2010 Fpm Spring Meeting Handbook

8/6/2019 2010 Fpm Spring Meeting Handbook

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TRANSITIONSIN PAIN

2010 SPRINGMEETING

FACULTY OF PAIN MEDICINEAUSTRALIAN AND NEW ZEALANDCOLLEGE OF ANAESTHETISTS


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Major Sponsors Exhibitors


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Contents

Welcome message 2Invited speakers 4Scientifc program 69

AbstractsApplying a long term conditions model to pain services 10The Australian story 12Reworking the inter ace between primary care andMultidisciplinary Pain Centres the Adelaide experience 14Chronic pain and li estyle medicine 16The role o microglia in the regulation o mood state:Implications or depression 17Nutrition and pain 18Meaning and personal story 19The Pain Story: practical approaches 20The impact o triage on a pain service 21Primary care story 22Outcomes o the STEPS programme at Fremantle Hospital 23Mind, body and relationships: treating pain in context 24Using unctional genomics to understand pain 26Ageing well 28The role o music in linking mind and body 30

PBLD and Topical Session outlines 3138

TRANSITIONSIN PAIN

FACULTY OF PAIN MEDICINE

AUSTRALIAN AND NEW ZEALAND

COLLEGE OF ANAESTHETISTS


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Welcome

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Welcome message rom the Dean

The Faculty o Pain Medicine is pleased toprovide you with such a good program or this2010 Spring meeting in Newcastle, Transitionsin Pain. There will be something or all PainMedicine Fellows and other colleagues workingwith those su ering pain.We welcome our invited visiting speakers

Dr Cathy Price (Southampton), Pro Brian Broom(Auckland) and Pro Garry Egger (New SouthWales). Our thanks to them, as well as to allour local contributors.On behal o the Faculty we wish to thank theorganising committee or their excellent work Chris Hayes, Susie Lord, Di Pacey, Marc Russoand Stephanie Oak. They have constructed aprogram with some novel yet important subjects

or us as we work together to deliver more serviceto an increasing population o persons in need,but o ten with less resources. Topics such asModels o Care will likely mean di erent thingsto each o you, so this is an opportunity to hear,discuss and exchange ideas about yours andothers approaches to similar problems.To complement the scienti c program there isan excellent social program, at which you have

an opportunity to meet colleagues and makenew contacts. I look orward to talking with manyo you at this, our Facultys 4th Spring Meeting.

Dr David JonesDean, Faculty o Pain Medicine


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Welcome message rom the Convenor

It is with great pleasure that I welcomeyou to the Faculty o Pain Medicines

ourth Spring Meeting at City Hall inNewcastle.

The theme o the meeting is Transitions in Pain.My hope is that you get a sense o Newcastlestransition rom industrial town to a diverse and thrivingmodern city as we consider multiple transitions incontemporary health care. The exciting program o lectures, topical sessions and problem based learningdiscussions presented by International and Nationalspeakers addresses key aspects o the emergingparadigm in pain medicine. Focus areas includemodel o service delivery, meaning and personalstory and the role o li estyle and nutritional actors.

Thank you or coming to participate in the con erence.I trust that you enjoy the city, the scienti c program,catching up with old riends and making new ones aswe collectively explore Transitions in Pain.

Thanks are also extended to our sponsors and exhibitorsor their generous support o the meeting.

Chris HayesConvenor


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4 2010 SPRING MEETING FACULTY OF PAIN MEDICINE AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS

Pro Brian BroomPro essor Brian Broom is a philosopher physician,with a passion or whole person approaches to illness.He leads the unique post-graduate MindBodyHealthcare Diploma and Masters Program at AUTUniversity, Auckland. On the body side o his workhe is a Consultant Physician in Clinical Immunology

(in the Department o Immunology at Auckland CityHospital, Auckland, New Zealand), but is consultedor many types o physical illness by people wanting a

clinician who will look at both physical and non-physicalactors that may be playing a part in their illnesses.

On the mind side he is a New Zealand registeredpsychotherapist and has long experience training andsupervising psychotherapists working with patients witha wide range o physical conditions. His psychotherapystyle is eclectic and strongly interpersonal. He haswritten two books or clinicians emphasising how thepersons personal li e story relates to the emergence

and progression o illness and disease.

Pro Garry EggerDr Garry Egger MPH, PhD has worked in public,corporate and clinical health or nearly 4 decades.He is the author o 30 books (including our texts)over 150 scienti c articles and numerous popularmedia articles on health and tness. He is an AdjunctPro essor o Health Sciences at Southern Cross and

Deakin Universities and the University o SouthAustralia, and an Advisor to the World HealthOrganisation and several Government and corporatebodies in chronic disease prevention. In the 1990sDr Egger initiated the GutBusters, mens waist lossprogram, the rst o its kind in the world, which hasnow developed into the Pro essor Trims Weight LossProgram or men. He is one o the initiators o theAustralian Li estyle Medicine Association and runstraining programs in Li estyle Medicine or doctorsand allied health pro essionals.

Australian and New Zealand In ited Speakers

Dr Cathy Price Dr Cathy Price is a consultant in Pain Medicine at Southampton University HospitalsTrust in the UK. In 2003 in response to signi cant pressures on the services thelocal health community took the innovative step o shi ting specialist painmanagement care out o hospital and adopting a whole systems approach to

management. For this Cathy and her manager received a Medical Futures InnovationAward or Leadership in 2005 rom McKinsey.

She has been a member o the British Pain Society Council 2006-9 and is currentlyan executive member o the UK Chronic Pain Policy Coalition. She assisted withproduction o the Chie Medical O cers report on pain in 2009.

She is also currently vice chair o the clinical leadership arm o the local health board.

International In ited Speaker


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National In ited SpeakersDr Penny BriscoeRoyal Adelaide Hospital,SAPro Clare CollinsUniversity o Newcastle,NSWDr Myles ConroyBarwon Health, VICMs Denise DauntJohn Hunter Hospital,NSW Mr Carl GrahamFremantle Hospital, WADr Newman HarrisRoyal North ShoreHospital, NSWDr Isabel HigginsUniversity o Newcastle,NSW

Ms Meredith JordanJohn Hunter Hospital,NSW Dr Michael KatekarJohn Hunter Hospital,NSW Dr Kasia KozlowskaThe Childrens Hospitalat Westmead, NSWDr Stephen LeowGeneral Practitioner,Adelaide, SADr Susie LordJohn Hunter Hospital,NSW Dr John MalcolmGeneral Physician,Newcastle, NSW

Dr Frank NewPsychiatrist, Brisbane,QLDMr Sean NolanJohn Hunter Hospital,NSWDr Stephanie OakJohn Hunter Hospital,NSW Dr Di PaceyJohn Hunter Hospital,NSW Dr Matthew PolsJohn Hunter Hospital,NSW Dr Marc RussoHunter Pain Clinic, NSW

Pro Rodney ScottUniversity o Newcastle,NSWDr Tim SempleRoyal Adelaide Hospital,SADr Simon TameHunter Pain Clinic, NSWDr Rohan WalkerUniversity o Newcastle,NSWMs Ruth WhiteJohn Hunter Hospital,NSWPro Ian WhyteCalvary Mater Hospital,NSW


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FRIDAY 08 OCTOBER

09001000 REGISTRATION

10051015 Opening WelcomeDr Chris Hayes

Mr Mick Da idson Didgeridoo

10151230 PLENARY LECTURES Concert Hall Chair: Dr Paul Wrigley

Dr Cathy PriceApplying a long term conditions model to pain servicesDr Penny BriscoeThe Australian storyDr Tim SempleReworking the interface between primary care and MultidisciplinaryPain Centers: the Adelaide experience

12301330 Lunch

13301500 PBLD and Topical Discussion SessionsPBLD 01 Waratah Room Facilitator Dr Susie Lord

Transgenerational CRPSPBLD 02 Newcastle RoomFacilitator Dr Myles ConroyManaging the Risk Transition from acute to persistent postsurgical pain

PBLD 03 Mulubinba RoomFacilitator Dr Matthew PolsFinding meaning in pain

Topical Session 01 Concert HallFacilitator Prof Julia FlemmingPresenters Dr Carl Graham and Dr Newman HarrisHidden drivers of pain: psychological/psychiatric perspectives

Topical Session 02 Cummings RoomFacilitator Dr Brendan MoorePresenters Dr Frank New, Dr Di Pacey and Dr Simon TameBlueprinting pain medicine as a specialty

15001530 A ternoon Tea

15301730 LECTURES Concert Hall Chair Dr Chris Hayes

Prof Garry EggerChronic pain and lifestyle medicineDr Rohan WalkerThe role of microglia in the regulation of mood state: Implications for depressionProf Clare Collins Nutrition and pain

19002200 Con erence Dinner Jonahs on the Beach *

Program

Transitions in Pain:1 Models o Care2 Li estyle3 Meaning4 Plasticity5 Li espan

*Please be aware that the complimentary coach transfer to the conference dinnerwill depart from the Crowne Plaza Hotel, Newcastle, at 1845sharp


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SATURDAY 09 October

07300845 Mundipharma Break ast Meeting Introducing TARGIN Tablets Cummings Room

08300900 REGISTRATION

09001100 LECTURES Concert HallTherapeutic opportunities arising through understanding patients personal meanings and storiesChair Dr Raymond GarrickProf Brian BroomMeaning and personal storyDr Stephanie OakThe Pain Story: practical approachesDiscussion of story concepts

11001130 Morning Tea

11301300 LECTURES Concert Hall Models of Care

Chair Dr Milton CohenDr Cathy PriceThe impact of triage on a pain serviceDr Stephen LeowPrimary care storyDr Carl GrahamOutcomes of the STEPS programme at Fremantle Hospital

13001400 Lunch

14001530 PBLD and Topical Discussion SessionsPBLD 04 Waratah Room

Facilitator Dr John MalcolmMore than meets the eye: A young main with pain in his head

PBLD 05 Newcastle Room Facilitator Dr Simon Tame

Neuromodulation in a complex case. How did we get there? Topical Session 03 Concert Hall Facilitator Dr Toby Newton-John

Presenters Ms Denise Daunt, Ms Meredith Jordan and Ms Ruth WhiteImplementing short group interventions at Hunter Integrated Pain Service

Topical Session 04 Cummings Rooms Facilitator Dr Da id Jones

Presenters Dr Michael Katekar, Dr Marc Russo and Prof Ian WhyteHidden drivers of pain: biological

15301600 A ternoon Tea

16001700 Panel Discussion Concert HallWhere will pain medicine be in 10 years time?

Moderator Prof Michael CousinsSpeakers Dr Penny Briscoe, Prof Brian Broom, Prof Garry Egger and Dr Cathy Price(5-10 minutes per speaker)Interacti e Discussion

17001900 Cocktail Reception


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SUNDAY 10 OCTOBER

09001100 LECTURES Concert Hall Lifespan

Chair Dr Jeniffer Ste ensDr Kasia KozlowskaMind, body and relationships: treating pain in contextProf Rodney ScottUsing functional genomics to understand painDr Isabel Higgins

Ageing well11001130 Morning Tea

11301230 LECTURES Concert HallChair Dr Di PaceyMr Sean NolanThe role of music in linking mind and body

1235 CloseDr David JonesDr Geo rey Speldewinde presents the 2011 Spring Meeting


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PBLD 01Friday 08 October13301500Facilitator: Dr Susie Lord

Transgenerational CRPSWhat is the geneticcontribution to CRPS?What is nature and whatis nurture? This casediscussion looks at a amilyin which 3 generationshave been given the labelo CRPS.

PBLD 02Friday 08 October13301500Facilitator: Dr Myles Conroy

Managing the Risk Transition fromacute to persistentpostsurgical pain Discussion o this casewill explore the risk o transition or acute topersistent pain. Howdo you identi y a patientat risk and havingidenti ed them whatcan be done about it?

PBLD 03Friday 08 October13301500Facilitator: Dr Matthew Pols

Finding meaning in painThis discussion will bebased around a typicalpersistent pain patient.Links will be exploredbetween the patientsresponse to li e events andthe persistence o theirpain. The infuence o themindbody connection willbe analysed in terms o both diagnostic ormulationand practical managementstrategy.

Topical Session 01Friday 08 October13301500Facilitator:Pro Julia Fleming

Hidden dri ers of pain:psychological/psychiatricperspecti esNot all mental healthpro essionals are thesame! Beyond the clinicalstandard o including amental health practitionerin the pain team, thisclinical case discussionexamines the di erentbut complementaryroles o psychiatrist andclinical psychologist inthe pain clinic.

Topical Session 02Friday 08 October13301500Facilitator:Dr Brendan Moore

Blueprinting Pain Medicineas a SpecialityA Faculty o Pain Medicineblueprinting subcommittee

has been addressing thechallenge o de ning apain medicine specialist.This is o vital importanceto service delivery,training, examination andongoing education. The 3speakers will put orwardperspectives encompassingthe spectrum rompsychiatry to rehabilitationmedicine to procedural painmedicine and across the

public and private sectors.Active discussion will beencouraged. Come andexpress your views aboutwhat a pain medicinespecialist is or could be.

PBLD 04Saturday 09 October14001530

Facilitator: Dr John Malcolm More than meets the eye:

A young man with painin his headThis case has manyelements: the di cultyo obtaining an accuratehistory and the value o detective work to check the

acts; persistent pain ina person with a signi cantpsychiatric disorder;managing the relationshipwith the patientspsychiatrist; problems o polypharmacy; negotiatingwith and containing thepatient without insight;managing the enmeshedand co-dependent parent;and more!

PBLD 05Saturday 09 October14001530Facilitator: Dr Simon Tame

Neuromodulation in a

comple case. How didwe get there?This case history involvesdiagnostic uncertainty,a multidisciplinarytreatment algorithm,di cult interactions withthe insurance industry,signi cant developmentalissues and ultimatelytrying to enmeshneuromodulation withsel management.

Come and explorethese and other issues.

Topical Session 03Saturday 09 October14001530

Facilitator:Dr Toby Newton-John

Implementing short groupinter entions at HunterIntegrated Pain Ser iceCan less equal more?This session will describethe ongoing evolution o short group interventionsat Hunter Integrated PainService. Concepts o strati ed service designand emerging in ormationcontent will be exploredand the challenges o short group interventionsdiscussed. Preliminaryoutcome data will bepresented.

Topical Session 04Saturday 09 October14001530

Facilitator: Dr David Jones Hidden dri ers of pain:

biologicalSometimes all is not as

it seems. In this Topicalsession we will be lookingat some issues that mayoccasionally be drivingor contributing to thepersistent pain state.Dr Michael Katekar willbe presenting the worldo mitochondropathiesand review medicationsthat may adversely a ectthe mitochondria andmitochondrial pain.

Dr Ian Whyte will reviewthe cytochrome P450system and how geneticor pharmacologicalinter erence can contributeto analgesic ailure.Dr Marc Russo will bereviewing a potpourrio biological driversthat adversely a ect thepain state.

Continuing Medical Education ApprovalsAustralian and New Zealand College o AnaesthetistsLecture sessions: Category 1 Level 1: 1 Credit per hourTopical sessions: Category 1/Level 2: 2 Credits per hourPBLDs: Category 3/Level 1: 2 Credits per hourThe approval number is 1673

Summary of PBLDs and Topical Sessions


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Usual medical care o ten ails to meet the needs o chronically ill patients. Many years ago Ed Wagnerproposed a model or the management o long term

conditions that has been adopted worldwide withcarrying levels o success.

The essential components o this model are: The use of evidence based planned care Rapid access to specialist expertise self management support decision support systems shared information systems

This requires carers and people with their long termcondition to be health literate. It requires in ormation

to be shared amongst pro essionals and an agreementon the best way to manage a person rom all parties.In ormation systems need to have registration, recalland review procedures and recognize those with morethan one long-term condition. People and carersneed support, to sel -care. The more activated andcon dent are more likely to sel care. Appropriatepatient education needs to orm part o this approach.

Admission to hospital needs to be accepted as a parto managing someone with severe long-term condition.However, stays need to be minimized although there

are o ten barriers to achieving this. Financial incentivesthat can address this include a Year o Care approach,penalties or requent admissions and readmissionsand risk sharing amongst organizations.

Gathering the evidence or the e cacy o this modelhas to be approached in a variety o ways. Examples o sensitive indicators are emergency room visits, sel e cacy, use o expensive second line agents to managethe condition. The e ectiveness o primary care in thisremains unanswered. O ten the knowledge and skillso primary care sta especially in supporting sel careare insu cient to support sel care, most so amongstphysicians.

In the past our decades there have been signi cantadvances in our understanding o the complexity o the nervous system, and in our knowledge about thecauses o pain. Increasing evidence shows that chronicpain is in act a separate disease entity with associatedpatterns o central nervous system abnormalities.We know that or most people chronic pain can besuccess ully managed in a variety o simple ways.However, a long-term conditions model as outlinedabove has rarely been applied to chronic pain in asystematic ashion. This has been partly due to the lacko appreciation o the underlying pathophysiology andoutcomes rom epidemiological studies.

Dr Cathy PriceSouthampton Uni ersity Hospitals Trust, UK

APPLYING A LONG TERM CONDITIONSMODEL TO PAIN SERvICES


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In the UK there is evidence that some regions havestarted to do this. These have ocused mainly onthe use o patient education and supported sel care.

Less well organized are shared in ormation systemsand decision support systems. Even less well organizedis rapid access to specialist care and managemento inpatients. Outcomes rom systems are poorlydeveloped. Primary care management o pain is inits in ancy. Emerging models will be presented thatgive some grounds or optimism.

I chronic pain is to be managed e ectively as a long-term condition then it is likely that pain managementservices will need to drive change in ensuring that allelements o the system are adopted. Greater use o population measures o health that include measureso pain will also support such change.

REFERENCESOrganising Care or Patients with chronic illness: Wagner EH, AustinBA, Von Kor M. The Millbank quarterly, 1996: 74:4: 511-544

Skolasky RL, Mackenzie EJ, Wegener ST, Lee HR. Patient activation andadherence to physical therapy in persons undergoing spine surgery.Spine.33 (21). 2009.

Chie Medical O cer or Englands report on the health o the nation.150th annual report. 2008: Pain: breaking through the barrier.

Henry JL. The need or knowledge translation in chronic pain.Pain Res Manage. 2008;13:465476.

Steven K. Dobscha, MD; Kathryn Corson, PhD; Nancy A. Perrin, PhD;Ginger C. Hanson, MS; Ruth Q. Leibowitz, PhD; Melanie N. Doak, MD;Kathryn C. Dickinson, MPH; Mark D. Sullivan, MD, PhD; Martha S.Gerrity, MD, PhD . Collaborative Care or Chronic Pain in Primary Care.A Cluster Randomized Trial. JAMA, March 25, 2009Vol 301, No. 12


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Dr Tim SempleRoyal Adelaide Hospital, SA

Whilst the South Australian multidisciplinary paincentres have long had involvement in generalpractitioner education and close working

relationships with individual general practitioners,the commencement o the South AustralianCollaborative Pain Project(SACoPP) in 2005 has ledon to a much closer integration between the paincentres and primary care medicine.

In 2005 Drugs and Alcohol Services South Australia(DASSA) and senior sta rom the Royal AdelaideHospital and Flinders Medical Centre Pain ManagementUnits initiated the SA Collaborative Pain Project(SACoPP) with a core goal o improving generalpractitioner prescribing o opioid S8 medications.South Australian legislation, similar to that in WesternAustralia and Queensland, requires a higher level o overview and regulation o long term opioid prescribing

or chronic noncancer pain(CNCP) than in someother states. DASSA retrospectively reviews all opioidprescriptions and were aware o a substantial anddisturbing increase in both the numbers o individualson longterm opioids (currently exceeding 7000) aswell as apparent high dose prescribing in the absenceo specialist review or use o non-opioid painmanagement modalities.

The project was unded mainly by a grant rom theIntergovernmental Committee on Drugs supplementedby healthcare industry support. There was consensus

rom all collaborators that improving general practitionerknowledge and clinical expertise was essential prior toachieving any positive outcome in the management o the overwhelming unmet burden o CNCP in SA andchanging opioid prescription practice.

The prevalence o CNCP in SA and impact uponhealthcare workload can be predicted rom a range o sources. Focus group surveys o SA general practitioners

prior to SACoPP estimated CNCP occupied 25% o theirworkload. This is similar to the recent results rom theBEACH survey o Australian general practice in which19.6% o patients had chronic pain1. The SouthAustralian Health Omnibus Survey in 2006 utilising2973 ace-to- ace interviews reported that the prevalenceo chronic pain was 19.7% and that 5% (65000individuals in real terms) experienced pain inter eringseverely with daily activities2.

O these 65,000 individuals, how many are gettingaccess to multidisciplinary pain centre (MPC)management? The Australian Pain Society Waiting InPain : a systematic investigation into the provision of persistent pain services in Australiainterim report 2010reveals that 2418 patients per annum with non-urgentCNCP are assessed in SA at a MPC with a mean waitingtime o 205.5 days (Australian mean waiting time 143days ). It is not clear whether those assessed are in themost needy categories.

SACoPP ocused upon two approaches rstly, thegeneration o a guideline or opioid prescribing orSA general practitioners and secondly, providing

unded training attachments o up to 52 hrs durationor interested GPs at either RAH or FMC PMUs.

Opioid Prescription in Chronic Pain Guidelines for South Australian GPs3 was based upon a document

rom USA and was developed to provide acomprehensive educational resource to optimiseprescribing practice. Whilst a range o urther resources

ocused on opioid prescribing have since emerged,this remains a valuable tool.

The training attachment to pain centres undertakenby 10 general practitioners proved to be very valuableat a number o levels.

REWORKING THE INTERFACE BETWEEN PRIMARYCARE AND MULTIDISCIPLINARY PAIN CENTRESThe Adelaide E perience

(CONTINUED)


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The goal o generating a group o general practitionerswith a speci c interest in pain management (GPsi-Pain)was achieved. Several o the metropolitan-based GPshave gone on to provide input and patient review ortheir primary care colleagues as well as undertakinga shared care approach to complex pain patients withthe pain centres.

Two rural practitioners rom the same practice havecommenced a pain management project in their town,utilising an interdisciplinary model with mental health-trained practice nurse and an occupational therapistwith a speci c pain management background as wellas utilising a visiting psychiatrist with extensive painexpertise.

The recognition o the need or improved basic paineducation or all general practitioners led to engagementwith the SA branch o RACGP and eventual ormationo the Chapter o Pain Management within the Facultyo Speci c Interests. A Pain Education Group hasbeen meeting over the past two years and collation

o educational resources or GPs is underway includinginput rom the pain centres.

Bridging the gap between tertiary hospital-based servicesand primary care or management o chronic diseaseis now a major ocus o the SA Health strategic plan.The new SA HEALTH GP PLUS centres are aimed atincreasing the capacity o the primary care sector torespond to chronic conditions and clearly provide anopportunity to improve chronic pain management. Inconjunction with two o the local GPsi-Pain practitioners(Dr S Leow and Dr R Heah), RAH Pain ManagementUnit is initiating a pilot project at the Elizabeth GP PLUS.FMC PMU has proposed both pain medicineassessment and a modi ed PMP or Marion GP PLUS.Allied health practitioners and nurses with chronicdisease management expertise will be available at thesecentres translating these skills to contribute to CNCPmanagement will be critical to achieving the bestoutcomes rom this opportunity.

In the ve years since the project began, has much beenactually achieved? Waiting lists or the pain managementcentres remain unacceptably long and access to servicesin the primary care sector limited. However, the coreaspects o an improved uture model o care involving anintegrated pain network are beginning to all into place.There are GPs setting up services or their colleaguesand patients to expand options at a primary care level.The rst steps o integrated interdisciplinary secondary

care services at the GP PLUS centres are underway.Perhaps most importantly, the concept o GP ownershipo and responsibility or CNCP appears established.There is a group o enthusiastic GPsi-Pain workingwith their parent college to improve basic painknowledge in all GPs and to provide a training pathway

or those GPs who wish to take their interest in painmanagement urther.

REFERENCES1. BEACH (Bettering the evaluation and care o health), Sand Abstract

112, 2007-20082. Currow DC et al. Chronic Pain in South Australia population levels

that inter ere extremely with activities o daily living. Aust NZ JournalPublic Health.2010;34(3):232-239

3. Opioid prescription in Chronic Pain Guidelines or South AustralianGPs @www.dassa.sa.gov.au/website/resources


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Pro Garry EggerSouthern Cross Uni ersity, Lismore Centre for Health Promotion and Research, Sydney, NSW

Chronic pain is an increasingly common phenomenonin modern societies. Its not coincidental that thiscorresponds to an increase in several other li estyle-related chronic diseases or risk actors (type 2 diabetes,depression, cancers etc), which have recently beenshown to have a common physiological aetiology inlow grade, systemic, infammation (metafammation).

CHRONIC PAIN AND LIFESTYLE MEDICINE

Coupled with ndings o increased plasticity inthe brain, it is not outrageous to speculate thatmetafammation may extend to both central andperipheral glial connections associated with painperception, thus linking li estyle-related inducersto non-speci c and unresolvable chronic pain.Even without such a biological basis, there isevidence to suggest that li estyle change may havea positive e ect as part o a systems-theory approach

to chronic pain management. The potential bene tso a Li estyle Medicine approach to chronic painmanagement are considered in this regard.

Dr Frederick Rohan WalkerUni ersity of Newcastle, NSW

This presentation will introduce the audience the roleso microglia within the CNS, and also recent workdemonstrating the ability o psychological stress tostructurally and unctionally alter microglia. Microglialcells are pivotal to the production and maintenance o a neuroinfammatory states in the CNS, they have alsobeen implicated in chronic pain. These cells are the rstline o de ence against pathogens and other threatsto the integrity o CNS. As stress is recognized to bea major antecedent o mood disorders and in particulardepression our research group has begun to examinethe relationship between stress induced microglialchanges and alterations in mood state in the rat.

Over several years we have identi ed that chronicstress (i) decreases an animals pre erence or sucrose(ii) reduces their motivation to explore a novelenvironment (iii) as well as signi cantly increasingmicroglial activation in several mood regulatory orebrainnuclei including the medial pre rontal cortex andamygdala. We have more recently shown that reducingmicroglial activity in the brain can attenuate several o these stress induced alterations. Currently, our groupis now unctionally characterizing, using a variety o ex-vivo techniques, the precise infammatory phenotypeo microglia within the mood regulatory nuclei wherewe have observed di erences ollowing exposurechronic stress.

THE ROLE OF MICROGLIA IN THE REGULATION OFMOOD STATE: IMPLICATIONS FOR DEPRESSION


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Pro Clare CollinsUni ersity of Newcastle, NSW

Does what you eat matter when it comes to pain? Doesbeing in pain a ect the decisions made about what toeat and drink? Pain infuences dietary intake andnutritional status through a broad range o mechanismsand in ways that can increase the risk or protein-energymalnutrition or increase the risk o excessive weight gain.

The majority o patients with pain report eating lessduring acute episodes and i requent, this cancontribute to the risk o malnutrition. For thoseexperiencing chronic pain, it is reportedly common toperceive that weight a ects pain levels, while beingoverweight is an important predictor o pain ulconditions such as lower back pain. The combination o dietary restriction and exercise to achieve weight loss hasbeen shown to improve sel -reported physical unctionand pain levels. This is important as being able to move

reely without pain improves a persons ability to shop,cook and eed themselves with enjoyment. Providingappropriate assistance to individuals in order toundertake these tasks can help to prevent malnutritionand unctional decline, while improving or maintainingnutritional status. Nutrient requirements may be alteredby episodes o chronic pain and there is some evidencethat increasing intakes o speci c amino acids includingadministration o D-phenylalanine or diets enriched withtryptophan can increase an individuals tolerance to pain.Supplementation with a class o essential atty acidsre erred to as Omega 3s has been sown in a meta-analysis to improve a number o pain outcomes a terthree months, including patient assessed pain, durationo morning sti ness, number o pain ul or tender jointsand use o non-steroidal anti-infammatory medication.

Other medications or pain can also negatively impactnutritional status due to side e ects such asconstipation, nausea and/or appetite changes.While pain that keeps people awake can impair sleepquality, impair glucose tolerance secondary to thealtered hormonal response that ensues and therebyincrease the risk or type 2 diabetes.

Research in the area o nutrition and pain is limitedand studies are required i an evidence base orsupportive and e ective dietary interventions tosupport people experiencing pain is to be developed.

NUTRITION AND PAIN


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Pro Brian BroomAuckland City Hospital, Auckland, NZ

The practice o medicine largely operates rom dualisticassumptions, that body and mind, physicality, andsubjectivity are relatively autonomous dimensions.The severance o body and mind, o illness andpersonal story, severely restricts clinical and therapeuticopportunity. But i one assumes that mind and bodyare expressions o a unity, the kind o medicine thatemerges is one where physical actors and personalmeanings and story actors work together in illness

and in treatment. Moreover, the clinician becomeswilling and able to allow the body and mind (story)to be responded to in the same clinical time/space.

MEANING AND PERSONAL STORY

In short, because all persons have unique storiesclinicians become person-centred rather than bodyor mind or modality or discipline or expertise orinstitution-centred. How this plays out in practicewill be illustrated, particularly in relation to painmanagement.

Dr Stephanie OakJohn Hunter Hospital, NSW

Recently neuroscientists and philosophers have shi tedaway rom dualistic conceptions o pain, includingEngels biopsychosocial ramework. They are beginningto articulate a more complex and integrated way o thinking about the pain experience. Researchers areexploring the intricacies o and complex interplaybetween mind, brain, body and environment as dynamicprocesses. However clinicians are struggling to translatethese ideas into practical applications that can capturethe complexity o intersubjective experiences such aspain, and that will be use ul in clinical settings.

This paper argues that patients stories and theprinciples o narrative medicine have the potentialto broaden our understanding o pain as a uniqueexperience infuenced by a multiplicity o interlinked

actors. With this understanding, new painmanagement strategies can be developed.

I will explore the nature o the resistances and challengesthat currently exist in medical practice and that we mustovercome i we are to bene t rom these neuroscienti cinsights in developing innovative new practices orpain management. I will outline several practicalstrategies that can be readily integrated into clinicalpractice without unduly overloading our alreadydemanding schedules.

THE PAIN STORY: PRACTICAL APPROACHES


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Dr Stephen LeowGeneral Practitioner, Adelaide, SA

Anyone who has any involvement in Pain Medicineis well aware o the current demand or Pain Servicesand the supply o Pain Specialists in Australia. We can

count ourselves lucky as we have a relatively goodsupply o specialists, compared to many other countriesin the world. Is there a solution? I so where would itcome rom?

O ten the rst place to look or solutions are thegeneralists. A ter all, they are the most populous groupo doctors, they are not specialized and they are alllargely dissatis ed (?). Once given the chance, shouldmany GPs jump at the chance o becoming a specialist?

EDUCATIONAL OBJECTIVESThis address ocuses on the complex issuessurrounding General Practice and includes

topics such as: The recognition of Pain Medicine as

a specialized eld The multifaceted nature of Pain Medicine Why Pain Medicine is a natural extension

o General Practice Monetary issues Dealing with pain in a primary care setting

vs a tertiary setting Using primary care practitioners in

a tertiary setting

Moves to engage primary care To extend the primary care setting To engage primary care practitioners in

the tertiary setting Managing the interface between primary

and tertiary care Is there a need for a secondary level of care? Education issues Pathways to specialties Pain Service Delivery Models

PRIMARY CARE STORY


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Dr Carl GrahamFremantle Hospital, WA

An historic emphasis towards passive management o chronic pain using primarily medications and procedureshad resulted in relatively high, and recurrent, utilisation

o health resources amongst persistent pain patientsaccessing the pain medicine unit at Fremantle Hospital.Chronic disease modelling high-lighted the need ora shi t towards increasing utilisation o active sel -management strategies to improve both treatmentand management outcomes. The STEPS approach wasdeveloped to recognise sel -management o chronicpain as an integral part o out approach to patient care.

STEPS involves an interpro essional collaboration toprovide education and skills based training orientedtowards unctional improvement alongside the normalemphasis on pain symptom management. By providingpatients with a participatory orientation and integratingthem in an active role within the multidisciplinaryoutpatient treatment processes a reduction in medicallyoriented service utilisation has been achieved while alsoreducing wait list times and providing improved levelso patient satis action.

While persistent pain is the ocus o this current project,the underlying emphasis on patient involvement,orientation towards underlying unctional improvement

in addition to symptom management and the titrationo intervention rom high patient involvement towardshigher health service utilisation serves as a model orthe management o other chronic health conditions.

OUTCOMES OF THE STEPS PROGRAMMEAT FREMANTLE HOSPITAL


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Dr Kasia KozlowskaThe Childrens Hospital at Westmead, NSW

Contemporary research suggests that psychosocialactors negatively a ect post-surgical pain and

predispose to chronic pain syndromes 1-4. Psychosocial

actors range broadly and include: chronic stress onthe mind or body resulting rom cumulative li e events,unresolved loss or trauma, or chronic relationshipstress; the manner in which patients bodies managephysiological arousal and respond to negative emotionalstates; and the manner in which patients organisepsychologically whether they try to inhibit subjectiveknowledge/experience o pain or whether they exaggerateit (catastrophize), how they signal pain, whom theyblame or their pain and li e predicaments and whomthey engage rom their relationship network to managetheir pain and share their li e predicaments. The impacto psychosocial actors appears to be mediated, at leastin part, by the manner in which patients li e experiencesshape and ne-tune the bodys stress systems thosesystems involved in a sel -protective response onphysiological, hormonal, neurological and psychologicalsystem levels1-3, 5, 6. It is now becoming increasingly clearthat patients who su er rom chronic pain syndromesshow di erences in how they process somatic andemotional stimuli on multiple levels o the mind-bodysystem. For example, patients with unctional abdominalpain show an increased auditory startle response 7, 8,and patients with irritable bowel syndrome show alteredautonomic and brain responses to neutral, somaticor emotional stimuli 9-14. Catastrophic thinking,negative recovery expectations, external attributionso responsibility, and patients capacities to managenegative a ective states have all been identi ed as being

associated with poor surgical outcomes and chronicpain syndromes 4, 15-20. Many o these actors aremodi able with treatment which requires, however,

that the actors be identi ed and speci cally addressed.To that end, I begin by presenting the case o a 15-year-old girl with a seven-year history o chronic pain. I thenexplore how to translate the case presentation, alongwith the amilys medical history, into psychologicallanguage, resulting in a psychosocial story orpsychological ormulation that enables us to understandthe girls chronic pain in the context o her li e story.The goal here is to help pain physicians understand howto move rom a medical case history to a psychologicalcase history that will provide insight into their patientschronic pain and help them to understand and address(with appropriate interventions rom other clinicians)the actors that are causing and maintaining it. That is,a comprehensive ormulation not only serves to identi ythe mind, body and relationship actors that contributeand maintain medically unexplained chronic pain, but

unctions to guide treatment planning, it helps theclinician identi y and implement the relevant multimodalinterventions that, taken together, will alleviate thepatients pain and emotional su ering.

MIND, BODY AND RELATIONSHIPS:TREATING PAIN IN CONTExT

(CONTINUED)


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REFERENCES1. Melzack R. Pain and Stress: A New Perpective. In: Gatchel RJ,

Turk DC, eds. Psychosocial actors in pain : critical perspectives.New York: Guil ord Press; 1999:89-105.

2. Chrousos GP, Gold PW. The concepts o stress and stress systemdisorders. Overview o physical and behavioral homeostasis.JAMA 1992;267:1244-52.

3. Chrousos GP, Gold PW. A healthy body in a healthy mind--andvice versa--the damaging power o uncontrollable stress.J Clin Endocrinol Metab 1998;83:1842-5.

4. Clay FJ, Newstead SV, Watson WL, Ozanne-Smith J, Guy J, McClure RJ.Bio-psychosocial determinants o persistent pain 6 months a ternon-li e-threatening acute orthopaedic trauma. J Pain 2010;11:420-30.

5. Kozlowska K, Williams LM. Sel -protective organization in childrenwith conversion and somato orm disorders. Journal o PsychosomaticResearch 2009;67:223-33.

6. Elzinga BM, Roelo s K, Tollenaar MS, Bakvis P, van Pelt J,Spinhoven P. Diminished cortisol responses to psychosocial stressassociated with li etime adverse events a study among healthy youngsubjects. Psychoneuroendocrinology 2008;33:227-37.

7. Bakker MJ, Boer F, Benninga MA, Koelman JH, Tijssen MA.Increased auditory startle refex in children with unctionalabdominal pain. J Pediatr 2009;156:285-91 e1.

8. Nalibo BD, Waters AM, Labus JS, et al. Increased acoustic startleresponses in IBS patients during abdominal and nonabdominal threat.Psychosom Med 2008;70:920-7.

9. Chang L, Mayer EA, Johnson T, FitzGerald LZ, Nalibo B. Di erencesin somatic perception in emale patients with irritable bowel syndromewith and without bromyalgia. Pain 2000;84:297-307.

10. Andresen V, Bach DR, Poellinger A, et al. Brain activation responsesto subliminal or supraliminal rectal stimuli and to auditory stimuli inirritable bowel syndrome. Neurogastroenterol Motil 2005;17:827-37.

11. Berman SM, Nalibo BD, Chang L, et al. Enhanced preattentivecentral nervous system reactivity in irritable bowel syndrome.Am J Gastroenterol 2002;97:2791-7.

12. Blomho S, Jacobsen MB, Spetalen S, Dahm A, Malt UF. Perceptualhyperreactivity to auditory stimuli in patients with irritable bowelsyndrome. Scand J Gastroenterol 2000;35:583-9.

13. Verne GN, Himes NC, Robinson ME, et al. Central representation o visceral and cutaneous hypersensitivity in the irritable bowel syndrome.Pain 2003;103:99-110.

14. Spetalen S, Sandvik L, Blomho S, Jacobsen MB. Autonomic unctionat rest and in response to emotional and rectal stimuli in womanwith irritable bowel syndrome. Digestive Diseases and Sciences2008;53:1652-9.

15. Mayer EA, Nalibo BD, Craig AD. Neuroimaging o the brain-gut axis:rom basic understanding to treatment o unctional GI disorders.

Gastroenterology 2006;131:1925-42.16. Vervoort T, Goubert L, Eccleston C, Bijttebier P, Crombez G.

Catastrophic thinking about pain is independently associated withpain severity, disability, and somatic complaints in school childrenand children with chronic pain. J Pediatr Psychol 2006;31:674-83.

17. Kozlowska K. Attachment relationships shape pain-signaling behavior.J Pain 2009;10:1020-8.

18. Ploghaus A, Narain C, Beckmann CF, et al. Exacerbation o painby anxiety is associated with activity in a hippocampal network.J Neurosci 2001;21:9896-903.

19. Neugebauer V, Li W, Bird GC, Han JS. The amygdala and persistentpain. Neuroscientist 2004;10:221-34.

20. Seminowicz DA, Davis KD. Cortical responses to pain in healthyindividuals depends on pain catastrophizing. Pain 2006;120:297-306.


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Pro Rodney ScottUni ersity of Newcastle, NSW

Pain has evolved to alert each and every one o us o environmental actors that cause us harm. It has beenrecognised or quite some time that there are di erences

in pain thresholds and perception between individualsand that these two actors alter with age. Similar to manyother complex biological processes pain perception isincreasingly being scrutinised at a molecular level tobetter understand the mechanisms involved and toidenti y potentially new treatment targets.

The di erent types o pain, acute, allodynia andneuropathic are all underpinned by speci c genes.Acute pain is experienced as a result o nociceptors

stimulation (a ter injury) that requires the coordinatedexpression o genes associated with transducers,ion channels and receptors. Once the initial event ispassed a second phase o pain sensation is establishedto protect the site o tissue injury characterised by anincrease in sensitivity to innocuous stimuli. This processis characterised by molecules that sensitize the primarya erent and second order spinal chord neurons.Finally neuropathic pain is generally considered to bemaladaptive and a result o long term changes in theprocessing o pain messages by both the spinal cordand brain stem neurons. Many, i not all, o the changesassociated with neuropathic pain are a result o geneinduction and loss o control delity.

This review will provide a brie overview o howunctional genomics can aid in better understanding

pain perception and potentially treatment.

USING FUNCTIONAL GENOMICSTO UNDERSTAND PAIN


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One o the most crucial aspects o establishing thenotion o wellbeing or older persons is whether or notour processes as health care pro essionals is humanisingor dehumanising. Arguably, i we are to make acontribution to maximising the health and wel areopportunities or older people in the community then weneed to critically refect upon what it means to age well.Armed with this knowledge we need to review and alignour attitudes, expectations and health care practicesaccordingly. In this paper I explore Rowe and Kahns(1999) model o Success ul Aging along with some o the more recent science regarding healthy ageing andthe meaning that ageing well and success ully has orolder people.

Success ul ageing is multidimensional with threecomponents including; the low probability o diseaseand disease related disability, high cognitive and physical

unctional capacity and active engagement with li e.The low probability o disease is not only the absenceor presence o disease but the absence o risk actors ordisease. Both physical and cognitive capacity highlightpotential or activity; they tell us what a person can do;not what they do and active engagement with li eincludes and individuals interpersonal relations andproductive activity. Interpersonal relations however mustinvolve meaning ul contact with others and activity withsocietal value whether or not it is reimbursed (Rowe& Kahn, 1999, p. 27).

On disease and the absence o disease, there are a rangeo measures or Australians that suggest we are ageingwell. According to the latest report rom the AustralianInstitute o Health and Wel are; Australias Health 2010,we are a healthy nation. Our li e expectancy is amongstthe highest in the world and it has been so or sometime. Australia is ranked third in the world or li eexpectancy rom birth at 79 and 84 years or males and

emales respectively. For those now aged 65 years, malescan expect to live to 84 years and emales to around 87years. These gures contrast li e expectancy in the 1900swhere it was 55 years or males and 59 years or emales.When considering Australias health within the OECD(Organisation or Co-operation and Development) interms o mortality, risk and protection, and morbidity,with some exceptions such as obesity and in antmortality, we are mostly in the top third on thesemeasures. However, it seems that we are a healthynation, but not in every way (AIHW, 2010). When theimpact o di erent health problems are comparedusing the burden o disease and injury measure cancerand cardiovascular disease are the highest. The nexthighly rated group includes problems such as dementia.Over 200,000 people have dementia and this gure willdouble over the next 20 years. Clearly, on some o thesemeasures, not everyone is ageing well. In terms o the

value o continuing engagement with li e however, thereis an increasing awareness o the importance o this tothe health o older people in later li e and in terms o the community at large.

Dr Isabel HigginsUni ersity of Newcastle, NSW

AGEING WELL


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Mr Sean NolanJohn Hunter Hospital, NSW

The intuitive use o music to a ect mind and body in apositive way is documented throughout history. Egyptianmusic healers combined chant therapies with medical

practices (including pain reduction during childbirth)and Chinese healers prescribed music or emotional andphysical health. Even urther back in antiquity the Greekgod Apollo is described as presiding over both musicand medicine. The rst king o Israel, Saul, was known tolisten to lyre music or relie o symptoms o depressionand Hippocrates, re erred to as the ather o medicine,incorporated music and medicine to treat diseases.Modern history records that the therapeutic bene ts o music have continued to be used in conjunction withmedical treatments to acilitate emotional and physicalhealth, supported by Descartian theories regardingmusics ability to infuence and regulate emotionalconditions, thus a ecting physical conditions.

In recent times, advances in medical technology, andincreasing research in areas such as biomedical musictherapy, unctional neuroscience andpsychoneuroimmunology (PNI), have demonstratedthe measurable e ects on the mind as it processesmusic, and the subsequent e ects on the body. For the

rst time, what has been known intuitively has beenunderpinned by scienti c evidence.

The MindBody Imagery & Musictechnique has beendeveloped by the presenter over a period o twelve yearsto take advantage not only o the mind-body connection,but also the power ul and demonstrated e ects o musicto promote health and wellbeing. This technique canbe adapted or the bene t o diverse populations witha wide range o conditions and symptoms.

Participants will be given a brie historical outlineo the infuence o music on mind and body, theneurophysiological basis o receptive music and

its implications or pain management, a descriptiono the components o calming receptive music, anda practical experience o the role o music in linkingmind and body through the agency o the Mind BodyImagery & Musictechnique.

REFERENCESButler, D.S., Moseley, G.L. (2003)Explain Pain, Noigroup, Adelaide

Hodges, D.A. (2000) Implications o music and brain research,Music Educators Journal, Sep, Vol. 87 Issue 2, p17

Kern, P. (2006) Biomedical music therapy: Research-based oundationo the e ects o music An interview with Dale Taylor.Music TherapyToday(Online) Vol.VII (2) 430-435.

Kiecolt-Glaser, J. K., McGuire, L., Robles, T. R, & Glaser (2002).Psychoneuroimmunology: Psychological infuences on immune

unction and health. Journal of Consulting and Clinical Psychology,70 (3), 537-547.

Koelsch, S. (2009) A neuroscienti c perspective on music therapy,The Neurosciences and Music IIIDisorders and Plasticity:Ann. N.Y.Acad. Sci. 1169: 374384

Krout, R.E. (2007) Music listening to acilitate relaxation andpromote wellness: Integrated aspects o our neurophysiologicalresponses to music The Arts in Psychotherapy34, 134141

Sternberg, EM. (2000) The balance within: The science connectinghealth and emotions, New York: W.H. Freeman and Company.

Taylor, D. B. (2004). Biomedical music therapy. In A. A. Darrow (Ed.),Introduction to approaches in music therapy(pp. 159174). SilverSpring, MD: American Music Therapy Association.

Wieseler-Frank, J., Maier, S.F., Watkins, L.R. (2005) Immune-to-braincommunication dynamically modulates pain: Physiological andpathological consequences, Brain, Behavior, and Immunity19, 104111

THE ROLE OF MUSIC INLINKING MIND AND BODY


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Dr Susie LordJohn Hunter Hospital, NSW

PBLD 01TRANSGENERATIONAL CRPS

This case discussion looks at a amily in which 3generations have been given the label o CRPS. OBJECTIVES

List clinically relevant differences between childhood-onset and adult-onset CRPS

De ne sporadic and familial CRPS Apply current knowledge regarding the genetics of

pain, and CRPS in particular, to the clinical case.Explain how patterns o thinking about pain andways o communicating distress are transmittedbetween generations.

Apply strategies for managing dif cult adult patients to managing di cult amilies

Outline the role of the pain specialist in child protection

REFERENCESde Mos M, Sturkenboom MCJM, Huygen FJPM.Current understandings on complex regional pain syndrome.Pain Practice 2009;9:8699.

Berde CB. Complex regional pain syndromes in childrenand adolescents. Anesthesiology 2005; 102:2525.

de Rooij AM, de Mos M, Sturkenboom MCJM, et al.Familial occurrence o complex regional pain syndrome.Eur J Pain, 2009;13:171-177.

Higashimoto T, Baldwin EE, Gold JI, et al. Refex sympatheticdystrophy: complex regional pain syndrome type I in childrenwith mitochondrial disease and maternal inheritance.

Craig KD. Pain in In ants and children: Sociodevelopmentalvariations on the theme. In: Pain 2002-An Updated Review:Re resher Course Syllabus, edited by Giamberardino MA.IASP Press, Seattle, 2002, pp305-314.

Dies eld K. Interpersonal issues between pain physician and patient:Strategies to reduce confict. Pain Medicine, 2008;9:11181124.


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Dr Myles ConroyBarwon Health, vIC

OBJECTIVESAt the end o this PBLD, participants should be able to:

1. Understand the scope and burden o persistent

post-surgical pain in Australia2. Propose mechanisms or persistent pain related to

speci c surgery types3. Identi y patients at risk or this problem4. Propose preventive strategies or patients at risk5. Initiate appropriate early management when persistent

post-surgical pain is identi ed

REFERENCES1. Kehlet, H, Troels, SJ. Persistent Postsurgical Pain: Risk Factors

and Prevention. Lancet 2006;367:1618-252. Buvanendram, A Regional Anesthesia and Analgesia: Prevention

o Chronic Pain. Techniques in Regional Anesthesia and PainManagement 2008 12(4) 199-202

3. Lois, F. Does Regional Anesthesia Improve Long-term Outcome?Techniques in Regional Anesthesia and Pain Management 200812(4) 203-208

4. Sen H., et al. A Comparison o Ketamine and Gabapentin in Acuteand Chronic Pain a ter Hysterectomy. Anesthesia and Analgesia 2009109(5) 1645-50

5. Mackey, S, Feinberg, S. Pharmacologic Therapies or Complex RegionalPain Syndrome. Current Pain and Headache Reports 2007; 11:38-43

6. Katz, J. Seltzer, Z. Transition rom Acute to Chronic Postsurgical Pain:Risk Factors and Protective Factors. Expert Review Neurotherapeutics2009: 9 (5) pp.723-744

CASE STUDY PREOPERATIVE Tania, 29YO girl Chronic Right knee pain & instability

Booked for knee arthroscopy (MRI normal, suspect occult meniscal tear.)

7 previous arthroscopies including ACL repair and revision

Takes regular panadeine forte, mirtazepine Previous treatment with pregabalin for Rt leg

pain by GP Moved home to live with parents, ceased

clerical work due to knee painWhat features about Tanias presentationmight predict post-op pain?

What issues should be addressed inpre-operative planning?How should she be managed peri-operatively?

PBLD 02MANAGING THE RISKTRANSITION FROMACUTE TO PERSISTENT POSTSURGICAL PAIN


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POSTOPERATIVE Acute Pain Service asked to review Tania in recovery Had GA, parecoxib, morphine 10mg

Complaining of severe Right leg pain, unresponsive to urther morphine in recovery

What issues are important to consider in assessing Tania?What strategies can be employed to control Tanias pain?What is the role of regional analgesia in preventingpersistent pain?

REVIEW DAY 1 Nursing staff report Tania has had a dif cult night Seen by anaesthesia registrar twice. Tania complains of severe constant sharp posterior

knee pain, and a constant burning sensation downthe medial aspect o the cal , with sudden stabs o sharp pain in a similar distribution

Currently she is on a ketamine 12mg/h and a morphinePCA (60mg in last 12/24)What diagnoses should be considered?What suggestions can be made about further management?

HOSPITAL DISCHARGE DAY 8At discharge Tania is taking the ollowing medications:

Prednisolone 50mg

Duloxetine 60mg Daily Oxycontin 60 mg BD Celecoxib 200mg BD Pregabalin 150mg BD Oxycodone 10mg prn Why had her anti-depressant changed?

Why prednisolone?What is the role of gabapentinoids in acute pain andneuropathic pain management?How should she be managed from here?

PAIN CLINIC REVIEW DAY 28

Tania reports ongoing di culty with pain, poor sleep,and lack o interest in social activities. Her mother hasbeen caring or her at home and brings her to clinic.She is concerned about her medications and enquiresabout urther surgery or Tania, as her pain hasnot improved.


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Dr Matthew PolsJohn Hunter Hospital, NSW

OBJECTIVES1. To clari y aspects o the patient history with particular

attention to the psychosocial aspects o the case.2. To contribute to the diagnostic ormulation.

The emphasis will be on psychosocial aspects.3. To use the case ormulation to in orm potential

management strategies with particular attentionto psychosocial aspects.

BRIEF CASE OUTLINE

A 48 year old woman who works as a bus driverpresents to a multidisciplinary pain clinic with a historyo 2 years o persistent pain in her posterior right

orearm projecting down to her ngers. She describedher pain as throbbing, burning and tingling. Her painis exacerbated by li ting. The onset o her pain wasa ter a all at her home.

She has had several investigations includingan ultrasound and nerve conduction studies.The ultrasound soon a ter the injury showed smallpartial tears in the deep bres around the acromion.Nerve conduction studies were normal.Corticosteroid injections provided temporaryrelie yet her pain has persisted.

Her current medication is Oxycontin 20 mg bd andvenla axine XR 225 mg daily.

She has a history o a non-melancholic depressionassociated with prominent anxiety symptoms overthe last 2 years.

She is married and has 2 teenage children. She has hada dispute with her neighbour over the last ew years.She and her husband have also been having relationshipdi culties. There are also more long-standing confictsin her relationships with her sister and her mother.REFERENCES

1. Broom, B.Meaning-full disease. How personal experiences and meaningscause and maintain physical illness.London. Karnac Books. 2007

2. Engel G.L. The clinical application o the biopsychosocial model.American Journal of Psychiatry1980; 137: 535-544.

3. Perry S, Cooper AM, Michels R. The psychodynamic ormulation:its purpose, structure and clinical application. American Journalof Psychiatry1987; 144: 543-550.

PBLD 03 FINDING MEANING IN PAIN


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Dr John MalcolmGeneral Physician, NSW

PBLD 04 MORE THAN MEETS THE EYE:A YOUNG MAN WITH PAIN IN HIS HEAD

This case has many elements: the di culty o obtainingan accurate history and the value o detective workto check the acts; persistent pain in person witha signi cant psychiatric disorder; managing therelationship with the patients psychiatrists; problemso polypharmacy negotiating with and containingthe patient without insight; managing the enmeshedand co-dependent parent; and more!

A young man with acial pain has rather more to hispain problems than was at rst apparent. This casepresentation and discussion raises issues o clinicalassessment, management o long-term opioidtreatment on a background o problematic relationships,psychiatric illness and the di culties in multidisciplinarymanagement in multiple locations.

Dr Simon TateHunter Pain Clinic, NSW

A complex case o neuropathic pain. This case hasprominent biological, psychological and social-developmental aspects. The challenges includediagnostic uncertainty and the application o multimodal therapeutic algorithms where only expertopinion rather than high quality evidence is available.The PDBL also explores the issues surroundingselection o patients or neuromodulation.

OBJECTIVES1. Explain how developmental issues and personal

story impact the presentation2. Describe the main diagnostic and treatment

algorithms or CRPS3. Describe the evidence base or biological

therapy in CRPS4. Explain how you would justi y (or not justi y)

neuromodulation in terms o its cost

REFERENCES1. Harden R and Bruehl S et al. 2010. Validation o proposed diagnostic

criteria (the Budapest Criteria) or Complex Regional Pain Syndrome.Pain. 150 (2) 268-274.

2. Stanton-Hicks MD, Burton AW, Bruehl SP, Carr DB, Harden RN,Hassenbusch SJ, Lubenow TR, Oakley JC, Racz GB, Raj PP, Rauck RL,Rezai AR. 2002. An updated interdisciplinary clinical pathway or CRPS:report o an expert panel.Pain Pract. 2(1):1-16.

3. Bala M, Riemsma R et al. 2008. Systematic Review o the (Cost-)e ectiveness o Spinal Cord Stimulation or People With FailedBack Surgery Syndrome. Clin J Pain. 24(9) 741-756.

4. Simpson E, Duenas A et al. 2009. Spinal cord stimulation orchronic pain o neuropathic or ischaemic origin: systematicreview and economic evaluation. Health Technology Assessment(Winchester, England). 13(17) 1-154.

PBLD 05 NEUROMODULATION IN A COMPLEx CASE.HOW DID WE GET THERE?


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Mr Carl GrahamFremantle Hospital, WA

Dr Newman HarrisRoyal North Shore Hospital, NSW

Dr Frank NewPsychiatrist, QldDr Di PaceyJohn Hunter Hospital, NSW

Dr Simon TameHunter Pain Clinic NSW

TOPICAL SESSION 01HIDDEN DRIvERS OF PAIN:PSYCHOLOGICAL/PSYCHIATRIC PERSPECTIvES

TOPICAL SESSION 02BLUEPRINTING PAINMEDICINE AS A SPECIALTY

A Faculty o Pain Medicine blueprinting subcommitteehas been addressing the challenge o de ning a painmedicine specialist. This is o vital importance to servicedelivery, training, examination and ongoing education.

Not all mental health pro essionals are the same!Beyond the clinical standard o including a mental healthpractitioner in the pain team, this clinical casediscussion examines the di erent but complementaryroles o psychiatrist and clinical psychologist in thepain clinic.

This session will encourage participant interaction basedaround several case studies. There will be discussiono the roles o psychologists and psychiatrists in theassessment and management o persistent pain andthe evolution o therapy beyond the traditional cognitivebehavioural approach.

OBJECTIVESThose attending will be able to:

Describe the Blueprinting process Describe the advantages and disadvantages

o the multidisciplinary nature o the Specialty Describe some of the tasks for trainees in

a multidisciplinary specialty. Make effective use of the special perspectives o colleagues


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Ms Denise DauntJohn Hunter Hospital, NSWMs Meredith JordanJohn Hunter Hospital, NSW

Ms Ruth WhiteJohn Hunter Hospital, NSW

Can less equal more? This session will describe theongoing evolution o short group interventions at HunterIntegrated Pain Service. Concepts o strati ed servicedesign and emerging in ormation content will beexplored and the challenges o short group interventionsdiscussed. Preliminary outcome data will be presented.

1. LOOKING AT THE BIG PICTURE:EVOLVING STRUCTURES IN PAIN MANAGEMENT DELIVERYMs Denise DauntOBJECTIVESAt the conclusion o the session the learner will beable to:

de ne the process for introducing short groupinterventions or pain management

incorporate the principles of HIPS integrated holistic model

explain how patients are coping better with this approach

2. WHAT ARE THE KEY MESSAGES?EVOLVING COMMUNICATION IN PAIN MANAGEMENTMs Ruth WhiteOBJECTIVESAt the conclusion o the session the learner will beable to:

list 10 key ideas for communicating the pain message utilise the language of pain used at HIPS identify options for optimising available resources to

assist implementation

3. IS IT WORKING?IMPROVING qUALITY BY EVALUATING THE OUTCOMESMeredith JordanOBJECTIVESAt the conclusion o the session the learner will beable to:

describe how and where shorter programs can improveoutcomes

describe the effectiveness of short group interventions identify areas requiring further research and

development

REFERENCESBattersby M, 2009 Capabilities or Supporting Prevention and ChronicCondition Sel -Management: A Resource or Educators o PrimaryHealth Care Pro essionals

Flinders Human Behaviour and Health Research Unit,ISBN: 1-74186-584-0

Bodenheimer T; Lorig K;Holman H; Grumbach K, 2002,Patient Sel -management o Chronic Disease in Primary CareJAMA.;288(19):2469-2475

Dennis SM., Zwar N., Gri ths R., Roland M., Hasan I., Powell DaviesG and Harris M., 2008 Chronic disease management in primary care:

rom evidence to policy; MJA ,88: S53S56

Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH, 2004, Improvingthe quality o health care or chronic conditions, Qual Sa HealthCare;13:299305.

Lamb SE, Hansen Z, Lall R, Castelnuovo E, Wither EJ, Nichols V,Potter R, Underwood MR, on behal o the Back Skills Training Trialinvestigators* Group cognitive behavioural treatment or low-back painin primary care: a randomised controlled trial and cost-e ectivenessanalysis www.thelancet.com Published online February 26, 2010

Westman A., Linton SJ., OHrvik J., Wahlen P., Theorell T., LeppertJ., 2010 Controlled 3-year ollow-up o a multidisciplinary painrehabilitation program in primary health care. Disability andRehabilitation,; 32(4): 307316

TOPICAL SESSION 03IMPLEMENTING SHORT GROUP INTERvENTIONSAT THE HUNTER INTEGRATED PAIN SERvICE


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There are various hidden drivers o pain that lie in thebiophysical domain. Awareness o these is the rstprerequisite or identi ying and treating them when they

are present. Without a sound knowledge o these actorssome pain syndromes will orever remain idiopathic.

It is no secret to pain clinicians that there is a vastarray o bio-psycho-social actors infuencing the painexperience. This session brings together some less wellknown biologic actors infuencing pain and some o our methods o dealing with it. These items stem roman increasing scienti c knowledgebase especially inthe eld o metabolic pathways o drug metabolism.For example, an included update will describe enzymaticpolymorphisms o the cytochrome P450 system a ectingmetabolism o common analgesics NSAIDS byCYP2C9, codeine, tramadol and tricyclics by CYP2D6,and buprenorphine, methadone and entanyl byCYP3A4/5 enzymes. Pro Ian Whyte will give an overviewo this and more during this topical session.

Recent research will be presented (Dr Michael Katekar)on mitochondrial dys unction and its relationshipto nociception, tolerance, neuropathies, migraine

and neurodenerative disease plus possible roles inbromyalgia, chronic atigue syndromes and treatment

resistant depression. And Dr Marc Russo will presenton a wide variety o metabolic matters which may eithercontribute to pain conditions or limit responsivenessto our treatments including de ciencies o Vit B12,Vit D, Magnesium in connection with NMDA receptor

unction, nitric oxide signalling, thyroid dys unctione ects on pain and hypercholesterolaemia alterationo response to opioids.

In summary, the three presenters will bring to yourattention a host o matters in the biologic domain whichmay have been lost or hidden rom our considerationas to their e ects on pain and our e orts to relieve it.

TOPICAL SESSION 04HIDDEN DRIvERS OF PAIN: BIOLOGICAL

Dr Michael KatekarJohn Hunter Hospital, NSWDr Marc RussoHunter Pain Clinic, NSW

Pro Ian WhyteCal ary Mater Hospital, NSW


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Notes


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Notes


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Organising CommitteeConvenor Dr Chris Hayes

Committee Members Dr Susie LordDr Stephanie OakDr Di PaceyDr Marc Russo

Con erence SecretariatMs Nina LyonFaculty o Pain Medicine630 St Kilda RdMelbourne VIC 3004Ph: +61 3 9510 6299Fax: +61 3 9510 6786

2010 Fpm Spring Meeting Handbook

Documents

Transcript of 2010 Fpm Spring Meeting Handbook