many patients for facilities and so many will be managed in GP
• GP in good position over time and several consultations to assess effects of pain

  Management

• Need to agree goals e.g return to work
• Cure may not be an achievable cure

  Drug

• Analgesic ladder
• Co analgesics
• TCA and anticonvulsants
• Co morbobidty e.g. drepression
• PAMS
• Support

  Rehabilitative model of management is often appropriate.

Rehab is often the aim of management rather than “cure”

The following have a role:

• Assessment
• Education
• Improving physical condition
• Recovery or maintenance of activities
• Relaxation and sleep management
• Medication reduction
• Improving mood and confidence
• Improving social functioning
• Improving socio-economic circumstances

Self help groups often provide help, advice and support.  

What about complementary therapy. No evidence as such but research may help in the future.

Managing chronic pain in children and adolescents. BMJ 2003 28 june.

Editorial.  

• Common, 15% of children, F>M peak age 14.
• Examples , headache, abdo pain and musculoskeletal pain.
• Often “over” investigated
• Often no cause found, leading to frustration between family and doctor
• Terms such as functional pain are often misinterpreted as pointing the finger of blame at the family
• May lead to chronic disability, psychological distress, school refusal, and social withdrawal as well as causing an increase in family stress
• Treatments are often extrapolated from adult studies
• Cognitive work has been shown to help In the management of chronic headache but it is not clear that what it effect it has on disability
• Chronic pain if it does not respond to first line treatment will require interdisciplinary management but this is difficult to come by.
• Need more research
• CP children like to develop into CP adults with effects on individuals and society.

Feedback and comments to Fran Machado

Fm 27/08/2003