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NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - AUTUMN 2002

FROM THE EDITOR: you would like covered, please send them in the costs of research projects are available. An
t o a d d r e s s b e l o w. A n y p h o t o g r a p h s , outline of the proposed study should be sent to: -
We l c o m e t o t h e a u t u m n e d i t i o n o f embarrassing or otherwise, suitable for the
Threshold. I would like to thank Janssen Cilag caption competition would be much Dr. Mick Serpell,
for sponsoring this issue of Threshold. Many appreciated. Consultant Anaesthetist,
thanks to A. Menarini for sponsoring the last Department of Anaesthesia,
issue. Post them to: - Gartnavel General Hospital,
Great Western Road,
It seems a long time since Ruhy Parris Dr. Colin Rae Glasgow.
casually dropped a small bombshell into our Department of Anaesthesia,
conversation over a cup of coffee. “How do Stobhill Hospital,
you fancy being the new Editor of Threshold, 133 Balornock Road,
Glasgow.
Colin? You’d be good.” Immediate panic. “No
G21 3UW NBPA Competition 2003
I wouldn’t be.” I thought, desperately thinking
Tel no: 0141 201 3005 - PRIZE £750
of an excuse. Seeing the determined look on
Ruhy’s face, I quickly decided that even Fax no: 0141 201 4167
Email: The closing date for this years competition
pretending I am dyslexic wuoldn’t be enuohg.
Colin.Rae@NorthGlasgow.Scot.NHS.uk is March 31st 2003. This competition is open
Could I really be an Editor? It sounded good.
NBPA web-site: http://www.nbpa.org.uk to everyone. To enter, please submit one of the
Editor of Threshold! Why shouldn’t I be able
following to a maximum of 3,000 words.
to do it? Well, English was my worst subject
at school. I don’t suppose that will matter.
1. An essay on a pain related topic, OR
There is that tendency I have to leave
2. The report of completed audit or research
everything to the last minute. Mmmmm. It’s
project, OR
only twice a year though. It’s a challenge. Yes,
3. A case report
I’ll do it!!
Entries should be sent to: -
Well, here we are, several months later.
Dr Ruhy Parris,
It’s nearly midnight and the pressure is
Consultant in Anaesthesia and Pain
beginning to tell. Ruhy is a hard act to follow.
Management,
I know you’ll go easy on me for the first
NHS Dept. of Anaesthesia,
couple of issues while I learn the ropes. By
Walton Building,
then, I’m sure I will have another excuse
Glasgow Royal Infirmary.
prepared…….
G4 OSF
Ruhy Parris and Colin Rae, outgoing and
On a more serious note, we are all indebted incoming Editors of Threshold
to Ruhy for her hard work over the last four
years as Editor. I am sure that you will agree
she has done an excellent job. Her journalistic MINUTES OF THE
flair, style and red lipstick will be sorely
EIGHTEENTH ANNUAL
missed. She will, however, still grace the
pages of Threshold in her new role as NEWS FROM GENERAL MEETING
Secretary of the NBPA. NBPA COUNCIL OF THE NORTH BRITISH PAIN
ASSOCIATION,
It has been a busy year since the Spring Council would like to remind everyone that
POLLOCK HALLS, UNIVERSITY
Scientific Meeting with many developments membership of the NBPA is open to
in the North British Pain Association. Many undergraduates of all specialties. Membership OF EDINBURGH
of you (the lucky ones) have been on a long forms can be downloaded from the NBPA web- Friday 10th of May 2002.
haul trip to San Diego to the IASP Congress. site.
Dr. Lisa Manchanda, winner of the 2002 Chairman’s Report: Dr Murray
NBPA Essay Competition, has sent in some Travel grants are available to attend Carmichael started by welcoming everyone to
photographs from the congress, which will be meetings or work abroad and applications the meeting. He announced that since the
used at a later date for caption competitions - should be sent to Dr. Alan Semple at Falkirk departure of Dr Dil Kapur for a sabbatical in
so be warned! and District Royal Infirmary. Australia, the post of Secretary was in a
transition phase and records were not entirely
If there are any articles you would like to The research group of the NBPA would like available (in Dil Kapur ’s luggage). As a
submit to Threshold, suggestions, or topics to publicise that grants of up to £1000 towards consequence, the minutes of the AGM of 11th
May 2001 would be tabled at the next meeting.
Dr Serpell was acting temporary Secretary until
the post could be filled.
He then summarised the past year. The AGM
last May on the Economics of Pain and the
Autumn meetings had both been well attended.
At the last AGM, MSP Dorothy Grace Elder
had voiced her support for Chronic Pain services
in Scotland and indeed had tabled a discussion
of it in the Scottish Parliament in March. This
produced a great amount of interest, which
resulted in the highest ever number of hits to
the Parliamentary website. One issue, which
arose, was the fact that, although Pain was a
speciality with a formal training pathway under
the Royal College of Anaesthetists, it did not
have a Koerner number (unlike England &
Wales). This may hamper its recognition and
allocation of recourses in the health services.
This point had been made to the Health Minister
and there was to be a meeting with her in the
next few weeks.
Dr. Lisa Manchanda had won the trainee
prize competition with her essay “Is Surgery
the Answer?” and was awarded expenses of
£750 to attend a pain meeting of her choice
(IASP, San Diego, of course!).
Murray Carmichael congratulates Lisa
Manchanda, winner of the NBPA Essay
Competition 2002-10-08
Financial Report: Dr Alan Semple thanked
the pharmaceutical trade for their support at
these meetings. He then presented the accounts
for the year to February ’02. The current
financial position remains healthy with assets
of £29,385. He had deposited £ 20k into a higher
interest account, which requires a notification
time of 3 months. The accounts were proposed
for approval by Dr Carmichael and seconded
by Dr Macrae.
Threshold: Dr Ruhy Parris was retiring
from her position as Editor of “Threshold” and
would be replaced by Dr Colin Rae. She was
thanked for her hard work and high standard of
journalism.
Research Group: Dr Mick Serpell
summarised the recommendations of a steering
group, which had been formed to encourage
research activity within the NBPA membership.
A.O.C.B. Dr Carmichael announced that
several new council members were required to
replace the departure of Drs. Kapur, McCubbin,
Stuckey and Liz Mcleod. Also, the position of
Secretary was vacant. Members were asked to
consider nominations over lunchtime. At the
start of the afternoon session proposed new
council members were all accepted by acclaim.
A list of the new NBPA council is given
below.
Council Membership of NBPA - May 2002
Chairman
Dr Murray Carmichael
East Scotland - Anaesthesia
Secretary
Dr Ruhy Paris
West Scotland - Anaesthesia
Treasurer
Dr Alan Semple
East Scotland - Anaesthesia
Threshold
Dr Colin Rae
West Scotland - Anaesthesia
Membership Secretary
Dr Mike Basler
West Scotland - Anaesthesia
Council Members
Dr Mick Serpell
West Scotland - Anaesthesia
Dr Dick Davidson-Lamb
NE Scotland - Anaesthesia
Dr Mhoira Leng
NE Scotland – Palliative Care
Sister Anne Kelly
NE Scotland - Nursing
Dr Janet Braidwood
East Scotland – Anaesthesia
Mrs Kath Smith
North England - Physiotherapy
Dr Lyndia Green
West Scotland – Clinical Psychology
Dr Danny McQueen
East Scotland - Pharmacology
SCIENTIFIC MEETINGS
The theme of the Winter Scientific meeting
on Friday 22nd November 2002 is “Hard Nuts
to crack”. A good follow on from the last
meeting on “Urogenital Pain”!
The theme of the Spring Scientific Meeting,
Friday 9th May 2003, will be “Pain and
Conflict”.
Both meetings will be held at the usual
venue, John MacIntyre Building, Pollock Halls,
Edinburgh.
REPORT FROM SPRING
SCIENTIFIC MEETING
Friday 10th May 2002,
Pollock Halls, Edinburgh
There was an excellent attendance at the
Spring Scientific Meeting on Urogenital Pain.
RDG Medical, NAPP Pharmaceuticals,
Pharmacia, Pfizer, Chiesi and Elan
Pharmaceuticals kindly sponsored the meeting.
Dr Murray Carmichael, Chairman of the
North British Pain Association, gave a warm
welcome to both delegates and speakers.
The title of the first lecture was “Pain in
Gynaecological Disease” given by Dr Paul
Dewart, Consultant Gynaecologist, St. John’s
Hospital, Livingstone.
His talk commenced with a description of
the causes of pelvic pain. The differential
diagnosis of chronic pelvic pain includes both
gynaecological and non-gynaecological causes.
The former includes endometriosis,
adenomyosis, chronic pelvic inflammatory
disease, adhesions, pelvic congestion and
ovarian cysts. Non-gynaecological causes
include pathology in the GI tract including
irritable bowel syndrome, interstitial cystitis,
musculo-skeletal conditions and psychological
disorders.
Acute pelvic pain tends to have a well-
defined onset, be of a short duration, of variable
intensity and associated with a discreet disease
process. Chronic pelvic pain often has a poorly
defined onset, an unpredictable duration and no
apparent biological function. As with other
causes of chronic pain, chronic pelvic pain
causes a great deal of distress to the individual
with associated disability, suffering and
depression. This has both healthcare and social
implications. Patients are often unhappy with
their treatment, have distrust for the medical
establishment and there may be ongoing
litigation. Those attending pain management
clinics may have had multiple investigations,
medical treatments and surgical procedures.
The mainstay of management of chronic
pelvic pain is a multi-disciplinary approach,
addressing bio-psychosocial factors affecting
their chronic pain condition.
Several gynaecological conditions can cause
pain. Endometriosis affects one third of women
referred to a Gynaecology Clinic.
Endometriosis may be present without pain and
it is not entirely clear why it does cause pain in
some women. It occurs in the reproductive years
affecting 10% of the female population.
Endometriosis may be related to retrograde
menstruation and it has been suggested there is
both an immunological and a genetic
component. A full pain history, including
factors associated with the pain and the success
or failure of previous treatments should be
obtained. It is important to ask the patient to
describe their worst symptom, their fears and
beliefs and the effect the pain has on their life.
Typical endometriosis symptoms include chronic
pelvic pain, dysmenorrhoea, dyspareunia, loss
of energy and infertility. Examination,
including bimanual palpation of the uterus, may
reveal utero-sacral ligament nodules, pelvic
tenderness or fixation, a thickening of the recto-
vaginal septum, adnexal masses or a fixed
retroverted uterus.
Most patients will proceed to have a
diagnostic laparoscopy. Treatment of
endometriosis includes both medical and surgical
options. Medical treatments include GNRH
analogues, Danazol and the oral contraceptive
pill. These treatments are not free from side
effects and tend to produce only short-term
benefit. Surgical treatments include laparoscopy
and haemo-coagulation/laser of areas of
endometriosis. Few studies have looked at the
long-term outcomes from these treatments and
those that have do not demonstrate good results.
A case history was presented of a 28-year-
old nulliparous lady with chronic pain. She had
a long history of painful periods, which had led
to prolonged sickness from work and also
resulted in deep dyspareunia. This patient’s
highest concerns were her fertility, her
relationship, work, her quality of life, treatment
options and recurrence of the problems. The
importance of finding out a patient’s priorities
and worries was emphasised.
 Dr Dewart moved on to discuss
dysmenorrhoea, which may be primary or
secondary and dyspareunia. Normal
investigations include microbiology, ultrasound
and endometrial biopsy. Pharmacological
management revolves around modification or
suppression of menstruation and the use of
appropriate analgesics. Dyspareunia may be
classified as superficial or deep. A full history
must be taken and examination performed.
Infective causes should be excluded and
laparoscopy may be required to exclude other
diagnoses. Management includes counselling,
relaxation, dilators, lubrication, physiotherapy
and treatment of any specific causes. Chronic
pelvic pain in general may respond to
psychological treatment approaches including
cognitive behavioural therapy, which may
involve the patient’s partner.
Discussion at the end of the lecture included
the relevance of adhesions to chronic pelvic pain
and whether there is a role for awake
laparoscopy to allow accurate determination of
the exact location of pain.
Dr. Paul Dewart and Dr. Andrew Rice
We were privileged to have Dr Andrew Rice,
Senior Lecturer in Anaesthesia, University
College, London giving the next lecture titled
“Physiology of Visceral Nociception” .
He started with a description of the visceral
nociceptors and sensory afferents, which travel
with autonomic fibres and visceral pain
pathways in the dorsal columns of the spinal
cord. He outlined the hypothesis of visceral
hyperalgesia. With persistent tissue injury and
inflammation, a subject may develop both
primary and secondary hyperalgesia, due to
peripheral and central sensitisation. He
described research in a rat model of turpentine-
induced bladder inflammation, which
demonstrated marked changes in intravesical
pressure and contraction following
inflammation.
There followed a brief description of the
factors involved in dorsal horn neurone
sensitisation and c-fos gene expression in
response to afferent nociception. Many
receptors and neurotransmitters may be involved
in this process including sodium channels,
vanilloid receptor 1, nerve growth factor,
cytokines, serotonin, histamine and bradykinin.
There is increased expression of nerve growth
factor in inflamed viscera and nerve growth
factor itself can induce features of visceral
hyperalgesia. There is evidence in addition that
antagonism of nerve growth factor can attenuate
visceral hyperalgesia.
Intravesical nerve growth factor provokes
visceral hyper-reflexia and induced c fos
expression in spinal cord neurones. Primary
visceral afferent neurones also have
cannabinoid-1 receptors and endocannabinoids
such as anandamide can attenuate viscero-
visceral hyper-reflexia, turpentine-induced c fos
expression and turpentine-induced referral
hyperalgesia. Endogenous cannabinoids
physiologically antagonise the pro-hyperalgesic
effect of nerve growth factor and act both
centrally and peripherally.
There followed a discussion of the potential
for cannabinoids as an effective treatment in this
area.
Following an excellent lunch, the afternoon
scientific session began with an entertaining
lecture on “Urinary Tract Pain” given by Mr
Peter Paterson, Consultant Urologist at Glasgow
Royal Infirmary.
This proved to be a very interesting overview
of urological pain syndromes, concentrating on
three main topics: loin pain haematuria
syndrome, essential testodynia and prostatitis.
Loin pain haematuria syndrome. As in many
other chronic pain conditions, the evidence for
treatment options in loin pain haematuria
syndrome is poor. Options include
Sulphinpyrazone, retrograde injection of
Capsaicin, surgical sympathectomy, renal auto
transplantation and renal denervation.
Testicular pain. This may present post-
vasectomy, associated with epididymal swelling
or infection or as essential testodynia. One
reassuring factor is that testicular neoplasia
tends to be painless and is relatively easily
excluded with testicular ultrasound. However,
if examination of the testicle is normal, there is
little to be gained by an ultrasound examination.
Mr Paterson stresses the importance of taking a
full sexual history and exploring psychological
factors that may be contributing to the chronic
pain problem. The exact aetiology of essential
testodynia has not been determined but one
theory is that there is an increase in pressure
within the testicle.
Chronic prostatitis. This may be bacterial,
associated with recurrent urinary tract infections
and positive bacteriological culture. It is usually
treated with prolonged courses of antibiotics
with some patients proceeding to a transurethral
resection of their prostate. There is a condition
known as abacterial prostatitis with a similar
presentation but negative bacteriological
culture. This may be an allergic phenomenon
and there have also been cases of radiation-
induced prostatitis.
Mr Paterson finished with an interesting
conclusion that perhaps self-stimulation may be
as beneficial as any other treatments.
Dr Beverly Collet and Mr Peter Paterson
This lecture was followed by a talk on the
“Clinical Management of Urogenital Pain”. We
were privileged to have Dr Beverley Collett,
Consultant in Anaesthesia and Pain
Management from Leicester Royal Infirmary to
give this talk.
Chronic pelvic pain affects 38/1000 women
in the UK. Of all the laparoscopies performed
to investigate pelvic pain, 40% demonstrate no
abnormality. Chronic pelvic pain leads to
70,000 hysterectomies being carried out every
year in the USA. Of attendees to the Urogenital
Pain clinic, 30% have undergone hysterectomy.
Chronic pelvic pain is a complex problem
with gynaecological, urological, gastrointestinal
and musculoskeletal aetiologies as possible
contributing factors. There does seem to be an
increased incidence of both sexual and physical
abuse in women with chronic pelvic pain, which
suggests that psychological factors can also be
important.
Treatment should involve a multidisciplinary
approach provided by a team consisting of a
gynaecologist, psychologist, pain clinician,
physiotherapist, nurse and secretary. All
patients referred to the Urogenital pain clinic
will receive a multidisciplinary assessment and
formulation of a joint management plan.
The psychologists aims are to enable the
patient to control their pain, reduce their
disability, promote well being and address any
psychological morbidity. Strategies include
relaxation, stress management, distraction and
other pain management techniques. Disability
can be reduced by encouraging a progressive
increase in activity and modifying pain
behaviour with the ultimate aim of returning the
individual to employment. Advice is given on
nutrition, sleep and physical exercise. Patients
may suffer from anxiety and/or depression and
may have a history of abuse. Treatment may
involve marital and family counselling and sex
therapy.
Physical treatments include active and
passive muscle stretching, active and passive
lumbar flexion exercises, abdominal muscle
strengthening exercises, joint mobilisation and
posture instruction. King et al in 1991 looked
at 132 patients with CPP. They found a variety
of physical problems including faulty posture,
iliopsoas shortening, decreased lumbar flexion,
increased pelvic floor muscle tone, loss of
passive hip rotation and abdominal weakness.
The consultant in pain management provides
advice about oral medication, trigger point
injections, peripheral nerve blocks, sympathetic
nerve blocks and joint injections.
The nurse acts as a co-ordinator, educator
and health promoter. They will also act as
liaison between the pain team and ward staff.
The title of the next lecture was “Overview
of Sexual Abuse” given by Dr Rhiannan Pugh,
Consultant Psychiatrist in Psychotherapy, Royal
Edinburgh Hospital. The organisers were very
grateful to Dr Pugh for stepping in at short
notice.
The prevalence of sexual abuse in the
general population is estimated to be 12% of
women and 8% of men from a survey by Baker
and Duncan. 20% of these individuals will
subsequently develop psychopathology. In a
survey of 100 psychiatric in-patients, 19%
reported a history of child sexual abuse.
Psychiatric Condition Percentage suffering
from childhood sexual
abuse
Schizophrenia 60%
Drug Abuse 44%
Eating Disorders 51%
Sexual Dysfunction 90%
Somatisation Disorder 55%
Dr Pugh emphasised that there was not
necessarily a cause and effect relationship
between a psychiatric disorder and childhood
sexual abuse or vice versa. Individuals who
have suffered childhood sexual abuse however
may develop psychological problems including
depression and anxiety, low self-esteem, guilt
and sleep disturbance. They may have
borderline personality disorders and develop
eating disorders. There is increased incidence
of problem behaviours such as self-harm, drug
use, promiscuity/prostitution, running away
from home and conduct disorders. Individuals
may also have problems with social
relationships. They have an increased incidence
of social withdrawal and are more likely to be
in abusive relationships. A previous history of
childhood sexual abuse is present in 35% of
perpetrators of sexual abuse.
Dr Pugh then moved on to talk about incest.
This more commonly occurs in a family with a
CROSS PARLIAMENTARY GROUP ON CHRONIC PAIN
The next meeting of this group is in November. There was a constructive meeting with Mary
Mulligan, Deputy Health Minister on 24 th June 2002. There was agreement reached that the
recommendations of the CSAG report should be implemented.
Liz Beattie, Sara Brookes and Kath Smith
from Ashington
CAPTION COMPETITION
As there have been no entries for
last issues caption competition we are
in a rollover situation! Entries for this
issues competition should be sent to the
Editor and will be announced in the next
issue. The prize will be an even bigger
book token.
Dr. Rhiannan Pugh
typically rigid patriarchal set up with a dominant
father and a passive mother ceding duties to a
daughter. The oldest daughter is likely to be
the first victim and the commonest age group
being 8 – 12 years. The onset is normal
insidious. The victim usually fears that they will
be punished, blamed, not believed, and have a
fear of abandonment. Dr Pugh emphasised that
healthcare professionals should be encouraged
to routinely ask about a history of childhood
sexual abuse.
Lisa Manchanda and Bill Macrae, Glasgow
PAIN NEWS AND GOSSIP
Murray Carmichael, our Chairman, has
retired from the Western General in Edinburgh.
I am sure everyone would like to wish him a
long and happy retirement. Despite his retiral,
he has returned to work his own locum. Now
that is dedication.
Congratulations to Dr. Lyndia Green on
becoming a mother in law. Congratulations also
to Dr. Pauline Adair on her recent marriage, new
job and new house! Glasgow is delighted to
welcome her as our new Consultant Clinical
Psychologist for pain management. Dundee’s
loss is Glasgow’s gain.
Pauline Adair and Lyndia Green
Ruhy Parris is very proud of her son Iain,
who you may remember from the last issue of
Threshold. He has gained 9 A stars in his
GCSE’s. Well done, Iain.
Dr. Theresa Houseman, Clinical
psychologist from Glasgow Royal and Stobhill
has left to take up a new post working in
Lanarkshire in the diabetes service. We wish
her well. Her post has recently been advertised
and we hope a replacement will be appointed
soon.
Alison Crofts (physiotherapy, Glasgow
Royal) has left to take up a new job in Sports
Medicine at Hampden. We would like to
welcome her replacement, Holly Daniel from
North Carolina.
Dr Lars Williams, Specialist Registrar in
Anaesthesia is the new Glasgow Pain Fellow.
This is a new post for one year. It is hoped that
this post will be recognised for training in Pain
Management by the Royal College of
Anaesthetists. During this time Lars is visiting
all the clinics in Glasgow and is also planning
visits further afield. There is increasing interest
from trainee Anaesthetists in chronic pain
management.
As mentioned in the last issue of Threshold,
new Greater Glasgow Health Board guidelines
have been issued to primary care. There are
separate protocols for treatment of back pain,
large joint pain and neuropathic pain and
standard referral forms to the chronic pain
service are now in use. They were launched at
a well attended meeting on the 7th of March in
the Milton Hotel. In addition, the back pain
early intervention service is now up and running.
It will be interesting to see the effect this has
on referral patterns to the chronic pain service.
I apologise for the Glasgow slant but you
can update me with news from the regions at
the meeting in November.