Interdisciplinary and multispeciality investigation and management in specialised abdomino-pelvic pain centers

Transcription

1 Interdisciplinary and multispeciality investigation and management in specialised abdomino-pelvic pain centers Andrew Paul Baranowski The Urogenital and Visceral Pain Management Centre

2 Interdisciplinary and multispeciality investigation and management in specialised abdomino-pelvic pain centers Andrew Paul Baranowski The Urogenital and Visceral Pain Management Centre

3 Key documents that influenced my thinking: Sir Liam Donaldson. Pain - Breaking through the barrier. The Chief Medical Of?icers Annual Report, 2008 Health Survey for England, Chapter 9: Chronic Pain BPS / Dr Foster, National Pain Audit, Prostate Cancer Alcohol Antimicrobrial resistance Safety Pain Baranowski AP, Johnson M, Price C, et al. British Pain Society Pain Patient Pathway Maps in conjunction with Map of Medicine, 2012 Baranowski A, Paul, Abrams P, Berger R, et al. Visceral and other pain syndromes of the trunk other than spinal and radicular pain - GROUP XXIII: CHRONIC PELVIC PAIN SYNDROMES Classi?ication of Chronic Pain. Descriptions of Chronic Pain Syndromes and De?initions of Pain Terms, 2012 Engeler S, Baranowski A, Elneil S, et al. EAU Guidelines on Chronic Pelvic Pain, 2012 Baranowski AP, Abrams P, Fall M. Urogenital Pain in Clinical Practice. New York: Informa Healthcare, 2008 Baranowski AP, Ward J, Harris J, et al. NHSCB, Clinical Reference Group, Specialised Services for Pain Management England, 2012

4 Levels of Health Care in England Tertiary Specialised Care Secondary Hospital Care Community Care General Practice

5 BPS guidelines for Investigation and management in the community

6 The role of Diagnosis in the Pain Management Centre investigations for symptoms must be requested by individuals with the skills to organise, interpret and act on them BPS Maps of Medicine Guidelines 2012

7 Pelvic pain - primary care Medicine > Pain management > Pelvic pain Care map information Self care management and patient education Pharmacological information Chronic pelvic pain presentation History Examination Investigations in primary care Consider differential diagnosis RED FLAG! Refer to specialist care (within 2 weeks) R Chronic pelvic pain (CPP) No well-defined condition - consider differential diagnosis Go to pain - initial assessment CPP well-defined condition - consider rereferral to specialist Chronic pelvic pain syndrome (CPPS) System specific

8 BPS guidelines for Ix community when considering investigations it is sensible to avoid unnecessary repetition as that may have a negative impact on the patient's expectations of management simple tests such as swabs and cultures, e.g. mid stream urine (MSU), HVS, and Chlamydia simple investigations, for example U/S for dysmenorrhea, MRI for pelvic masses KUB, Barium studies, endoscopy, USS, CT/MRI may be available if in doubt discuss appropriateness with radiologist or relevant specialty more complex investigations such as urodynamics, ano-rectal physiology, and formal pelvic floor muscle assessments to investigate function may require specialist referral

9 CPP well-defined condition - consider rereferral to specialist Chronic pelvic pain syndrome (CPPS) Refer to specialist System specific symptoms R Develop management plan Physical intervention Psychological considerations Pharmacological intervention Reassess patient (routine review 8-12 weeks) Refer to pain management centre Refer to specialist urogenital pain management unit On-going management in primary care Go to pelvic pain - specialist care Published: Valid until: Printed on: 14-Jun-2012 Map of Medicine Ltd This care map was published by. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

10 Generalist Pain Management Centre is a pain management unit that does not have a specialist in pelvic pain such units may exist in a primary care setting but are more commonly under the banner of secondary care increasingly the divide is changing with specialists in pain medicine interfacing at a primary care level

11 Specialised Pain Management Centres 10% of NHS budget ( 11 billion) for all specialised services Deliver interdisciplinary and multispeciality pain assessment, management and rehabilitation by appropriately trained pain specialists Patients with complex pain and pain associateddisability Provide complex pain interventions Provide training for pain management specialists working in secondary and community care settings Operate in an dedicated pain management environment Collect pain management specific outcome data to inform future developments, engage in research Referrals are usually from secondary or tertiary care

12 Natasha APB Maya UGP Ali Jamie Barbara?Maya General and Spinal Facial MDT Jo Sam Neurological disease Paul Sam Neuromodulation Paul APB? Maya Brigitta APB Ali UCLH / ITP

13 Interdisciplinary An interdisciplinary team is an integrated working group where each individual (which should include: physicians, psychologists, physiotherapists, specialist nurses, and access to others such as pharmacists and occupational therapists, cross cover should be available indicating that there must be at least 2 persons able to provide the service) has a high level of expertise in different aspects of management of patients with complex pain. There is appropriate accommodation, support and administration support for this team. Members of the team would work closely together through joint clinics and interdisciplinary / multidisciplinary Team (MDT) meetings and agree management plans with patients and GPs.

14 Multispeciality A multispeciality pain team is a team of speciality experts that represent different specialities involved in the assessment and management of pain and associated illness. Members of a multispeciality pain team would be determined by the specific group of specialist patients and the members of the multispeciality team could include: anaesthetists, neurologists, oral specialists, gynaecologists, uro-gynaecologists, urologists, rheumatologists, psychiatrists, oncologists, palliative medicine, spinal surgeons, orthopaedic surgeons, paediatricians, as appropriate. Members of the team would all work closely together, through joint clinics and multispeciality meetings/mdts as appropriate; they would develop and agree a pain management plan with the patient, the referral team and GP that would include an ongoing review.

15 Pat Wall said Don t forget the old research Wells JC, Miles JB. Pain clinics and pain clinic treatments. Br Med Bull Jul;47(3): Abstract Chronic pain is multi-factorial, and consequently a multidisciplinary approach is essential for its proper management. Pain Clinics may treat acute pain, chronic pain and cancer pain, and need to differentiate between these different conditions. Careful diagnosis and assessment is essential, including history, examination, questionnaires and relevant investigations. A variety of treatments exist to manage chronic pain, some of which have already been discussed in this issue. Treatments may be summarized as drugs, surgical (including nerve blocks), stimulation techniques, psychological techniques and general or physical measures. If a Pain Relief Unit has the ability to provide all of these types of treatment, then it can manage any type of pain, with the ability to relieve pain and improve quality of life greatly in a significant number of sufferers.

16 Pat Wall said Don t forget the old research Wells JC, Miles JB. Pain clinics and pain clinic treatments. Br Med Bull Jul;47(3): Abstract Chronic pain is multi-factorial, and consequently a multidisciplinary approach is essential for its proper management. Pain Clinics may treat acute pain, chronic pain and cancer pain, and need to differentiate between these different conditions. Careful diagnosis and assessment is essential, including history, examination, questionnaires and relevant investigations. A variety of treatments exist to manage chronic pain, some of which have already been discussed in this issue. Treatments may be summarized as drugs, surgical (including nerve blocks), stimulation techniques, psychological techniques and general or physical measures. If a Pain Relief Unit has the ability to provide all of these types of treatment, then it can manage any type of pain, with the ability to relieve pain and improve quality of life greatly in a significant number of sufferers.

17 The Pain Management Physician Diagnostician pain mechanisms pelvic floor, urological, colorectal, gynae etc. Ix pain associated distress and disability associated dysfunctions Therapist complex drug manipulation interventions (injection and neuromodulation)

18 Diagnostician - Pain Mechanisms Arendt-Nielsen L, Petersen-Felix S. Wind-up and neuroplasticity: is there a correlation to clinical pain? Eur J Anaesthesiol Suppl May;10:1-7. Abstract It is neurophysiologically and neurobiologically verified that the central nociceptive system can undergo changes and become hyperexcitable. Hyperexcitability involves wind-up (exaggerated responses) of dorsal horn neurones which in humans can be studied (temporal summation) by electrophysiological and psychophysical reactions to repeated nociceptive stimuli. Temporal summation occurs if repeated stimuli evoke increasing pain reactions. Human experimental models are adequate to investigate basic aspects and pharmacological modulation of summation and to bridge the gap between basic and clinical sciences facilitating the transfer of knowledge from basic science into the clinic. Human experimental investigations have confirmed animal studies that show that central summation is a potent mechanism in both normal and pathophysiological (hyperexcitable) conditions. Central summation should be considered as a target for the development of new centrally acting analgesics, for designing management regimens to treat intractable pain, and as a possible way of inhibiting surgically-induced afferent barrage from reaching brain centres (subconscious pain) during anaesthesia.

19 John Jarrell, Maria Adele Giamberardino, Magali Robert, and Maryam Nasr- Esfahani. Bedside Testing for Chronic Pelvic Pain: Discriminating Visceral from Somatic Pain. Pain Res Treat. 2011; 2011:

20 The Pain Management Physician and investigation Trigger point assessment MRI spine and pelvis 3T MR Neurography Pudendal and other NCS / EMGs Flow and pressure urodynamics, videocysto mictogram Defecting proctograms (MRI, CT, Fluroscopy) Urethral sphincter pressure and EMGs

21 The role of Diagnosis in the Pain Management Centre investigations for symptoms must be requested by individuals with the skills to organise, interpret and act on them BPS Maps of Medicine Guidelines 2012

22 The Pain Management Physician Drugs opioids, neuropathic, ketamine, lidocaine Interventions CT, US and x-ray guided Neuromodulation

23 Predisposing factors genetics psychological state recurrent somatic trauma Causes surgery trauma infection Peripheral nerve injury Peripheral sensitisation Abnormal peripheral afferent signalling Increased peripheral afferent signalling Central Sensitisation Abnormal central afferent signalling Abnormal central efferent signalling Abnormal central processing Consequences include: sensory problems Consequences include: changes in organ function Psychological, behavioural and sexual consequences Regional and systemic changes referred pain, viscero-visceral hyperalgesia, viscero-somatic hyperalgesia. Trophic, autonomic, endocrine and immunological responses