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NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - AUTUMN 2004


FROM THE EDITOR Anyway, that’s enough from me. To save an overview of pain service priorities within
another rant from appearing in the next issue the limited resources of the NHS.
Welcome to the latest edition of Threshold, please send any contributions for Threshold
newsletter of the North British Pain (all will be printed) to me at the address below. Acute Pain: Continuing efforts as being
made to forge links with the Scottish Acute
Association. Read on for up to date
Dr. Colin P. Rae Pain Interest Group. Margaret Baggit, Clinical
information on the activities of the NBPA,
Nurse Specialist at Edinburgh Royal
information on forthcoming events, the usual Consultant in Anaesthesia and Pain
Infirmary, has been co-opted to NBPA
gossip and pictures of Council members Management,
Council. There is a plan for reciprocal
caught unawares. Sponsorship for Threshold Department of Anaesthesia, representation from the NBPA.
for 2004/5 is being provided by NAPP Stobhill Hospital,
Pharmaceuticals and we are indebted to them. 133, Balornock Road, Website: This continues to be developed
Thanks again to Pfizer for their support over Glasgow. by Dr Alan Semple. It provides information
2003 and 2004. G21 3UW about forthcoming meetings, links to other
Is there anything you find frustrating Tel. No. 0141 201 3005 pain-related websites and past issues of
about working in pain management? Is there Fax. No. 0141 201 4167 Threshold can be downloaded.
anything you think could be done better? Email colin.rae@northglasgow.scot.nhs.uk
Possibly, quite a few things? Ever get annoyed Website www.nbpa.ac.uk Election of Council Members: Dr Ruhy
by waiting times? Patients do. I don’t just Parris is standing down as Secretary having
mean when your clinic is running late, I mean served on Council since 1998. Dr. Alan
Semple has resigned as Treasurer after serving
for first and return appointments. Imagine if DATES FOR YOUR DIARY for several years. He will remain on Council
there were no waiting times. After all, we’re
Spring Scientific Meeting (Palliative Care) as representative for Forth Valley. Nursing
here to provide a service, aren’t we? Give the representative, Sister Ann Kelly, has also now
best deal we can to people with chronic pain? Friday 6th May 2005
retired. Thanks were given to all three
Make a difference? Provide that seamless Winter Scientific Meeting outgoing colleagues. Proposers and seconders
patient journey through pain management Friday 11th November 2005 were received for the replacement Council
services with multi disciplinary assessment members. Dr Mike Basler, Consultant
and individually tailored management. Closing date for NBPA Essay competition Anaesthetist, at Glasgow Royal Infirmary
Appropriate interventions provided before, or 31st January 2005 becomes the new Secretary, Dr Janet
alongside a pain management approach, Braidwood, Consultant Anaesthetist at
resulting in an individual empowered by their Borders General Hospital, new Treasurer and
new knowledge and able to self-manage their REPORT FROM AGM – 7/5/04 Dr Andrea Harvey, Consultant Anaesthetist at
chronic condition without medical Aberdeen Royal Infirmary, new Membership
intervention. Wow, that would be good The minutes of the previous Annual Secretary. Mrs Lisa Henderson was elected
wouldn’t it? They may even have attended a General Meetings were accepted as read. as the new nursing representative, but as since
had to resign as she is now working for Pain
Pain Management Programme.
Chairman’s Report: Dr Nicola Stuckey Association Scotland. Dr Jonathan Bannister,
The real world? I don’t think so. More
reflected on the two successful meetings held Consultant Anaesthetist at Ninewells Hospital,
likely is the ongoing treatment plan that is Dundee as the Tayside Area Representative.
taking a long time due to waiting times and in the last year, the Spring Scientific Meeting
“Pain in conflict” and the Winter Scientific Special thanks were given to Sandra Lee,
inefficient communication between secondary Secretary at Glasgow Royal Infirmary Pain
Meeting “An inflammatory view of pain”.
and primary care. Then there are the hidden Both meetings had been well attended and the
waiting times to see other pain team members feedback received positive. Suggestions of
such as physiotherapy or clinical psychology. themes for future meetings can be sent to any
It is amazing how quickly you stop Council member.
noticing the deficiencies in the service you
provide. The very deficiencies that are Threshold Report: The newsletter
glaringly obvious to patients, newcomers to continues to provide a focus for members’
the specialty and those who have worked in activities and a chance to keep up to date with
other healthcare systems. developments within the Association. Colin
I have great admiration for colleagues who Rae continues as Editor.
have worked in chronic pain management for
many years. They have worked hard to Scottish Parliament: The NBPA has been
improve the situation, remain optimistic and asked to send representatives from Council to
have only a healthy degree of cynicism. I hope future meetings of the Cross Parliamentary
Group on Pain. Several NBPA members have
I can say the same in a few years time.
already attended this group and at the last
meeting Dr. Michael Basler, then Membership Ruhy Parris is presented with flowers
Secretary of NBPA, gave a presentation giving by Nicola Stuckey
Management Clinic who has continued to asking if they can have this new wonder
provide secretarial support to the NBPA and treatment.
Council particularly in the organisation of Brian reviewed the indications for spinal
meetings. cord stimulation and the conditions for which
it is most likely to be successful. Good
Research Group: Mick Serpell presented indications seem to be neuropathic leg or arm
a report on behalf of the Research Group pain following lumbar or cervical spine
which comprises of Ian Comrie, Mike Basler, surgery, complex regional pain syndrome,
Denis Martin and Ian Power. There is now a neuropathic pain secondary to peripheral
research database of NBPA members. nerve damage, pain associated with peripheral
Research activity is being encouraged. Funds vascular disease and refractory angina. Poor
are available for primary research projects. results have been found with phantom limb
Submissions for the NBPA essay competition Dr. Pete MacKenzie and Mr. Brian Simpson pain, facial pain, spinal cord injury pain,
could include original research. perineal pain and genital pain. Spinal cord
interviews on several occasions. The title of stimulation is expensive and there is a drive
IT Sub-Group: Dr Robin McKinlay made his lecture was “What is consciousness” to obtain evidence of effectiveness.
a presentation on behalf of this group. He started by asking, “How can millions A small number of studies have been
Members include Andrea Harvey and Jonathan of neurones produce experience and performed. Six on critical limb ischaemia, four
Bannister. The subgroup suggests that the consciousness?” He pointed out how difficult on refractory angina and one each on failed
NBPA be clearly seen as the professional voice it is, even now, to define consciousness. There back syndrome, complex regional pain and
of pain management. The idea is to encourage are scientific and philosophical perspectives. diabetic neuropathy.
meaningful data collection across the North Consciousness includes wakefulness,
British Pain Association region, which is awareness and experience. The areas of the
required for Clinical Governance. The hope brain associated with consciousness are the
is to perform an initial survey to record the thalamus and the upper brain stem. A survey
present set-up. Different methods of achieving of medical students revealed that a sizeable
data collection and audit will be assessed. number believed that the mind and soul were
Funding sources will be addressed and the separate from the brain and there was a belief
plan will be to work towards a minimum in life after death. This is startling considering
dataset. Constructive comments are requested. their scientific teaching. Brain function can
be monitored with an EEG. During sleep,
Financial Report: outgoing Treasurer, Dr different patterns occur during different stages
Alan Semple, presented this. The bank of sleep and also during Random Eye
balance in January 2004 stood at £41,141.21. Movement (REM) sleep. Normally during
REM sleep, the body is paralysed. There can,
however, be an overlap with either NBPA East of Scotland Team photo
Secretarial Report: Fourteen new
members across the disciplines have been sleepwalking (still asleep but able to move)
There are obvious blinding issues with
accepted and two members have moved out or sleep paralysis (awake but unable to move).
these studies and difficulty eliminating the
of the area and terminated their membership. One of the most fascinating and illuminating
placebo effect. Many studies use 50% pain
areas in the research of consciousness is
relief as an endpoint, which many would
Prize Essay: Four entries have been following brain injury. This sad event can give
argue, is too strict. Many treatments for
received this year. The judging panel was Dr an insight into the role of the damaged area
chronic pain do not achieve this degree of pain
Nicola Stuckey, Professor Ian Power and of the brain. Different states are produced
relief. Dr. Simpson argued that simple pain
Dennis Martin. The winner of the prize for following brain injury including coma,
scores do not give the whole picture. Chronic
the year is Stephen Feltbower, a Medical vegetative state, brain death and ‘being locked
pain is poorly remembered and also prompts
Student at Edinburgh University. He will be in’. As technology advances, there is interest
the memory of previous pain. There is
invited to present his work at the forthcoming in the possibility of using functional MRI or
variability in the time of a patient’s pain and
Winter Scientific Meeting. PET scanning to more accurately locate the
snapshot assessments may give the wrong
areas of brain associated with consciousness.
impression.
One method of trying to eliminate some of
THE 2005 PRIZE ESSAY these problems is to switch off the stimulator
COMPETITION for a period of time, perform pain scores, then
recommence stimulation and repeat the scores.
The 2005 Prize Essay Competition will be Pain relief in the order of 10% - 15% is most
announced at the Winter Scientific Meeting. commonly reported.
Entrants must write an essay on the topic “The Coffee was followed by a talk from Dr Kim
Far Side of Pain”. The prize is £2000 to fund Jobst, Consultant Physician and Medical
a trip to the IASP World Congress in Sydney Homeopath based in Hereford. His talk
with £1000 as a runner up prize for the “Integrated Medicine: The Road Forward” was
meeting. The closing date will be 31st January passionate, reflective and personal. He
2005. Watch out for more information on the reviewed how mainstream and alternative
website. Flyers will be circulated. Entries will healthcare is provided today in the United
be judged by a panel who will decide if the Dr. Kim Jobst and Dr. Adam Zeman Kingdom.
entries are of a high enough standard to award Kim firmly believes that the integration of
the prize. Self-consciousness is a concept within the complementary and alternative practice into
idea of consciousness. It is the awareness of mainstream medicine is the only way forward.
being aware. To have knowledge about oneself There are a large number of complementary
REPORT FROM SPRING and awareness of stimuli impinging on your and alternative medicines available and the
own body. It is the basis of uneasiness in social public spend a vast amount of money on it.
SCIENTIFIC MEETING situations. Why is this? Many factors are involved but
- “NEEDLES AND PINS” This was a very thought provoking start to dissatisfaction with the medical establishment
- FRIDAY 7/5/04 the day. The next lecture was equally thought is one of the main causes. A common
provoking but on a completely different topic. perception is that doctors will simply promote
Dr Peter McKenzie from the Southern Dr Brian Simpson, a Consultant the use of drugs and surgery against patient’s
General Hospital in Glasgow expertly chaired Neurosurgeon from the University Hospital of wishes. Doctors have also been under attack
the morning session. Wales in Cardiff, gave the next lecture. Dr in the media. In 1998, JAMA published a
Dr Adam Zemen, Consultant Neurologist Simpson, a graduate of Cambridge University, paper reporting serious adverse drug reactions
and Senior Lecturer at the Edinburgh Institute qualified at the Royal London Hospital. He in routine hospital practice in the USA. They
of Neuro-Sciences gave the first lecture. He is married, has two daughters and a passion found that iatrogenic causes were between the
is married (to another Neurologist) and has for motor racing. fourth and sixth commonest cause of death in
three children. Of note, he completed a degree His lecture was on spinal cord stimulation, hospital. This study was well publicised.
in philosophy prior to entering medical school. which has received an increasing profile In America, 629,000,000 visits were made
He is a prominent figure in the world of recently. Many a patient has arrived in the to complementary and alternative medicine in
neurology and has been invited to give radio clinic clutching an article from the Daily Mail 1997 compared with 427,000,000 visits in
1990. Over the same time period there has used to give a prognostic indicator of the is already severe, then it may be too late for
been no change in the number of visits to efficacy of radiofrequency denervation of the this procedure(sounds like a bit of a get out
primary care. median branch. Radiofrequency denervation clause to me!).
Kim believes that integration of has been performed since approximately 1974. The next talk was given by Dr John Brown,
mainstream and alternative medicine will be The duration of effect is variable but is usually Consultant in Anaesthesia and Pain
led by patient demand. There are four basic more prolonged than local anaesthetic and Management at Gartnavel General Hospital,
models of integrative care with varying steroid block. Many uncontrolled trials have Glasgow on “Acupuncture review : “Beauty
degrees of regulation and an emphasis of shown between 60% and 90% incidence of and the Beast”.
power shift from the professional back to the pain relief. There are also a limited number He started with an overview of the Chinese
patient. There are, however barriers to of trials that show continuing improvement at and Japanese origins of acupuncture, and its
integration, such as a lack of credible research six and twelve months. subsequent westernisation. Traditional ideas
and ignorance amongst referring physicians. involved in acupuncture are those of a vital
A lack of profession standards and energy with circulation of Qi. There may be
competition amongst providers does not help a deficiency or an excess of Yin and Yang.
matters. Meridians run throughout the body, which can
Despite these obstacles, Kim firmly be stimulated by acupuncture needles. The
believes that integration will and must happen. western approach to acupuncture is orientated
Dr. Janet Braidwood chaired the afternoon towards musculo-skeletal pain. Modern
session. Dr Nick Padfield from St Thomas’ acupuncture varies between either the
Hospital, London spoke on “Pain: traditional or the western. Traditional Chinese
Interventional Techniques – Who do they acupuncture may also include heating and
help?” Interventional techniques are intended herbs whereas Japanese traditional
to reduce the physical sensation of pain. The acupuncture may involve massage. Western
practitioner and the patient, however, can acupuncture can include musculo-skeletal
perceive their purpose differently. Invasive Drs Jonathan McGhie and Andrew Jarvie trigger point injections and periosteal
procedures do not address the psycho-social stimulation. There may also be hi tech
issues associated with chronic pain and should The next procedure to be discussed was equipment augmentation such as TENS,
be considered as one part of an overall IDET (Intradiscal Electrothermal electro-acupuncture and laser. Despite the
management plan. There followed an overview Annuloplasty) , a procedure for discogenic long history of acupuncture, there is still no
of different interventional techniques, which pain (is that pain from dancing??). It is a new evidence for the existence of meridians at
Dr. Padfield uses in his everyday practice. procedure that provides an alternative to more present.
invasive surgical procedures for patients who Acupuncture studies have multiple
suffer from back pain caused by certain types methodological faults. However, there is good
of disc problems. It has become possible due evidence that acupuncture can help both
to the development of electrothermal catheters dental pain and temporo-mandibular joint
that allow careful and accurate temperature pain. There is little evidence to support its
control. The procedure works by cauterising use for neck pain but increasing evidence that
the nerve endings within the disc wall to it can help low back pain. There is no
reduce pain transmission. The procedure is evidence that acupuncture will help
minimally invasive and can be performed as osteoarthritis.
an outpatient. Dr Brown then gave an overview of the
The IDET process takes about an hour to local audit that he has conducted at Gartnavel
complete and is done as follows: General Hospital. He questioned 150 patients
• The procedure is performed with a local receiving regular acupuncture. He asked them
Drs. John Brown, Bob Leckridge
anaesthetic and mild intravenous how much relief acupuncture gave with 88%
and Nick Padfield
sedation saying it was excellent. The average duration
The first area he addressed was that of facet • A hollow introducer needle is inserted of effect was 5.2 weeks and patients attended
joint injections versus blockade of the nerve into the painful lumbar disc space using for treatment approximately every 5.6 weeks.
supply to the facet joint, i.e. median branch a portable x-ray machine for proper This is one of the problems of an
block. It has not been demonstrated that pain placement acupuncture clinic. It becomes a victim of its
relief following successful facet joint injection • An electrothermal catheter (heating own success with increasing number of people
correlates with successful outcome of facet wire) is then passed through the needle requiring regular acupuncture “top ups”.
joint denervation. Despite this, widespread and positioned along the back inner In the future, there should be an assessment
practice is to continue to perform peri- wall of the disc (the annulus), the site of the health economics of acupuncture versus
articular facet joint injections. Median branch believed to be responsible for the other therapies. Statutory regulation of
block which blocks the nerve supply to the chronic pain providers of acupuncture should be an aim.
facet joint has been shown to be prognostic. • The catheter tip is then slowly heated As in many other areas, there is a need for
Facet joint injections are commonly performed up to 90 degrees Celsius for 15-17 quality research into the effects of acupuncture
but there are no agreed criteria for this minutes that addresses the difficulty of providing a
procedure. It is true that facet joints may have • The heat contracts and thickens the suitable control group
osteoarthritis within them and that they can collagen fibers making up the disc wall,
be damaged by trauma. Can these injections thereby promoting closure of the tears
work? Evidence base is a problem. A and cracks. Tiny nerve endings within
systematic review found only three well- these tears are cauterized (burned),
designed trials. There was no evidence of short making them less sensitive
or long-term efficacy but studies were small • The catheter is removed along with the
and therefore underpowered. Facet joint needle and, after a short period of
injections and median nerve blocks are often observation, the patient goes home
• A lumbar support is worn for 6 to 8
weeks, followed by an appropriate
course of physical therapy. Lifting and
bending precautions are necessary
during this time to allow for adequate
healing of the disc. Drs Adam Zeman, Bob Leckridge, Mhoira Leng,
The hope is that this procedure will reduce James Campbell and Nicola Stuckey
the incidence of disc surgery. The source of
pain should be confirmed by imaging and by Dr. Bob Leckridge, from the Homeopathic
provocative discography. The best Hospital in Glasgow, gave the last talk of the
investigation to perform is T2 weighted day. He originally worked in General Practice
sagittal MRI, which gives the best view of the but moved to work full time in homeopathy
discs. The MRI scan should also exclude and is currently President of the Faculty of
adhesions and nerve root involvement and Homeopathy.
other pain generators such as facet joint Homeopathic remedies are a system of
Lisa Henderson and Anne Hay arthritis. Unfortunately, if disc degeneration medicine based on three principles:
1. Like cures like PAIN NEWS AND GOSSIP
2. Minimal Dose
The remedy is taken in an extremely Kath Smith has just resigned as
dilute form; normally one part of the physiotherapy representative on Council. We
remedy to around 1,000,000,000,000 are grateful for her contributions over the
parts of water. years. Caroline Hoskins, pain management
3. The Single Remedy physiotherapist at Stobhill is leaving the field
No matter how many symptoms are of pain management and taking up a post as a
experienced, only one remedy is taken, specialist orthopaedic physiotherapist at
and that remedy will be aimed at all Gartnavel General Hospital. She will be
those symptoms. greatly missed. Lisa Henderson has left her
Success is thought to be fuelled by several post as Chronic pain sister for North Glasgow
factors: Hospitals to take up a career with Pain
• When the correct remedy is taken, Association Scotland. We wish her all the best.
results can be rapid, complete and Three new clinical psychologists have been
permanent. appointed in Glasgow to Gartnavel General,
• Homeopathy is safe. Even babies and Glasgow Royal and the Victoria Infirmary.
pregnant women can use Homeopathy These appointments were desperately needed Alan Semple, Anne Kelly and Mick Serpell
without side effects. Homeopathic and will take some of the pressure off over-
remedies can also be taken alongside stretched colleagues.
other medication without producing
unwanted side effects.
• Homeopathy is natural. Homeopathic
remedies are normally based on natural
ingredients.
• Homeopathy works in harmony with
your immune system, unlike some
conventional medicines which suppress
the immune system.
• Homeopathy is holistic. It treats all the
symptoms as one, which in practical
terms means that it addresses the cause,
not the symptoms. This often means
Janet Braidwood and Nicola Stuckey
that symptoms tackled with
Homeopathy do not recur. Andrea Harvey, Mike Basler and Ruhy Parris

I apologise again for the Glasgow slant, but


I did ask for news from the regions and there
doesn’t seem to be any because I didn’t get
any replies!
The report from Professor McEwan on pain
management services is still awaited.
There has been a spate of pain days
recently. I hope you all enjoyed Global Pain
day on the 11th October and National Back
Pain Week, which was the 11th-15th October.
Enjoy the photos in this issue. You never
know, you might make it into the next one!
Best wishes for the festive season. Speak to
Dietmar Hartmann & co enjoying the sun! you soon. Ed Anne Kelly and Adam Zeman

CAPTION COMPETITION

The winner of last issues Caption Competition is Andrea Harvey


from Aberdeen with:-

“…Califorian Pain Guru demonstrates the latest devices and


therapies coming to a clinic near you soon:
1/ UVB deep brain stimulation helmet
Submissions for this issues competition of Brian Simpson enjoying himself
2/ Rose tinted retinal biofeedback enhancers
at a certain Moroccan restaurant frequented by Dr. Parris should send entries
3/ Hockey-pockey core stabiliser manhipulation
to me, preferably by email at the address on the front cover.
4/ Herbal podiatry using Sandi-agi-toe ticklefeetium
For a free demonstration, contact Dr P MacKenzie at
Mackenziewhatdoyoulooklike.com”