...........................................................................................................................................................................
NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - SPRING 2001
FROM THE EDITOR
Welcome to the real new millennium
(for the purists)! This year Threshold is
sponsored by Napp. Many thanks for their
support. The world of pain expands.
More people are hearing of the CSAG
report (Services for Patients With Pain).
Hopefully, increased awareness will lead
to an increase in resources to enable
implementation of the recommendations.
Many of you will know that MSPs are
interested in chronic pain, with the
formation of a crossparty parliamentary
working group.
Please let me know of news and views.
You can contact me at:
Department of Anaesthetics
Walton Building
Glasgow Royal Infirmary
84 Castle Street
Glasgow G4 0SF
Tel: 0141 211 4621
Fax: 0141 211 4622
E mail: john@jparris.demon.co.uk
Ruhy Parris
NEWS FROM
NBPA COUNCIL
SPRING SCIENTIFIC MEETING
As the two annual fixtures are currently
March and December, it was felt that it
would be more balanced to spread the
meetings out a bit more (is this pacing?).
The December meeting stays as it is,
however the next Spring meeting now
moves to May. For your diaries, the date
is Friday 11 May 2001, at the usual venue,
Pollock Halls of Residence, University of
Edinburgh. The theme of the meeting will
be “Psychosocial Factors in Chronic
Pain”.
The secretary, Dr Dil Kapur, will
circulate registration forms imminently.
He can be contacted at:
Pain Management Unit
Royal Victoria Infirmary
Queen Victoria Road
Newcastle upon Tyne
NE1 4LP
Tel/Fax: 0191 282 4412
E mail: dilkapur@netcomuk.co.uk
NBPA website: http://www.netcomuk.
co.uk/~dilkapur/index.htm
WINTER SCIENTIFIC MEETING
8 December 2000
Pollock Halls, Edinburgh
The theme of the meeting was “Pain
in Children”, following last year’s highly
successful “Pain in the Elderly”. The
meeting was kindly sponsored by RDG,
Pfizer, Sims Portex, Elan, Rusch, and
Searle.
The first speaker of the morning was
Dr John Currie, Consultant Anaesthetist
at the Royal Hospital for Sick Children,
Glasgow. He is originally a Liverpool
graduate, and has worked in Edinburgh,
Great Ormond Street, Ayr, and for the last
eight years in Glasgow. He has been the
Regional Education Advisor for
anaesthetists for the last 18 months. His
remit was “Running a Chronic Pain
Service for Children”. He currently has
5 or 6 referrals per month of patients with
chronic pain. The approach is
multidisciplinary, and of course involves
the whole family. Paediatric pain is unique
in that everything occurs with a
background of growth and development.
He concentrated on the need for
adequate infrastructure (space, secretarial
support) and most of all time. There is
much emphasis on liaison with other
agencies such as schools, physiotherapy
and community nursing. He sees children
with a wide spectrum of conditions such
as complex regional pain syndrome, pain
after surgery (eg phantom limb pain), and
also atypical pains such as facial pain.
Being paediatric practice, pain from
congenital abnormalities such as spina
bifida, are relatively common. Terminal
disease also features, whether neoplastic
or chronic conditions such as renal failure
and cystic fibrosis.
The principles of pain management in
children echo those in adults, with
emphasis on adequate information, control
of pain, reassurance, increasing levels of
activity, and improving sleep (child and
parent!).
The team approach cannot be
overemphasised. Pharmacological
methods and nerve blocks all have a place
alongside encouragement by nursing,
physiotherapy, and clinical psychology
colleagues to increase function.
Children (as any parent thankfully
knows) grow up, and long term followup
of patients is an area where improved
liaison with adult pain services is vital.
Dr John Currie
The next speaker of the morning was
Ms Zoe Sully, Physiotherapist at the Royal
National Hospital for Rheumatic Diseases,
Bath. She has been involved with the adult
Pain Management Programme for 5 years.
She was then given the remit for
developing a feasibility and business plan
for an adolescent Pain Management
Programme. This has been up and running
for 18 months. Her presentation was on
“Pain Management in Adolescents”.
Adolescents (again as parents will attest)
present unique challenges. Adolescence
is a period of transition from dependence
to independence (Ed: my own children
bear more than a passing resemblance to
Kevin and Perry), when young people are
challenging boundaries (Ed: “you’re not
going out dressed like that!”), changing
schools, and developing their sexual
identities. There is clinical demand for
an adolescent service, indeed some 10%
of adults had pain in childhood.
Factors associated with adolescent pain
presentation are a family in crisis, stress,
school and social difficulties, physical
difficulties, and changes is family
dynamics. Pain associated disability
(PADS) in a young person includes low
mood / high anxiety, low self confidence,
dependence at a time of growing
independence, reduced fitness, poor
school attendance, reduced activity and
social withdrawal. These issues then
impinge on the wider family. In the
programme, again the emphasis is on a
team approach with the psychologist,
physiotherapist, occupational therapist,
nurse, paediatric rheumatologist, and
researchers.
The programme is a 3 week residential
one with parental involvement.
Accommodation is B & B to encourage
independence. There is a pool, and
therapy space. Cognitive behaviour
therapy is the mainstay of the programme
with skills training, family understandings,
physical rehabilitation, goal planning,
pacing and relaxation. There are
opportunities for sessions for parents /
carers only, and conversely sessions for
the young people on their own. Following
discharge, there is a comprehensive
Zoe Sully
summary for the referrer, and patient. Group Standing Committee on Medicines.
Follow-up occurs 3 months, 9 months and The conclusions were to choose medicines
2 years post programme. Telephone which offer the best prospect of benefit
support is available. Both the young for the child with due regard to cost,
person and their parents are assessed on informed use of unlicensed medicines is
various measures such as pain of child, necessary in paediatric practice, health
mood, anxiety and depression. To date, professionals need access to quality
the adolescents have improved on physical medicines information, Trusts and Boards
measures, and the parents show less stress, should support therapeutic practice which
anxiety and depression. It may well be commands peer support. It is important
that a major factor is changing the to have seamless prescribing solutions
attitudes of the parents who then mediate between secondary and primary care, such
change in adolescents. as using joint formularies, shared care
protocols, and of course effective
The final speaker of the morning was communication.
Dr Norman Lannigan, Chief Pharmacist
of Lothian Universities NHS Trust. He
has previously worked in Perth, Glasgow
and Inverclyde. His background is in
analytical chemistry. Special interests
include chronic pain, palliative medicine,
and quality of pharmaceutical services.
He spoke on “Using Medicines Out of
License – Considerations in Prescribing
for Childre n”. The Health Select
Committee (1999) described unlicensed
medicines use in children as “…an
unsatisfactory state of affairs”. The
Medicines Act (1968) requires medicines
to have a product license in order to
protect society from inappropriate
marketing by manufacturers. It is not
intended to prevent competent clinical Dr Norman Lannigan
practitioners from prescribing in the best The afternoon programme was chaired
interests of their patients. Indeed, medical by Dr Mhoira Leng. The first session was
practitioners have the right to prescribe a presentation by Dr Martin Ward Platt,
unlicensed medicine, pharmacists can Consultant Paediatrician, Royal Victoria
dispense them, and nurses are allowed to Infirmary, Newcastle, titled “Pain in
administer them following the direction of Children – Involving Families”. He spoke
the medical practitioner. “Named patient” on the necessity to speak separately to the
products can be prescribed, also child, exploring their particular fears and
unlicensed medicines may be used in anxieties. Pain may be a form of
clinical trials. Medical practitioners can communication within the family, an
use unlicensed medicines outwith Specific avoidance strategy (school or a family
Product Characteristics (SPC). member), or a safety valve. It takes time
to uncover the real issues, unpick
Turner et al (BMJ Jan 1998) estimated relationships, reveal unspoken fears, and
that 36% of children in hospital received identify the locus of control (adult or
an unlicensed medicine during admission, child). A thorough physical examination
and that 25% of all prescriptions for is mandatory, and to listen to the story
children in hospital were for unlicensed given. Once these have been done, it is
medicines. An unlicensed medicine may vital to formulate the problems in terms
be used “off label” (route, dose, age, of how the family sees them and how the
indication). Manufacturers have a health professionals see them. Once this
dilemma when considering clinical trials
in children such as ethical problems
(placebo controlled, exposure of children
to experimental medicines, informed
consent), and also liability issues (adverse
drug reactions, long term growth/
development). This has implications for
practitioners if prescribing outwith
product license as the liability is with the
practitioner not manufacturer.
In February 2000 a policy statement
was produced by the Joint Royal College
of Paediatrics and Child Health and Dr Martin Ward Platt
Neonatal and Paediatric Pharmacists and Dr Mhoira Leng
is done it is then possible to negotiate
solutions with all parties concerned, and
agree ways forward with communication
with the GP, parents etc.
Dr Bob Leckridge from the Glasgow
Homoeopathic Hospital, who is the
President of the Faculty of Homoeopathy,
spoke on “Using Homoeopathic
Medicines in Children”. He comes from
a general practice background, and has
been working using a homoeopathic
approach in the department of
developmental neurology, Royal Hospital
for Sick Children, Glasgow for a number
of years. He described chronic pain as
something which cannot be understood in
terms of tissue damage alone. He
emphasised the importance of “narrative
based research” where the story is
recounted, in detail, in the patients’ own
words. Understanding suffering is the key
task of any doctor. Homoeopathic
therapeutic modalities are based on “like
treats like”. “Remedies” are “potentised”
preparations. Remedies are prepared by
serial succussions and dilutions.
Naturally, there are questions about
standards of training and practice and
about regulation. It is vital to have
evidence based homoeopathy as a way
forward for the future, with meta-
analyses, RCTs, outcome studies, case
series, and qualitative research.
The final speaker of the day was Dr
Graham Carey, Medical Advisor to the
Medical and Dental Defence Union of
Scotland, who addressed “Legal Issues in
the Treatment of Children”. There are
Dr Graham Carey
differences in legal aspects between
England and Scotland. Children differ
from adults legally with regard to consent,
access to health records/Data Protection
Act, and litigation. Over the age of 16 a
person has capacity, but a person under
16 has capacity if they understand the
nature and possible consequences of the
proposed treatment. In Scotland there are
two relevant Acts, namely the Age of
Legal Capacity Act 1991, and the Children
Act 1995. In England & Wales courts can
overrule a child’s refusal of consent to
treatment if under 16, but the situation is
less clear in Scotland. In Scotland a child
under 16 can consent to “procedures and
treatment” for nontherapeutic research,
but probably cannot in England & Wales.
In England & Wales an unmarried father
cannot have access to a child’s health
records, but the situation is less clear in
Scotland. Laws keep changing so it is
important to keep abreast of them where
litigation involves children.
BOOK REVIEW
Our intrepid physiotherapist, Ian
Stevens, currently in Dunblane (ex
Glasgow) has contributed a book review
of Patrick Wall’s “Pain The Science of
Suffering”, below.
“Pain The Science of Suffering”
Patrick Wall
Weidenfield and Nicholson 1999
isbn 0 297 84255 2
Don ‘t judge a book by it’s cover. In
this case you could easily ignore this
advice. The book reviewed here has a
really eye catching cover with human
forms interlaced with a myriad of shapes,
arrows, squares and a maze of spirals .
The maze of shapes makes no sense and
the arrows and lines move easily between
the peripheral body to the head and back
again.
Such is the case with the subject of the
book. The contents weave between the
periphery to central relay sensations and
cognition - no area dominates , all areas
are ripe for study, all ripe for intervention.
We all like certainties and pain is far
from certain. Patrick Wall has spent a
lifetime studying pain and the contents of
this book demonstrate not only a depth
of understanding of the subject but a real
awareness of the focus of the book - man
and his suffering.
The book is no dry academic diatribe
on a complex perplexing subject but an
example of how scientific medicine can be.
The contents of the book are aimed at the
lay reader but no one who has an interest
in trying to understand pain will be
disappointed by its contents.
For Physiotherapists interested in
movement restoration and pain
amelioration the book is both relevant and
valuable. For instance on page 153 Wall
asks the question. ‘What are the
appropriate motor responses to the arrival
of injury signals?’
They attempt: first to remove the
stimulus; second, to adopt a posture to
limit further injury and optimise recovery;
and third, to seek safety, relief and cure.
The youngest, most inexperienced animal
may attempt a series of these responses
triggered by in- built mechanisms. As the
animal grows in experience, the reactions
will become more subtle, elaborate and
sophisticated .If the sequence is frustrated
at any stage, the sensation and posture
remain.
This paragraph alone could perhaps
offer a lifetime of study and on a practical
level it is one most therapists deal with
daily!
The book is full of case histories from
our own familiar culture and contrasts
other cultures’ approaches to dealing with
pain. Some cultures display amazing
stoicism, some religions encourage it
However, change the situation, alter the
circumstances and man’s biological
reaction to pain is universal.
Interestingly there is a section of the
book describing the treatment of pain
whose cause is known and approaches to
the management of conditions whose
cause is not. For Physiotherapists most of
the painful conditions routinely treated are
in the second category!
For Physiotherapists there are
interesting, challenging discussions on the
waxing and waning in terms of popularity
of acupuncture, the important placebo
phenomenon and the role of restoring
patients to functional health in ongoing
pain.
Most importantly the book
demonstrates the importance of movement
in pain and the role that movement has in
restoring bodily health. The book dashes
any notions of dualistic interpretations of
pain and does not offer any hope of finding
a pain ‘centre’ . What Patrick Wall does
offer is a humane need to offer individual
care to individuals suffering pain,
something Physiotherapists strive to offer
on a daily basis . Given the growth in
literature such as this it is hoped that the
understanding and management of those
in pain will only improve.
Ian Stevens BSc MCSP
SCOTTISH NETWORK FOR
CHRONIC PAIN RESEARCH
The 2nd Expert Group Meeting of the
Network was held in Stirling
Management Centre on 6 November
2000.
The morning session consisted of
presentations of ongoing and planned
research into chronic pain issues:
Pain in non-verbal individuals who
have learning disabilities. Brian Scott
(Stirling University) Pain exercise and
a g e i n g : c u r re n t & f u t u re n e t w o r k
research. Dr. Lindsey Carroll (Stirling
University)
Biopsychosocial needs-assessment of
c h ro n i c p a i n s u f f e re r s i n t h e
development of a community-based pain
management support programme Linda
Bates (Pain Association Scotland/Queen
Margaret University College)
Chronic non-malignant pain: health-
care professionals’ beliefs and attitudes.
T and Dr. Denis Martin (on behalf of
Derek Jones, Queen Margaret University
College/Pain Association Scotland)
Chronic non-malignant pain: paths
t h ro u g h t h e c a re m a z e D r. C l a i r e
Mortimer (Queen Margaret University
College).
Following lunch, the group split up
into two workshops - one on the CSAG
report Services for Patients with Pain
and the other on pain and the individual.
NEWS FROM THE REGIONS
GLASGOW: It is an exciting time here, NEWCASTLE: Our illustrious secretary,
planning services (now funded) for the Dr Dil Kapur, has expanded his family.
city. Many challenges and opportunities Welcome to baby Ben.
for all concerned. Only one new baby this
time, Felix Fraser-Krauss to Heidi
(formerly of Glasgow Interdisciplinary
School of Pain), now resident in Fife.
EDINBURGH: NBPA Council Member
Daniel McQueen, has just been appointed
to a Chair in Pharmacology. Dr Lesley
Colvin has been appointed consultant
anaesthetist at the Western General
Hospital. Members will recall her
presentation on neuropathic pain last year.
Welcome back to Scotland for Ian Power
who now is Professor of Anaesthesia. He
exiled himself first to Wales and then Ben Kapur and his big sister
Australia, but has returned home.
DUNDEE PAIN DISCOVERY DAY
Thursday 19 April, West Park Conference Centre, Dundee. The morning will
feature presentations on the basic science of pain. The afternoon will focus on back
pain and the keynote address (Tom Houston Memorial Lecture) will be delivered by
Professor Gordon Waddell.
It was with great sadness that NBPA members learnt of the death of Dr Tom
Houston. He was a Founder Member of the NBPA.
AND FINALLY
Please keep sending letters, e-mails, photos, articles etc. My son Iain (who now
towers above me) has, as ever, been an invaluable source of criticism, advice, technical
knowledge, and loans his digital camera for ever increasing bribes.
Ruhy Parris

The next one day scientific meeting

will be held on 18 May 2001 at the
Stirling Management Centre (9.30am –
CAPTION COMPETITION
4.30pm). Speakers in the morning
include Professor Sir Michael Bond, Dr. Gavin McCallum and Dr. Pete McKenzie (Glasgow)
Professor Ian Power, and Professor Ian
Russell. The afternoon programme
consists of workshops discussing
subjects such as the CSAG report, and
pain and the individual.

Further information from Mrs

Mohinder Watson, mwatson@gmuc.ac.uk
or 0131 554 8160 or SNCPR, Queen
Margaret University College, Duke
Street, Edinburgh, EH6 8HF.

Dr Denis Martin from QMUC has

introduced a new e mail discussion list
for the research, clinical and education
communities interested in the
management of people with pain. The
simplest way is to go to the pain list
www pages at: www.jiscmail.ac.uk/lists/
pain.html, alternatively send a message
to jiscmail@jiscmail.ac.uk with the
message join pain Denis Martin
(replacing Denis Martin with your own The winning caption is
forename and family name). “Pete, these new spinal cord stimulator leads are difficult to handle”
The prize of a £20 book token goes to Dr Mike Basler, Glasgow Royal Infirmary.