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The latest approaches to pain medicine

By Dermot - 02nd Mar 2016 | 11 views

Management of chronic musculoskeletal pain was the theme of the 8th Annual Congress of the Irish faculty of Pain Medicine. The meeting was held in Dublin on 22 and 23 January 2016 and attracted over 200 healthcare professionals and scientists. The disciplines represented included: consultants, GPs, occupational health physicians, clinical psychologists, nursing, physiotherapists, occupational therapists and neuroimmunology scientists. Along with well-recognised Irish speakers, the Faculty was delighted to welcome Prof Frank Huygen, Professor of Pain Medicine and Head of the Centre for Pain Medicine at Erasmus University Medical Centre in Rotterdam, the Netherlands; Prof Bart Morlion, Leuven University, Belgium; and Dr Shyam Balasubramamian, Consultant in Pain Medicine, Walsgrave Hospital, Coventry, UK. The first day of the meeting was held in the College of Anaesthetists on Merrion Square, Dublin, and the second day in the RCSI, Dublin.

As the meeting was organised by the Faculty of Pain Medicine, College of Anaesthetists of Ireland (CAI), the programme commenced with core topic workshops for trainees preparing for the pain medicine exams. It is worth noting that the Irish Faculty of Pain Medicine established the first clinical examination in the practice of pain medicine in Europe. This is now a two-part examination resulting in the award of the Fellowship in Pain Medicine (FPMCAI) qualification and is part of the National Training Programme in Pain Medicine. This ensures that Irish patients receive the highest possible standard of care from appropriately-trained clinicians.


The trainee workshop session was followed by the Clinical Research in Pain Medicine competition. Three clinical research presentations were judged by Prof Huyden. Dr Basabjit Das from the Department of Pain Medicine, St James’s Hospital, Dublin, was awarded the Clinical Research Medal for the best clinical research in pain medicine.

This work investigated the neuroinflammatory mechanisms, which potentiate chronicity in patients with radicular pain and the potential of pulsed radiofrequency (PRF) electrical stimulation of the dorsal root ganglion to reverse those changes. Despite the wide use of the PRF, the mechanisms behind its efficacy remained poorly defined <em>in vivo</em> and this work provides perhaps the first insight into the mechanism of action of this clinically-effective treatment modality.

<h3><strong>Scientific programme</strong></h3>

Following the Clinical Research Medal competition, the first module of the meeting opened with the ‘Fitness to Work after Injury’ session. Three lectures provided insights into the insidious nature of brain concussion, the challenges facing the physician regarding fitness of the patient to return to work and the last lecture, which attracted most debate, was delivered by the solicitor Mr Aidan Flahavan of Beauchamps Solicitors. Mr Flahavan dealt with the physician’s liability in issuing the final certificates.

Dr Connail McCrory, Dean, Faculty of Pain Medicine, CAI, then opened the conferring ceremony for those candidates who were successful in the FPM examinations. The Fellowship in Pain Medicine was awarded to two doctors who passed the final examination. Five doctors passed part one of the FPM examination.

<h3><strong>RYND lecture</strong></h3>

Dr McCrory then invited Prof Huygen to deliver the 2016 RYND lecture. Prof Huygen is a world-renowned expert in the diagnosis and management of complex regional pain syndrome (CRPS) and the title of his lecture was ‘New Insights into the Pathology of CRPS’.

CRPS is a potentially disabling disease characterised by severe pain, functional impairment, sensory disturbances, vasomotor and sudomotor abnormalities. Excruciating pain and marked loss of extremity function are hallmarks of the disease and lead to restriction in activity and participation and reduced quality of life. While many treatment regimens have been suggested, no single optimal therapy has emerged. Effective pain management has consistently proven to be extremely difficult to achieve.

The estimated incidence of CRPS varies from 5.46 to 26.2 per 100,000 person years. CRPS in adults occurs slightly more often in the upper extremities. A fracture is the most common initiating event. Women are affected 3.4-to-four times more often than men.

Prof Huygen highlighted the multifactorial mechanisms behind the pathophysiology giving rise to different subtypes of the condition, requiring different treatment approaches.

Prof Huygen started the lecture series on the second day with a further expansion of his first lecture focusing on therapeutic options. He broadened his initial concepts and provided a detailed, evidence-based approach used for CRPS treatment in his institution. 

After exclusion of other diagnoses — the list of conditions mimicking CRPS is extensive — the primary treatment consists of early active mobilisation.

Physical therapy combined with pharmacological pain treatment proved superior to occupational therapy and social work therapy in randomised, controlled trials.

The next step in treatment algorithm hinges around the clinical presentation of the condition. Prof Huygen distinguished four main groups of signs and symptoms: inflammatory, vasomotor, pain/sensory and motor disorder. Depending on which type is more prominent, different treatment modalities are used as the first-line treatment.

Inflammatory symptoms of the disease are treated with anti-inflammatory drugs; vasodilators are used to treat vasomotor symptoms of the disease, motor disorder symptoms may improve with spasmolytics and muscle relaxant therapy, and pain sensory symptoms may be treated with standard analgesic regimens. The issue remains the degree of response to pharmacological therapy. A common clinical observation is that the initial response to pharmacological therapy is not sustained.

Interestingly, the role of sympathetic blockade is being critically assessed. While sympathetic blockade was traditionally offered at the beginning of the interventional treatment programme, evidence for the long-term effectiveness of this modality of treatment is limited. Spinal cord stimulation can be considered if everything else fails, however the evidence supporting its efficacy is only moderate at best. Therefore CRPS remains a major clinical challenge.

<h3><strong>Joint replacement</strong></h3>

The next lecture of the day was delivered by Dr Balasubramamian. The topic was the medical management of chronic pain patients awaiting joint replacement. He provided a summary of the available treatments and the main message could be summarised with the phrase ‘start low and go slow’, as opioids and other medications used for treatment have significant side-effects, particularly in the elderly population. Finding the dose regimen with the optimal risk/benefit profile for the patient remains the goal of therapy.


The next session started with a lecture delivered by Prof Jim Meaney, Consultant Radiologist at St James’s Hospital, Dublin, who reviewed the main features of radiological spine assessment, with the main focus on MRI. This was a most informative lecture. Prof Meaney highlighted the potential pitfalls in scan interpretation and emphasised the importance of clinical assessment and correlating the scans with clinical findings.


The next lecture was delivered by Ms Helen O’Leary, HRB Clinical Research Fellow. It was titled ‘Amplification of the Pain Experience in Osteoarthritis and Chronic MSK Pain by Peripheral and Central Pain Mechanism — Implications for Practice’. Chronic pain is maintained by central sensitisation. This may explain why some patients do not experience a positive response to pain treatment and joint replacement.


The last module of the meeting opened with Prof Morlion, whose clinical research focuses on the organisational aspects of multidisciplinary pain management.

He stressed the fact that evidence suggests that the prevalence and societal burden of chronic pain are underestimated, and the appropriate treatment is not always instituted or adequate. Another important point made was that apart from the pain specialists, physiotherapists, psychologists and other medical specialties should also be involved in decision-making for managing chronic pain, and their roles within multimodal pain management should be defined more clearly. Pain teams and pain units within the hospital are cost effective and although conditions are chronic, improvement and savings can be made by appropriately staffed pain clinics.

<h3><strong>Neuropathic pain</strong></h3>

The final lecture was delivered by Dr Conor Hearty from the Mater Hospital, Dublin, who summarised the available knowledge in the management of neuropathic pain (see article on page 35). Dr Hearty presented the pharmacological and interventional regimens used to treat neuropathic pain in his institution.


Dr McCrory chaired the final session of the meeting, which was the Patient Forum. Members of the Irish Patients Association as well as members of the public attended this session. Dr Brendan Conroy (Vice Dean), Dr Hearty (Secretary) and Dr David O’Gorman (treasurer) took questions from the audience. This session was very informative for all.


Dr McCrory then closed the meeting, thanking all the speakers, sponsors, in particular Mundipharma and Grünenthal as main sponsors, Ms Carol Manweiler from Cielo as event organiser and the staff of the CAI and RCSI for their significant contributions to the success of the meeting.

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