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