Multi - Disciplinary Management

Pain is a personal experience and persistent pain can be challenging to treat as one therapy does not work for all. Patients with chronic pain require comprehensive solutions and these are best delivered by an experienced multi-disciplinary team which in simple terms means specialists from different fields work together to facilitate your recovery. The team members include pain specialists, specialist nurses, physiotherapists, occupational therapists, psychologists and dieticians. The interventions are tailored to your needs with an aim of

• Reducing pain
• Increasing function and
• Improving your quality of life

My team delivers care based on Biopsychosocial model of pain taking into account not only the pain but also the holistic impact on your life. Our aim is to address all components hampering your progress including unhelpful beliefs or attitudes, sleep disturbances, gait and physical activities, maladaptive coping mechanisms and any coexisting depression or anxiety. Our team gives emphasis on patient and family education as this helps in promoting active engagement and fosters realistic expectations

Pain Clinic Multi Disciplinary Team

Medication optimisation is an important component of multidisciplinary pain management. Pain reduction achieved with medications can allow you to pursue physical therapies and progress towards your goals. It is important that the correct medication is used in the right dose for the required duration to produce maximum benefit. Sometimes different medications need to be trailed to find the best combination which gives you maximum benefit with least side effects. Medications are selected keeping in mind a number of factors including:

• The type of pain you are experiencing
• Cause and severity of pain
• Other medical problems you may have such as epilepsy, kidney failure, stomach ulcers etc.
• Other medications you are taking
• The medications tried previously

Commonly used medications include

• Simple painkillers- these include drugs such as paracetamol and ibuprofen
• Weak opioids - Opioids are drugs related to morphine. Drugs such as codeine and tramadol are not as strong as morphine and are classified as weak opioids
• Strong opioids – this category includes drugs such as morphine and fentanyl. If you are taking these medications it is important that you understand the risks and side effects. It is essential that you comply with the instructions given to you and do not increase the dose without your doctor's approval. When using these medications it is helpful to set goals and if the medications are not helping then either their dose should be adjusted or they should be tapered and stopped.
  
  To find out more about Fentanyl Patch click here
  
  
• Neuropathic agents - these drugs are more effective in relieving neuropathic or nerve pain. Examples include gabapentin, amitriptyline. It may take as long as 4-6 weeks for the full effects of these drugs to become apparent. These medications are started at a low dose and gradually increased to minimise the side effects and to find the correct dose for you
• Other drugs like muscle relaxants, topical agents- creams, gels, patches, biphosphonates etc.

Physiotherapy is an essential component of chronic pain management. Physiotherapy approach in chronic pain is different compared to that after an injury (acute pain). Longstanding pain results in altered biomechanics and changes in the way nerves transmit the pain sensations to the brain. Altered biomechanics leads to more stress on some body parts at the expense of protecting the painful areas. Over a period of time this can lead to the relative weakening of certain muscles and one needs to be re-educated on the basics such as correct posture, gait and, weight bearing.

We understand that getting started can be difficult. Your physiotherapist will help tailor the exercises to your current functional status.

An experienced physiotherapist can help you by:

• Setting realistic goals
• Dividing exercises into smaller achievable steps giving you a sense of achievement and enabling achievement of bigger goals which may seem impossible initially
• Giving you advice on posture and activity levels
• Educating you about your pain condition and the do’s and don’ts
• Explaining the concept of pacing of activities, activity cycle and helping you implement these. In simple words, this means avoiding over activity at one time and undertaking a predetermined amount of minimal physical activity every day irrespective of pain severity. The amount of physical activity is then increased gradually and maintained to let the body get accustomed to the new activity levels. Hence the focus is on gradual increase and maintaining the positive trend. Doing too much at one time can lead to increase pain and inactivity over the next few days. This is unhelpful as it promotes deconditioning of muscles and reinforced the negative thoughts such as increasing activity means more pain
• Aim to make you independent and self-reliant so that in the long run you can continue with the exercises on your own
• Keep you motivated and guide you through the difficult time, helping you progress towards your goals.

Psychology deals with behaviour and mind. Long-term pain can lead to disability, reduced physical activity, social isolation and strained relations. It is not uncommon for people with chronic pain to become easily irritable, frustrated and moody. This is a normal human reaction which is often more visible to friends and family. Chronic pain can generate significant distress, anxiety and depression and all these, in turn, can magnify perceived pain. Addressing these factors can help in reducing perceived pain and in improving quality of life. This forms a part of the comprehensive pain management plan in keeping with the bio-psychosocial model of pain.

Psychologists can help you by challenging maladaptive beliefs, attitudes and emotions. This involves evaluating your understanding of the pain and any hidden fears, distressing factors. They can help by

• Teaching coping and self-help strategies
• Relaxation techniques- these can be a useful tool especially in dealing with sleep disturbances, periods of increased pain
• Cognitive Behavioural Therapy (CBT)
• Educating you and your family about your pain and the do’s and don’ts
• Helping you draw up a management plan (in liaison with other pain team members) to deal with periods of increased pain
• Promoting active engagement with life addressing any fears, avoidance behaviour and improving confidence levels

Transcutaneous Electrical Nerve Stimulation or TENS involves electrical stimulation of the nerves and other natural mechanisms aimed at providing pain relief. The electrical stimulation is delivered by using a small battery operated portable devices called TENS machine.

The rate, duration, and intensity of stimulus can be adjusted to achieve the best response. Altering the rate of stimulation can alter the predominant pain relief mechanisms being activated and hence the response obtained. The effects can also vary depending on the placement of electrodes. Varying the parameters can reduce the chances of developing tolerance to the beneficial effects. It has been used for a variety of conditions such as musculoskeletal pain, nerve pain, labour pain, osteoarthritis and spinal pain.

TENS has the advantage of having minimal side effects when compared to many other modalities. Your physiotherapist/ pain specialist can guide you regarding the optimal usage of the machine to achieve maximum benefits.

Acupuncture is a complementary pain relief therapy which has been in use for a long time. Traditional Chinese acupuncture involves placing fine needles at the specific points located along channels of energy flow (meridians) in an attempt to correct the imbalances.

Acupuncture is used for a variety of pain conditions including chronic back pain, neck pain, osteoarthritis, headaches, myofascial pain and chronic shoulder pain. Commonly used techniques include dry needling, laser acupuncture, moxibustion and electro acupuncture. As with TENS acupuncture is generally well tolerated with few adverse effects.

Central Nervous system plays an important role in regulating the signals being transmitted from other body parts. Meditation helps to relax body; mind and can help by reducing the amplification of these signals thus reducing the perceived pain. It can help in developing a positive outlook and getting rid of the negativity which exacerbates perceived pain. Whilst we may not have a choice in the diseases we acquire, we do have a choice in how manage them and meditation can help in this.

Effect of meditation on chronic pain conditions has been the subject of many research studies. In a recent systematic review on the effect of mindfulness on chronic pain the authors concluded that mindfulness meditation is associated with a small decrease in pain. They found statistically significant effects on depressive symptoms and quality of life. This systematic review analyzed 38 randomized controlled trials and the authors suggested that more large-scale studies should be conducted to decisively provide estimates of the efficacy of mindfulness.