Initial assessment and management of pain: a pathway for care developed by the British Pain Society.

There is wide variation in how pain is managed in the UK. Patients often find themselves caught in a sea of referrals while continuing to suffer with poorly relieved symptoms. The British Pain Society's (BPS) Initial Assessment and Management of Pain care pathway (one of the five new BPS care pathways published by the Map of Medicine(®)) sets out how best to initially manage persistent pain. Patient education and supported self-management is recommended from an early stage. This pathway focuses on the start of the journey of a patient with pain, where a full diagnostic work-up is not yet complete. The pathway covers diverse recommendations such as appropriate content of a pain consultation, the use of clinical decision management tools to aid stratification of care, and resources to support patients to make informed decisions. Recommendations for monitoring of therapeutic effect are also included. Early identification of people at high risk of chronic disability may allow more intensive management, better use of resources, and reduction in disability. Implementation poses significant challenges; more research is needed to determine the most effective interventions. This article highlights practice points for the non-specialist, discusses areas of controversy, and examines the challenges of implementation.

Pelvic pain: a pathway for care developed for both men and women by the British Pain Society.

This paper aims to explain the key points and highlight some of the controversies in the development of the British Pain Society's pelvic pain patient pathway map. Many clinicians lack experience and confidence with this group of patients, and this issue is highlighted. Additionally, the difficulties of classification and definitions in this area are discussed in detail. These are historical causes of disagreement among specialists which can lead to confused clinical care. This group of patients have multiple issues that cross many professional boundaries; they are best managed by the co-ordinated involvement of multiple teams. Patients suffer from significant distress and disability that often needs specialist assessment and intervention (interdisciplinary). This suggests that an integrated approach is required across the historic boundaries of primary and secondary care. A variety of interventions, including opioids and neuromodulation are recommended in the pathway and the controversies surrounding these inclusions are aired in detail.

Chronic widespread pain, including fibromyalgia: a pathway for care developed by the British Pain Society.

Chronic widespread pain (CWP), including fibromyalgia, is a highly prevalent condition with a range of disabling symptoms, both physical and psychological. The British Pain Society (BPS) is supporting the treatment of this group of patients through a care pathway and this article describes the rationale and discussion points relevant to the CWP and fibromyalgia pathway. There are several aims in producing this pathway: to reduce variation in the standards of care, to reduce delays at all stages of care, and in particular, to enable clinicians to help patients accept a diagnosis of CWP. This diagnosis should be based on the presence and distribution of symptoms in the absence of another defined pathological process: the features in the history or clinical examination are generally more important than laboratory investigations. There is an emphasis on addressing all aspects of symptomatology (physical, psychological, social, and personal needs) without an overemphasis on any one treatment modality. The pathway has focused on the potential pitfalls in the use of long-term opioids and the rationale is provided why these are not recommended. Patients with CWP value explanation and education and although clinicians may be unfamiliar with the condition, the majority of clinicians have generic skills in managing long-term conditions which can be supplemented by the interventions and actions detailed in this pathway.

Neuropathic pain: a pathway for care developed by the British Pain Society.

Neuropathic pain is a common chronic pain condition that can be challenging to treat, particularly for non-specialists. The development of the Map of Medicine care pathway for the management of neuropathic pain was led by the British Pain Society. Focusing on treatment by non-specialists, this pathway is based on new evidence, consensus, and the interests of service users. This paper presents the care pathway and accompanying evidence base, highlighting its salient features, and discussing important treatment points. After initial assessment, the pathway progresses through first-, second-, and third-line drug treatment, includes advice on topical treatment and opioids (in specific circumstances), and describes non-pharmacological approaches. Importantly, timely review of patients and referral to specialist secondary or tertiary care must be considered as vital components of the pathway. Although the emphasis was not on specialist treatment, advice is given on existing interventions, including neural stimulation and multi-disciplinary care. These, and other steps on the pathway, will be subject to further review as more evidence becomes available. In the meantime, the pathway represents a straightforward, valuable and accessible approach for healthcare professionals managing the distress and impact of neuropathic pain.

Low back and radicular pain: a pathway for care developed by the British Pain Society.

These consensus guidelines aim to provide an overview of best practice for managing chronic spinal pain reflecting the heterogeneity of low back pain. Most guidelines have covered only one aspect of spinal care and thus have been divisive and potentially worsened the quality of care. Additionally, some of the evidence base is subjective and of poor quality. The British Pain Society low back pain pathway has reached across all disciplines and involved input from patients. It is recognized, however, that there is an urgent need for further good-quality clinical research in this area to underpin future guidelines. Considerable work is still needed to clarify the evidence; however, foundations have been laid with this pathway. Key features include: risk stratification; clarification of intensity of psychological interventions; a logical progression for the management of sciatica; and decision points for considering structural interventions such as spinal injections and surgery.

EAU guidelines on chronic pelvic pain.

OBJECTIVES: On behalf of the European Association of Urology (EAU) guidelines for diagnosis, therapy and follow-up of chronic pelvic pain patients were established. METHOD: Guidelines were compiled by a working group and based on current literature following a systematic review using MEDLINE. References were weighted by the panel of experts. RESULTS: The full text of the guidelines is available through the EAU Central Office and the EAU website (www.uroweb.org). This article is a short version of this text and summarises the main conclusions from the guidelines on management of chronic pelvic pain. CONCLUSION: A guidelines text is presented including chapters on prostate pain and bladder pain syndromes, urethral pain, scrotal pain, pelvic pain in gynaecological practice, role of the pelvic floor and pudendal nerve, general treatment of chronic pelvic pain and neuromodulation. These guidelines have been drawn up to provide support in the management of the large and difficult group of patients suffering from chronic pelvic pain.

Comparison of a needle-free high-pressure injection system with needle-tipped injection of intracavernosal alprostadil for erectile dysfunction.

Patients identified from hospital records as using alprostadil injections for erectile dysfunction were invited to take part in this open crossover study. On alternate weeks eight patients were given intracavernosal needle injections and transdermal needle-free injection of alprostadil in a randomized order. Efficacy of injection and associated pain were assessed and compared for the two methods. Pain produced during injection was significantly greater with the needle-free system than with the needle-tipped injection whilst efficacy was significantly less. Bruising was reported in all except one patient following needle-free injection only. Patient ratings of the needle-free injector were significantly lower than ratings for needle-tipped alprostadil delivery and when asked to express a preference, every patient chose the needle-tipped injection over the needle-free device.

Characterization of secondary hyperalgesia produced by topical capsaicin jelly--a new experimental tool for pain research.

Peripheral administration of the nociceptive agent capsaicin is used as an experimental tool to study neurophysiological and pharmacological aspects of the generation and control of pain. When investigating secondary hyperalgesia phenomena, current topical and intradermal capsaicin delivery methods have two key limitations. Intradermal injection can evoke severe chemogenic pain and both delivery methods produce an unstable area of dynamic mechanical allodynia. We present validity studies of a new preparation for capsaicin delivery that overcomes these limitations. The novel capsaicin formulation consists of a water-based semisolid jelly preparation containing 1% capsaicin which is applied topically under adhesive-free occlusion to a small area of the skin. We demonstrate that in healthy human subjects this model evokes areas of flare, punctate hyperalgesia and mechanical allodynia which are equivalent to established models and that these areas are stable over time and reproducible on repeat experiments. The jelly formulation evokes only minimal chemogenic pain and, as the preparation remains in situ throughout the study providing constant capsaicin exposure, a stable area of dynamic mechanical allodynia is produced. These validation studies show that this novel capsaicin administration method is a practical, reliable and viable tool for investigating experimental secondary hyperalgesia.

Evaluation of a needle-free injection system for local anaesthesia prior to venous cannulation.

We evaluated a single-use, disposable, carbon-dioxide-powered, needleless injector (J-Tip, National Medical Products Inc., CA, USA), which is claimed to deliver a virtually painless, subcutaneous injection. Seventy-two patients undergoing various types of surgery had a large-bore intravenous cannula inserted prior to induction of general anaesthesia. Three minutes beforehand, a subcutaneous injection of 0.3 ml of 1% plain lidocaine was administered. Subjects were randomly allocated to receive the lidocaine either by the needleless injector or from a conventional syringe and a 25 G needle. Pain scores were recorded on injection of the lidocaine and on insertion of the cannula. There was significantly less pain on injection with the needleless injector than with the 25 G needle (p < 0.001) but, surprisingly, there was more pain on cannulation (p < 0. 001). We conclude that the device certainly delivers a less painful subcutaneous injection than a 25 G needle, but perhaps provides less effective skin anaesthesia for venous cannulation at sites where the subcutaneous space is small; its use might be better suited to areas where the subcutaneous space is deeper.

A trial of intravenous lidocaine on the pain and allodynia of postherpetic neuralgia.

This study investigated the effect of intravenous lidocaine at two doses (1 mg/kg and 5 mg/kg over 2 hours) and an intravenous saline placebo on the pain and allodynia of postherpetic neuralgia (PHN). Twenty-four patients were studied using a randomized, double-blind, within-patient crossover design. Each patient received normal saline, lidocaine 0.5 mg/kg/h, and lidocaine 2.5 mg/kg/h for a 2-h period. The McGill Pain Questionnaire Short Form, visual analogue scores (VAS), and area of allodynia were measured at intervals during the infusions. Free plasma lidocaine levels were also measured. The results were statistically analyzed using Student's t-test for paired data. The VAS for ongoing pain showed a significant reduction after all the infusions (P < 0.05). For dynamic pressure-provoked pain, the VAS was unaffected by placebo but showed a reduction at an equal level of significance with both lidocaine infusions (P < 0.05). The area of allodynia of PHN, as mapped by brush stroke, declined in association with intravenous lidocaine (0.5 mg/kg/h = P < 0.05; 2.5 mg/kg/h = P < 0.001). Placebo had no significant effect on the area of allodynia. These findings demonstrate a positive effect on pain and allodynia following a brief intravenous infusion of lidocaine. The higher dose infusion may produce plasma levels in the toxic range, with no significant clinical increase in response.

The twelfth rib syndrome.

The twelfth rib syndrome appears to be a fairly common and underdiagnosed chronic pain syndrome. It is more common in women than men (3:1) and is usually described as a constant dull ache or sharp stabbing pain that may last from several hours to many weeks. Lateral flexion, rotation of the trunk, and rising from a sitting position classically aggravate the pain. Manipulation of the affected rib and its costal cartilage reproduces it exactly. The diagnosis of this syndrome is clinical, requires exclusion of specific etiologies, and should only be made when the patient's symptoms can be exactly reproduced by manipulation of the affected rib. If symptomatology is complicated, it may be necessary to use an image intensifier for accurate location of the pain locus. Patients with this syndrome can be overinvestigated and have even undergone surgical procedures when this diagnosis has been overlooked. To describe the varied presentation of this syndrome, we describe the clinical manifestations in six patients.

Use of opioids in non-cancer pain.

The use of opioids for chronic pain of non-malignant origin remains controversial. However, problems anticipated from experience with animal experiments and pain-free abusers seldom cause difficulties when opioids are used appropriately to treat pain. With sensible guidelines, and in the context of a multidisciplinary pain clinic, opioids may provide the only hope of relief to many sufferers of chronic pain.

The consequence of delayed versus immediate nerve repair on the properties of regenerating sensory nerve fibres in the adult rat.

Transected saphenous neurones were allowed to regenerate for 3 months via distal stumps of sural nerve following an immediate or a 3 month delayed repair. The number of DRG neurons surviving following the 3 months regeneration period were approximately 60% of normal after both immediate and delayed repair. The percentage of DRG cell bodies identified by the application of Fluro-gold proximal to the repair site and immunopositive for SP, CGRP and galanin was increased following both early and delayed repair compared to baseline values. These values were not significantly different for early repair compared to late repair. Similarly, peripheral measurements of SP in the proximal stump of saphenous nerve (by radioimmunoassay) were not significantly different between models with primary repair compared to delayed repair. These results suggest that the intrinsic regeneration properties of primary sensory neurones are not impaired when repair is delayed.

Substance P in cutaneous primary sensory neurons--a comparison of models of nerve injury that allow varying degrees of regeneration.

We have studied changes in neuropeptide expression in four different models of nerve injury in adult rats. The models involved the cutaneous sural and saphenous nerves, and were associated with different degrees of regrowth and peripheral target reinnervation. These were: simple crush of the nerve, complete cut and self-anastomosis; cut and ligation, and cut and anastomosis of the nerve to an isolated stump of peripheral nerve. Thus, in the first two models a partial or complete reinnervation of peripheral targets was possible, while in the third and fourth it was not. The last model allowed regenerating fibres to come into contact with Schwann cells in the distal stump. We measured substance P-like immunoreactivity in the manipulated nerves (by radioimmunoassay) and the number of manipulated afferents expressing the peptide in dorsal root ganglion cells (by combined immunohistochemistry and retrograde labelling), at time points up to 12 weeks after the nerve manipulations. The retrograde labelling also allowed estimates of cell death. Two weeks after the nerve injuries, when no cell death had occurred, the nerves subjected to a cut lesion (last three models) all showed very low levels of substance P-like immunoreactivity, both in the amounts in peripheral nerve, and in the number of manipulated cell staining positively (P < 0.01). In contrast, the crush model showed no significant change in substance P levels in the nerve (P > 0.05), but a significant increase in the number of immunopositive cells (P < 0.01). Twelve weeks after the nerve manipulations, a variable degree of cell death was seen. Only 9% of afferents in the crush model were lost (P > 0.05 compared with normal) but a 39 and 45% loss was seen in tie and resuture models, respectively, (P < 0.05) for both, compared with normal), and a 63% loss in the stump model (P < 0.01 compared to normal, and P < 0.05 compared to tie and resuture models). An analysis of cell size distributions indicated that cell death affected both large and small cells. At 12 weeks, the levels of substance P in the first two models (associated with peripheral reinnervation) had returned towards, but did not reach, normal (P < 0.01), whilst the stump model showed no significant recovery and the tie model was intermediate. Proportionately more manipulated cells were found to express substance P immunoreactivity in the stump model than expected after allowing for cell death.(ABSTRACT TRUNCATED AT 400 WORDS)

Retrograde labelling of dorsal root ganglion cells in the rat: a quantitative and morphological comparison of Fluoro-Gold with horseradish peroxidase labelling.

We have compared retrograde labelling of rat primary sensory neurons using Fluoro-Gold (FG) and horseradish peroxide conjugated with wheat germ agglutinin (HRP-WGA). Fluoro-Gold 2.5% after 48 h transit time and FG 5% after 24 and 48 h retrogradely labelled similar numbers of cell profiles as HRP-WGA (P greater than 0.1% Student's t-test). The calculated cell size distribution for the above FG groups were similar to those for the HRP-WGA. However, FG 2.5% after a 24 h transit time labelled significantly fewer cells (P less than 0.001 Student's t-test). FG retrograde transport may be used to identify the same population of DRG cells as HRP-WGA.

The effect of a priming epidural injection of adrenaline on epidural blockade with bupivacaine.

Twenty-four patients receiving epidural anaesthesia were studied to test the hypothesis that 1:200,000 adrenaline administered into the epidural space 5 minutes before 20 ml bupivacaine 0.5% would improve nerve block and delay systemic absorption of the local anaesthetic. Group A/B received 20 ml adrenaline 1:200,000 5 minutes before 20 ml bupivacaine 0.5%, group S/BA 20 ml saline followed by 20 ml bupivacaine 0.5% with 100 micrograms adrenaline, and group S/B saline 20 ml followed by 20 ml plain bupivacaine 0.5%. Mean maximum plasma concentrations of bupivacaine tended to be lower in the adrenaline groups. A delay in the time to peak plasma concentration of bupivacaine was noted in the A/B group; this indicated that priming with adrenaline may be effective at delaying early systemic uptake of the local anaesthetic. In both adrenaline groups a more prolonged epidural block and increased efficacy were noted, although this was only significant for the duration of block at T6 (p = 0.023) and duration of motor block at Bromage level 1 (p = 0.016) in group A/B. There seems little clinical advantage in administering adrenaline 5 minutes before bupivacaine.