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The pain relief clinic
Ther. Vol. 12, pp 373-380 © Pergamon Press L'td 1981. Printed in Great Britain
0163-725881 0301-037350 500/0
Pharma(
Specialist Subject Editors: N. E. WILLIAMSand H. WILSON
THE
PAIN
RELIEF
CLINIC
MARK MEHTA
Norfolk and Norwich lnstit,ae for Medical Education, Teaching Centre, Norfolk and Norwict, Hospital, Norwich, NRI 3SR
1. INTRODUCTION The management of chronic pain is complex and demanding, because the aetiology is often uncertain and control or elimination of the underlying disease, as in terminal cancer, may not be possible. Chronic pain serves no useful purpose whereas acute pain at least directs our attention to injury or early disease. After many disappointments the patient is often dissatisfied, sullen and preoccupied with his troubles. On the other hand he may show his annoyance by uncharacteristic bursts of aggression. The physician is also under considerable strain, when faced with an apparently insoluble problem which has defied his best therapeutic efforts. The distress caused by unremitting pain spreads to involve the family circle and close friends. Its social and economic implications concern the whole community and may be of national or even international significance. Many valuable hours of work productivity are lost and there are also the very considerable costs of medical care, drug prescriptions, compensation claims and insurance benefits. Bonica (1977) rightly claims that chronic pain is a national disease of the greatest importance and he was a prime mover in the establishment of pain relief organisations to study and mange these problems. Normally we think of pain as a purely physical disturbance, but this is incorrect (Mersky, 1978) as we should be considering every component of this multi-faceted sensory disturbance (Table 1). A modern pain relief clinic harnesses the skills of a number of interested specialists to maintain this necessarily broad approach to the diagnosis and management of longstanding problems. Many units start in a modest way, perhaps as nerve-blocking clinics, but individual skills, whatever their nature, achieve very little in comparison with a balanced, multidisciplinary team and the present article discusses the evolution and development of this concept. 2. EVOLUTION OF THE PAIN RELIEF CLINIC The idea of a pain relief clinic developed during World War II when Bonica was faced with soldiers in continuous, severe pain as a result of battle injuries (Rovenstine and Wertheim, 1942). He was quick to appreciate that individual expertise, however great, was no substitute for a coordinated, well integrated group of skilled clinicians from different branches of medicine and surgery. Neurosurgeons, psychiatrists, anaesthetists and others were encouraged to pool their resources at regular meetings specifically arranged to discuss these complex problems. However the concept was slow to germinate TABLE 1. Components of the Pain Experience |.
2. 3. 4. 5. 6.
Organic (physical) disturbance Psychological (emotional) change Reaction to past experience e.g. accident in childhood, post-partum pain Cognitive (rational) interpretation of the pain e.g. new pain? Extension of the disease Personality traits--Race, religion, culture Environment--Home and at work, social and economic factors 373
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MARK MEHTA
in the immediate post-war years, possibly because of the immense practical difficulties of assembling busy hospital specialists at the same time and in the same place. There was also the trend towards overspecialisation and the narrow outlook which has been called tunnel vision. Nevertheless from small beginnings isolated units appeared, progressing gradually to more comprehensive organisations which addressed pain as a multifaceted event with social, economic, physiological and psychological representations. Even when pain is unresponsive to available therapy, highly developed pain relief centres have realised the need to create an atmosphere that provides every opportunity for the patient to come to terms with his disability and minimise factors that encourage its expression (Newman et al., 1978a).
3. AIMS 3.1. PAIN THERAPY A pain relief clinic does not exist to provide any individual form of treatment. The wide spectrum of currently available techniques is indicated in Table 2, and a basic aim of the clinic is to select the most appropriate single method or combination of them. Unlike the treatment of acute pain the results of similar techniques applied to chronic conditions are seldom perfect and are often incomplete or not maintained indefinitely. Patients and their advisers must therefore be encouraged to appreciate small improvements and to accept that analgesic drugs may have to be continued in combination with other treatments (Boulton, 1978).
3.2. DIAGNOSIS
Every attempt should be made to establish a diagnosis before commencing treatment and it is essential to take a full history and consider the physical findings. If physical examination does not provide an explanation then psychiatric assessment is advisable. Certainly the complaint of pain should never be dismissed or belittled in the absence of a definite organic factor. Pain is what the patient says it is and exists where ever he says it does (Sternbach, 1974). In this context it is relevant to consider the symptoms in relationship to mental state, life history, past experience and personality traits (Bond, 1979). Malingerers are rare in a pain relief clinic, but there are some patients to whom the disability is a crutch on which to lean, as a defence against an adverse economic or social environment. This situation must be recognized immediately to prevent unnecessary investigations and treatment. TABLE 2. Methods of Treating Chronic Pain 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
General measures e.g. improvements in general health, diet and environment Modify existing pathology e.g. Hormone, antibiotic and cytotoxic therapy. Palliative radiotherapy or limited surgical excision. Central modulation (non-invasive) Analgesic and allied drugs, inhalational analgesia, operant conditioning and biofeedback. Psychotherapy and hypnosis, Yoga and transcendental meditation Injections into the spinal canal--Subarachnoid, subdural or epidural injections of local anaesthetic or neurolytic solutions, barbotage and injection of hypertonic saline Pituitary adenolysis and percutaneous cordotomy Neurosurgery--e.g. Rhizotomy, cordotomy, myelotomy or thalamotomy Peripheral modulation (non-invasive)---Vibration: percussion: massage. Counter-irritation and pain relieving sprays. Trigger points--injection or application of ethyl chloride spray. Acupuncture. Transcutaneous nerve stimulation Peripheral nerve blocks--Injection of local analgesic or neurolytic solutions. Cryoanalgesia. Percutaneous thermal lesions Autonomic block--Surgical or chemical sympathectomy. Regional perfusion--guanethidine Fringe medicine---e.g, osteopathy or chiropractice
The pain relief clinic
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3.3. TEACHING AND TRAINING
There are ample opportunities to learn and develop technical skills, particularly in injection analgesia but an even more important aspect is the general management of a patient in chronic pain. This requires tact. sympathy and an understanding of attitudes and personality traits of those who seek help in the clinic (Bond, 1979). Those who work in a pain relief clinic must also train themselves to be versatile by adopting many roles in relation to their patients (Boulton, 1978). On occasions they need to be sympathetic adviser, friend, psychotherapist, acupuncturist, physiotherapist or even marriage guidance counsellor, but they should also know their limitations and decide when to call in the appropriate expert. 3.4. ANALYSIS AND COLLATION OF RELEVANT SCIENTIFIC AND ECONOMIC DATA
The importance of keeping accurate records cannot be overstated. Only in this way will a great deal of valuable information be collated. Particular facts can be analysed and integrated by computer. For example, it could be helpful to know the relationship between effectiveness of a certain treatment and the expectancy of a relatively pain-free existence. A similar approach is needed for analysis of cost-efficiency of a pain relief clinic. Statistics of this nature are repugnant to most doctors, who are motivated solely by humanitarian reasons, but they are invaluable, at committee level, in convincing administrators or even sceptical colleagues at a time when health budgets are so severely restricted. Figures available in this way substantiate claims for beds, personnel or additional equipment. 3.5. EVALUATION OF TECHNIQUES Initial improvement is often not maintained in chronic pain therapy. Consequently useful evaluation of a particular technique necessitates comparison with other methods and assessment over a reasonable interval of time. In this context results after a year are usually acceptable. Research is also necessary into the mechanism and alternative ways of treating pain. An undoubted benefit of a pain relief service is that it draws attention to many unusual complaints, which have been overlooked in the past because no effective treatment has been available. With the recent increase in our knowledge some help may be forthcoming but, even if this is impossible, it is reassuring for a patient to know that his problems are under continual review and there is always the possibility of a solution in the future. 4. ORGANIZATION It is generally agreed that every hospital serving a large community needs a service to deal with problems of chronic pain. Table 3 shows the wide variety of cases which come TABLE 3. Chronic Pain--Cases Referred to the Pain Relief Clinic 1. 2.
3. 4. 5. 6. 7. 8. 9. JPT.
Post-traumatic--e.g. fractured ribs or pain at site of bony union. Nerve damage neuroma: causalgia Amputation stump or phantom limb pain. Post-operative scars Musculo-skeletal--e.g. Low back pain with referral into the lower limb: "Disc" protrusion. Mechanical degenerative changes. Inflammatory neck pain with referral into upper limb: Cervical spondylosis. Degenerative changes. Inflammatory 'disc" Coccydynia. Ankylosing spondylitis or Paget's disease. Muscle pain. Joint pain--e.g, osteo-arthritic hip Neurological--e.g. Nerve lesions neuroma: neuritis. Nerve entrapment, neuralgia, facial and dental pain, headache, central pain, spasticity and muscle spasms, multiple sclerosis Neoplastic--Direct invasion or compression metastases Inflammatory---e.g. chronic pancreatitis Autonomic nervous system--Peripheral vascular insufficiency. Reflex sympathetic dystrophies. Sudden, unexplained unilateral deafness Mainly psychosomatic--e.g, anxiety neurosis: depression Obscure pain syndromes--e.g. Carotidynia: Mafucci's syndrome Miscellaneous--e.g. migraine 12/2 I
376
MARK MLHTA
into this category but there is considerable difference in opinion on tile nmnbers who should be managed by individual departments and the proportion who should come under the care of a Pain Relief Service. However, experience has shown that for difficult cases of long-standing pain no amount of individual expertise can compensate for the absence of a multidisciplinary approach. The problems encountered in assembling medical personnel, nursing staff, secretaries and other members of a well-run organization are discussed later but it is more important to make a start, even on a modest basis, than to be deterred by the initial difficulties. Indeed, the essential ingredient in any service, is the enthusiast who forms and develops the team and acts as a hub around whom all these activities revolve. He is often, but by no means exclusively, an anesthetist (Swerdlow et al., 1978) but needs to be an individual with considerable interest, patience, resource and unlimited energy, who is not easily put off"by apparently unsurmountable barriers at the beginning. Patients seen in the clinic are referred by specialists in the local hospitals or by general practitioners but some may come from outside the normal catchment area. Certainly no patients are accepted without suitable medical introduction and each letter is scrutinised to ensure the main complaint is chronic pain which has not responded to the usual treatment. This preliminary survey also makes it possible to decide on the degree of urgency of each request. If an anesthetist is running the clinic on his own he may be well advised to adopt a 'closed' service, whereby he sees and treats only patients who have been previously assessed and referred to him by one of his hospital colleagues. In larger centres the system is more flexible and pain patients do not necessarily have to be screened in the first instance by one of the consultants. Nevertheless each referral is carefully' considered and passed to the most appropriate member of the team (Mushin et al., 1977), who then assumes responsibility for all investigations and treatment and mainrains lines of communication with the family doctor and his hospital colleagues. Simpson and his colleagues (1965) emphasize the importance of having a single individual in charge, because most patients are bewildered by a panel of experts and need to know whom they can turn to for advice and information. Domiciliary visits are invaluable for the elderly, confused, disabled or very sick, who cannot travel to hospital (Swerdlow, 1972). The hospital clinician is able to assess home conditions, reactions of the family and help available from outside sources, such as the district nurse and welfare services. At the same time a decision must be made on the advisability of hospital admission. Diagnosis always takes precedence over treatment and this is particularly important with pain, which is sometimes the sole indication of organic disease. If, after a thorough search, the cause is not established it is permissible to identify.' the symptoms as part of a syndrome, like headache, which has known characteristics in regard to prognosis and treatment (Mersky, 1978). Nevertheless, a negative physical examination should always be followed by a psychiatric assessment to see if this will provide a satisfactory explanation for the presenting symptoms. It should be appreciated there is no sharp demarcation between organic, psychological and other components of the pain experience (Table 1). These factors often coexist and it is particularly dangerous, for example, to withhold a comprehensive investigation with X-rays and other tests because the problem appears to be mainly functional in origin. In some cases, when complicated tests are required or the patient has to be seen by a number of specialists, it is more convenient to complete these investigations in hospital. The treatment of chronic pain is difficult, either because the cause is uncertain or elimination of the source is impossible. Results are often unpredictable because the pathways of pain are complicated and interpretation of peripheral stimuli by the brain is confusing. Nevertheless, there is a wide choice of available therapy (Table 2) and greater use could be made of noninvasive techniques, which snpplement or replace the use of more traditional methods (Mehta, 1980). Much has been written about a multidisciplinary approach to diagnosis and treatment (Gerbergshagen et al., 1975: Newman et al., 1978b), but in practice a great deal can be
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achieved on a less ambitious basis with informal discussions between individual members of the pain team and simple methods of treatment. Large committees and group conferences become unwieldy and need firm direction to avoid personality clashes or domination by powerful minorities. It is almost impossible to arrange a meeting of busy specialists at a time and place which is mutually convenient and expect them to put aside heavy individual commitments for this purpose. Most pain-relief teams have to achieve a compromise, by seeing difficult cases individually or in small groups, preferably in hospital. Liaison with the family doctor is essential once the patient has left hospital and he should be informed of all aspects of treatment, especially drugs which are necessary to keep pain under control. In turn the hospital physician will need to know of any significant change in the patient's condition or the need for readmission to hospital. Lines of communication are also maintained by occasional letter cards or a diary with records of daily events. Relatives and friends can assist in the patient's recovery by encouraging outside interests and a return to former activities whenever practicable. Visits by medicosocial workers ensure that home conditions are satisfactory and additional help is summoned whenever necessary. Sometimes treatment is continued on an out-patient basis--as for example, by arrangement with the physiotherapy or occupational therapy department. All these strands of patient care need to be reviewed and integrated at the next visit to the pain relief clinic and appropriate adjustments made to the therapeutic programme. 5. SPACE AND E Q U I P M E N T 5.1. OUT-PATIENTS Although a great deal can be achieved with minimal space and equipment, a fully developed service needs organisation on a wider scale. Out-patients should be received in a pleasant and informal waiting room, where they are greeted individually and put at their ease by a nurse who can answer any preliminary enquiries. Notes, X-rays and other relevant documents are checked by the receptionist. They are available in the consulting room, which needs to have a good light and all the facilities for a comprehensive general medical or neurological examination. Nerve blocks and other minor procedures are conducted in an adjoining fully equipped out-patient theatre. Sterile syringes, needles, towels, galley pots and various solutions for injection are assembled on a tray and scrubbing-up facilities are available for the physician and his assistant. A separate recovery room is needed for recovery, where oxygen and other essential resuscitation equipment are immediately available. Ideally anothe? separate area should be available for noninvasive techniques, such as acupuncture and transcutaneous nerve stimulation, but many practitioners utilise part of the consulting room for this purpose. No-one who has had theatre treatment is allowed home unaccompanied by a responsible adult and when the receptionist or nurse in charge makes an appointment for the next visit, she also arranges suitable transport or notifies the patient of the procedure for hospital admission when this is required. When there is no limitation on space there is a great deal to be said for separate changing rooms and a waiting area for relatives and friends. Proper toilet and kitchen facilities are desirable and in hospitals with a large teaching commitment, it would be very helpful to have a small teaching centre with a library containing essential books on basic pain therapy and illustrations of the common nerve blocks. 5.2. IN-PATIENTS Hospital beds are needed for both emergency and elective pain cases. The use of beds belonging to another consultant is acceptable as a temporary measure but is inconvenient and often impracticable as a long-term arrangement. This is a delicate area for negotiation and requires a great deal of tact, patience and careful statement of need.
378
MARK MI2HIA
Difficulties are greatest in the formative stage of a pain-relief clinic but lessen as the potential of the service is appreciated and statistics on cost efficiency are a persuasive argument in favour of beds exclusively for this purpose. It can be pointed out. e.g., that the successful rehabilitation of any one patient, who has been receiving health insurance and other state subsidies, more than justifies the cost of a bed and the supporting services. Because the relief of chronic pain is a comparatively new venture there are no figures available for bed occupancy. However, in any district general hospital two beds for the smaller pain relief clinic and six beds for the fully developed regional service would not be an overstatement of need. Beds are needed for investigations and assessment, adjustment of drug schedules and for major pain-relieving procedures. Sometimes a patient has to be admitted for a short period because home care has placed an intolerable burden on relatives who need ~t well-deserved rest. Ideally these beds should be centralized in one ward. not only for the convenience of the physician in charge but also to familiarize nurses with the problems encountered in this work. Nevertheless the privilege of having patients under his cz~re imposes considerable responsibilities on the consultant, who may be an anesthetist with theatre commitments and limited time for writing notes and other mundane tasks usuaIh undertaken by a house surgeon or physician. It is also important for the consultant in pain relief to be available on request or make satisfactory arrangements for a deputy throughout the entire period of hospital admission. The recognition of pain relief in the syllabus for higher training and professional examinations might be the stimulus to encourage younger anesthetists to take their share of this commitment. As the service grows it becomes increasingly necessary to have at least one or t~o theatre sessions with full X-ray facilities for accurate control of major procedures like cordotomy, facet denervation and injections into the spinal canal. The danger of complications and the high risk of medico-legal proceedings in the event of a mishap make it almost mandatory to have all available help when performing complex techniques in the vicinity of the spinal cord. The general practitioner is notified when a patient is discharged, sent a full report of the treatment and given a complete list of drugs required on leaving hospital. It is also sometimes necessary to make suitable arrangements with the district nurse, social worker or indeed anyone who has a part to play in the patient's welfare while he is at home. 6. PERSONNEL The size and composition of the Pain Relief Team varies considerably according to local circumstances, financial resources, time available and the range of clinical conditions encountered. There are no exact figures available but at one end of the scale is the single clinician dealing with investigation, diagnosis and management of every case. This arrangement is unsatisfactory because of the wide spectrum presented by the patient with long-standing pain and no individual has sufficient knowledge to deal with every aspect of this complex phenomenon. In many hospitals there is an informal understanding between two or three interested specialists, who concentrate on different aspects of pain therapy but meet occasionally to discuss problems of a complicated nature. A fully evolved multidisciplinary team might involve up to 30 members, with representatives from the anesthetists, neurologists, general surgeons or physicians, general practitioners. psychologists, psychiatrists, physicians in rehabilitation medicine and specialist groups like orthopaedic, dental and neurosurgeons (Bonica and Butler, 1978). The aims and mission of this group are to work as a coordinated team, encourage independent and collaborative clinical investigations, organize teaching programmes and foster relevant research projects. However, this ideal is unattainable in most places and a compromise is reached somewhere between the two extremes (McEwen et al.. 1965). The team should have access to a wide range of other experts, notably a physicist, radiologist and a pharmacologist, who are not involved in the day to day running of the clinic but whose specialist knowledge is often invaluable. Others involved indirectly with the service are
The pain relief clinic
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physiotherapists, occupational therapists, medico--social workers and occasionally the parish priest. The large numbers involved in the successful running of a pain relief service place a high premium on smooth integration of all these units and efficient organization. Teaching is essential for progress but creates great problems in staffing for non-university departments with heavy service commitments. In practice, detailed instruction can be given only to senior residents and young consultants who wish to take up this work. Large groups are not only impracticable but unfair to the patient who needs personal and confidential attention. Nevertheless, it is permissible to have one or two bystanders who come in the role of interested observers. 6.1. NURSES Nurses have an important part to play in this sphere. They need to be fully conversant with operating theatre routine but, in addition to technical proficiency, must be cheerful, tactful and understand the apparently strange behavior and occasional eccentricities of patients in chronic pain. Outside the consulting room patients sometimes present an entirely different picture, when they no longer need to assume a pose or modify emotions specially for the benefit of the doctor. At times like these the nurse can be a shrewd observer and supply a great deal of useful information regarding the intensity of pain or the personality characteristics of the individual. Continuity is helpful, because it enables the nurse to become familiar with the drugs, methods of treatment and after-care of this particular group of patients. 6.2. SECRETARIALHELP
Secretarial help is essential for correspondence and maintaining lines of communication with other members of the team and doctors outside the hospital. In addition she monitors telephone calls and answers patients' queries. A records or filing clerk, who collects notes, X-rays and other essential documents for the clinic, is another useful member of the team. who can also be of assistance in the storage and retrieval of records for research. The difficulties of assembling these essential links in a pain relief team may seem insurmountable in the beginning. However, it is most important to make a start, even on a modest basis, because help gradually becomes available, particularly at the present time when there is greater understanding of the needs for such a service in every large general hospital. 7. PRESENT POSITION AND FUTURE DEVELOPMENTS The challenge of chronic pain, neglected for so many years, is being met but a great deal remains to be achieved. In Great Britain and Ireland the pain relief service has expanded in the last two decades from a handful of isolated units to nearly 200 centres, but these facilities should be available in every major hospital. The size and complexity of pain relief clinics varies considerably and there is no limit to what can be done by any individual at the periphery, but it should be possible for difficult problems to filter through to a regional centre, where there are staff and specialised equipment to deal with them (Swerdlow et al., 1978). There are also cogent reasons for a national institute for coordination of all activities in the pain field. The Medical Research Council in London has made a start by appointing a sub-committee, representing workers in many varied disciplines, to discuss and integrate developments in the understanding and treatment of pain. A clear definition together with a classification of pain syndromes is a case in point and this needs to be exhaustive with sub-sections which are mutually exclusive (Mersky, 1978). The task is extremely difficult for medicine in general and even more taxing for pain, which is essentially a subjective sensation and less precise in definition. Another useful function is the collection of data on uncommon conditions, like the reflex sym-
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MARK Mt:HTA
pathetic dystrophies. It is also necessary for a central, authoritative body to enquire critically into the many branches of fringe medicine like osteopathy, chiropractice and radiesthesia (Mehta, 1980). A great deal of money is spent by sections of the general public, disillusioned with conventional methods of treatment and it is important for these patients and their medical advisers to have a reliable opinion on the value of these techniques. Pain is a unique personal experience, which is difficult to quantify in conventional units and yet it is essential to have valid, acceptable criteria for standardization and comparison of drug potency and the efficacy of different modes of treatment. The use of visual analogue scales and a combination of reliable objective tests with the psychophysical approach {Chapman, 1975). in which both the sensory and psychological aspects of pain are considered, are steps in the right direction. More rigid criteria should limit the increasing number of highly acclaimed new drugs and techniques which do not stand the test of time. Progress emanates from better understanding. Despite recent advances there is still a great deal we do not know about basic pain mechanisms and the reasons for the return of original symptoms after an initial period of relief following ablation of the appropriate pathways, as for example after cordotomy. Even more fundamental is better education of doctors and the general public. Medical students conversant with nearly all aspects of acute pain, are seldom taught about the problems and management of the chronic condition. The press and news media in general are reluctant to feature subjects like chronic pain, which often reflect the inadequacies of modern medicine and do not have the glamour and appeal of heart operations or organ transplants. As a result there is a great deal of unnecessary fear and ignorance in the lay mind, certainly about terminal cancer. Reports on epidemiological studies encompassing the overall situation of the patient, with an emphasis on the social and economic environment, would make interesting reading and may be of greater importance than the current preoccupation with individual aspects of disease and the efficacy of a particular method of treatment. Sensibly presented information of this kind would undoubtedly stimulate interest and encourage better financial support for the growth and establishment of pain relief clinics in the future. REFERENCES BOND, M. (1979) Pain, Its Nature, Analysis and Treatment. Churchill Livingstone, Edinburgh, London and New York. BON'ICA, J. J. (1977) Introduction to Symposium on Pain. Arch. Surg. 112: 749. BONICA, J. J. and BUTLER. S. H. (1978) The management and functions of pain centres. In: Relief of Inrractahh' Pain (2nd ed.) pp. 49-64. SWERDLOW, M. (Ed,). Excerpta Medica, Amsterdam. BOULTON', T. B. (1978~ Editorial. Anaesthesia. 33: 225-226. CHAPMAN, C. R. (19751 Ps.~chophysical exaluation of acupuncture analgesia. Anaesrhesiology, 43(5): 501 505. GERBERSHAGEN. H. U , FREY, R., MAGIN. F., SCHOLL, W. and M{)LLER-SUuR (19751 The pain clinic Br. J. Anaesth. 47: 526-529. McEWEN, B. W.. DE WILDE, F. W., DW~ER, B., WOODFORI)E, J. M.. BLEASEL,K. and CONNELEY, T. J. 11965) The pain clinic: a clinic for the management of intractable pain. 3,Ied. J. Aust. l: 6"6-82. MEHTA, M. (1980) Current views on non-invasive methods of pain relief. In: Pain Therapy, SWERDLOW, M. (Ed.). Current Status of Modern Therapy, Vol. 8. M.T.P. Press Ltd. Lancaster. England. (Awaiting Publication.) MERSKEY, H. {1978) Diagnosis of the patient v,'ith chronic pain. J. Human Stress. 4t2): 3-7. MUSHIN, W. W., SWERDLOW, M., LIPTOX, S. and MEHTA. M. D. (1977) The pain centre. Practitioner 218: 439~440. NEWMAN, R. I., PAINTER. J. R. and SERES.J. L. (1978J A therapeutic milieu for chronic patients. J. Human Stress. 4(2): 8-12. NEWMAN, R. 1.. SERF,S. J. L.. YosPE, L. P. and GARLINOTON, B. (1978) Multidisciplinary treatment of chronic pain: Long-term follow-up of low-back pain patients. Pain 4: 283-292. ROVENSl-INE, E. A. and WERTHEIM, H. M. 11942t Present status of therapeutic regional analgesia. N. Y St. d. Med. 42:123 130. SIMPSON, D. A.. SAUNDERS,J. M., RISCHBIETH,R. H. C., BLRNELL, A. W. and CRAMOND, W. A. (19651 Experiences in a pain clinic. Med. J. Aust. I: 671 675. STERNBACH,R. A. (19741 Pain Patients: Traits and Treatment. Academic Press, New York. SWERDLOW, M. (19721 The pain clinic. Brit. J. Clm. Pruct. 26: 403-405. SWERDLOW, M., MEHTA. M. D. and LIPTON, S. (1978t The role of the anaesthetist in chronic pain management. Anaesthesia. 33: 25(~257.
0163-725881 0301-037350 500/0
Pharma(
Specialist Subject Editors: N. E. WILLIAMSand H. WILSON
THE
PAIN
RELIEF
CLINIC
MARK MEHTA
Norfolk and Norwich lnstit,ae for Medical Education, Teaching Centre, Norfolk and Norwict, Hospital, Norwich, NRI 3SR
1. INTRODUCTION The management of chronic pain is complex and demanding, because the aetiology is often uncertain and control or elimination of the underlying disease, as in terminal cancer, may not be possible. Chronic pain serves no useful purpose whereas acute pain at least directs our attention to injury or early disease. After many disappointments the patient is often dissatisfied, sullen and preoccupied with his troubles. On the other hand he may show his annoyance by uncharacteristic bursts of aggression. The physician is also under considerable strain, when faced with an apparently insoluble problem which has defied his best therapeutic efforts. The distress caused by unremitting pain spreads to involve the family circle and close friends. Its social and economic implications concern the whole community and may be of national or even international significance. Many valuable hours of work productivity are lost and there are also the very considerable costs of medical care, drug prescriptions, compensation claims and insurance benefits. Bonica (1977) rightly claims that chronic pain is a national disease of the greatest importance and he was a prime mover in the establishment of pain relief organisations to study and mange these problems. Normally we think of pain as a purely physical disturbance, but this is incorrect (Mersky, 1978) as we should be considering every component of this multi-faceted sensory disturbance (Table 1). A modern pain relief clinic harnesses the skills of a number of interested specialists to maintain this necessarily broad approach to the diagnosis and management of longstanding problems. Many units start in a modest way, perhaps as nerve-blocking clinics, but individual skills, whatever their nature, achieve very little in comparison with a balanced, multidisciplinary team and the present article discusses the evolution and development of this concept. 2. EVOLUTION OF THE PAIN RELIEF CLINIC The idea of a pain relief clinic developed during World War II when Bonica was faced with soldiers in continuous, severe pain as a result of battle injuries (Rovenstine and Wertheim, 1942). He was quick to appreciate that individual expertise, however great, was no substitute for a coordinated, well integrated group of skilled clinicians from different branches of medicine and surgery. Neurosurgeons, psychiatrists, anaesthetists and others were encouraged to pool their resources at regular meetings specifically arranged to discuss these complex problems. However the concept was slow to germinate TABLE 1. Components of the Pain Experience |.
2. 3. 4. 5. 6.
Organic (physical) disturbance Psychological (emotional) change Reaction to past experience e.g. accident in childhood, post-partum pain Cognitive (rational) interpretation of the pain e.g. new pain? Extension of the disease Personality traits--Race, religion, culture Environment--Home and at work, social and economic factors 373
374
MARK MEHTA
in the immediate post-war years, possibly because of the immense practical difficulties of assembling busy hospital specialists at the same time and in the same place. There was also the trend towards overspecialisation and the narrow outlook which has been called tunnel vision. Nevertheless from small beginnings isolated units appeared, progressing gradually to more comprehensive organisations which addressed pain as a multifaceted event with social, economic, physiological and psychological representations. Even when pain is unresponsive to available therapy, highly developed pain relief centres have realised the need to create an atmosphere that provides every opportunity for the patient to come to terms with his disability and minimise factors that encourage its expression (Newman et al., 1978a).
3. AIMS 3.1. PAIN THERAPY A pain relief clinic does not exist to provide any individual form of treatment. The wide spectrum of currently available techniques is indicated in Table 2, and a basic aim of the clinic is to select the most appropriate single method or combination of them. Unlike the treatment of acute pain the results of similar techniques applied to chronic conditions are seldom perfect and are often incomplete or not maintained indefinitely. Patients and their advisers must therefore be encouraged to appreciate small improvements and to accept that analgesic drugs may have to be continued in combination with other treatments (Boulton, 1978).
3.2. DIAGNOSIS
Every attempt should be made to establish a diagnosis before commencing treatment and it is essential to take a full history and consider the physical findings. If physical examination does not provide an explanation then psychiatric assessment is advisable. Certainly the complaint of pain should never be dismissed or belittled in the absence of a definite organic factor. Pain is what the patient says it is and exists where ever he says it does (Sternbach, 1974). In this context it is relevant to consider the symptoms in relationship to mental state, life history, past experience and personality traits (Bond, 1979). Malingerers are rare in a pain relief clinic, but there are some patients to whom the disability is a crutch on which to lean, as a defence against an adverse economic or social environment. This situation must be recognized immediately to prevent unnecessary investigations and treatment. TABLE 2. Methods of Treating Chronic Pain 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
General measures e.g. improvements in general health, diet and environment Modify existing pathology e.g. Hormone, antibiotic and cytotoxic therapy. Palliative radiotherapy or limited surgical excision. Central modulation (non-invasive) Analgesic and allied drugs, inhalational analgesia, operant conditioning and biofeedback. Psychotherapy and hypnosis, Yoga and transcendental meditation Injections into the spinal canal--Subarachnoid, subdural or epidural injections of local anaesthetic or neurolytic solutions, barbotage and injection of hypertonic saline Pituitary adenolysis and percutaneous cordotomy Neurosurgery--e.g. Rhizotomy, cordotomy, myelotomy or thalamotomy Peripheral modulation (non-invasive)---Vibration: percussion: massage. Counter-irritation and pain relieving sprays. Trigger points--injection or application of ethyl chloride spray. Acupuncture. Transcutaneous nerve stimulation Peripheral nerve blocks--Injection of local analgesic or neurolytic solutions. Cryoanalgesia. Percutaneous thermal lesions Autonomic block--Surgical or chemical sympathectomy. Regional perfusion--guanethidine Fringe medicine---e.g, osteopathy or chiropractice
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3.3. TEACHING AND TRAINING
There are ample opportunities to learn and develop technical skills, particularly in injection analgesia but an even more important aspect is the general management of a patient in chronic pain. This requires tact. sympathy and an understanding of attitudes and personality traits of those who seek help in the clinic (Bond, 1979). Those who work in a pain relief clinic must also train themselves to be versatile by adopting many roles in relation to their patients (Boulton, 1978). On occasions they need to be sympathetic adviser, friend, psychotherapist, acupuncturist, physiotherapist or even marriage guidance counsellor, but they should also know their limitations and decide when to call in the appropriate expert. 3.4. ANALYSIS AND COLLATION OF RELEVANT SCIENTIFIC AND ECONOMIC DATA
The importance of keeping accurate records cannot be overstated. Only in this way will a great deal of valuable information be collated. Particular facts can be analysed and integrated by computer. For example, it could be helpful to know the relationship between effectiveness of a certain treatment and the expectancy of a relatively pain-free existence. A similar approach is needed for analysis of cost-efficiency of a pain relief clinic. Statistics of this nature are repugnant to most doctors, who are motivated solely by humanitarian reasons, but they are invaluable, at committee level, in convincing administrators or even sceptical colleagues at a time when health budgets are so severely restricted. Figures available in this way substantiate claims for beds, personnel or additional equipment. 3.5. EVALUATION OF TECHNIQUES Initial improvement is often not maintained in chronic pain therapy. Consequently useful evaluation of a particular technique necessitates comparison with other methods and assessment over a reasonable interval of time. In this context results after a year are usually acceptable. Research is also necessary into the mechanism and alternative ways of treating pain. An undoubted benefit of a pain relief service is that it draws attention to many unusual complaints, which have been overlooked in the past because no effective treatment has been available. With the recent increase in our knowledge some help may be forthcoming but, even if this is impossible, it is reassuring for a patient to know that his problems are under continual review and there is always the possibility of a solution in the future. 4. ORGANIZATION It is generally agreed that every hospital serving a large community needs a service to deal with problems of chronic pain. Table 3 shows the wide variety of cases which come TABLE 3. Chronic Pain--Cases Referred to the Pain Relief Clinic 1. 2.
3. 4. 5. 6. 7. 8. 9. JPT.
Post-traumatic--e.g. fractured ribs or pain at site of bony union. Nerve damage neuroma: causalgia Amputation stump or phantom limb pain. Post-operative scars Musculo-skeletal--e.g. Low back pain with referral into the lower limb: "Disc" protrusion. Mechanical degenerative changes. Inflammatory neck pain with referral into upper limb: Cervical spondylosis. Degenerative changes. Inflammatory 'disc" Coccydynia. Ankylosing spondylitis or Paget's disease. Muscle pain. Joint pain--e.g, osteo-arthritic hip Neurological--e.g. Nerve lesions neuroma: neuritis. Nerve entrapment, neuralgia, facial and dental pain, headache, central pain, spasticity and muscle spasms, multiple sclerosis Neoplastic--Direct invasion or compression metastases Inflammatory---e.g. chronic pancreatitis Autonomic nervous system--Peripheral vascular insufficiency. Reflex sympathetic dystrophies. Sudden, unexplained unilateral deafness Mainly psychosomatic--e.g, anxiety neurosis: depression Obscure pain syndromes--e.g. Carotidynia: Mafucci's syndrome Miscellaneous--e.g. migraine 12/2 I
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into this category but there is considerable difference in opinion on tile nmnbers who should be managed by individual departments and the proportion who should come under the care of a Pain Relief Service. However, experience has shown that for difficult cases of long-standing pain no amount of individual expertise can compensate for the absence of a multidisciplinary approach. The problems encountered in assembling medical personnel, nursing staff, secretaries and other members of a well-run organization are discussed later but it is more important to make a start, even on a modest basis, than to be deterred by the initial difficulties. Indeed, the essential ingredient in any service, is the enthusiast who forms and develops the team and acts as a hub around whom all these activities revolve. He is often, but by no means exclusively, an anesthetist (Swerdlow et al., 1978) but needs to be an individual with considerable interest, patience, resource and unlimited energy, who is not easily put off"by apparently unsurmountable barriers at the beginning. Patients seen in the clinic are referred by specialists in the local hospitals or by general practitioners but some may come from outside the normal catchment area. Certainly no patients are accepted without suitable medical introduction and each letter is scrutinised to ensure the main complaint is chronic pain which has not responded to the usual treatment. This preliminary survey also makes it possible to decide on the degree of urgency of each request. If an anesthetist is running the clinic on his own he may be well advised to adopt a 'closed' service, whereby he sees and treats only patients who have been previously assessed and referred to him by one of his hospital colleagues. In larger centres the system is more flexible and pain patients do not necessarily have to be screened in the first instance by one of the consultants. Nevertheless each referral is carefully' considered and passed to the most appropriate member of the team (Mushin et al., 1977), who then assumes responsibility for all investigations and treatment and mainrains lines of communication with the family doctor and his hospital colleagues. Simpson and his colleagues (1965) emphasize the importance of having a single individual in charge, because most patients are bewildered by a panel of experts and need to know whom they can turn to for advice and information. Domiciliary visits are invaluable for the elderly, confused, disabled or very sick, who cannot travel to hospital (Swerdlow, 1972). The hospital clinician is able to assess home conditions, reactions of the family and help available from outside sources, such as the district nurse and welfare services. At the same time a decision must be made on the advisability of hospital admission. Diagnosis always takes precedence over treatment and this is particularly important with pain, which is sometimes the sole indication of organic disease. If, after a thorough search, the cause is not established it is permissible to identify.' the symptoms as part of a syndrome, like headache, which has known characteristics in regard to prognosis and treatment (Mersky, 1978). Nevertheless, a negative physical examination should always be followed by a psychiatric assessment to see if this will provide a satisfactory explanation for the presenting symptoms. It should be appreciated there is no sharp demarcation between organic, psychological and other components of the pain experience (Table 1). These factors often coexist and it is particularly dangerous, for example, to withhold a comprehensive investigation with X-rays and other tests because the problem appears to be mainly functional in origin. In some cases, when complicated tests are required or the patient has to be seen by a number of specialists, it is more convenient to complete these investigations in hospital. The treatment of chronic pain is difficult, either because the cause is uncertain or elimination of the source is impossible. Results are often unpredictable because the pathways of pain are complicated and interpretation of peripheral stimuli by the brain is confusing. Nevertheless, there is a wide choice of available therapy (Table 2) and greater use could be made of noninvasive techniques, which snpplement or replace the use of more traditional methods (Mehta, 1980). Much has been written about a multidisciplinary approach to diagnosis and treatment (Gerbergshagen et al., 1975: Newman et al., 1978b), but in practice a great deal can be
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achieved on a less ambitious basis with informal discussions between individual members of the pain team and simple methods of treatment. Large committees and group conferences become unwieldy and need firm direction to avoid personality clashes or domination by powerful minorities. It is almost impossible to arrange a meeting of busy specialists at a time and place which is mutually convenient and expect them to put aside heavy individual commitments for this purpose. Most pain-relief teams have to achieve a compromise, by seeing difficult cases individually or in small groups, preferably in hospital. Liaison with the family doctor is essential once the patient has left hospital and he should be informed of all aspects of treatment, especially drugs which are necessary to keep pain under control. In turn the hospital physician will need to know of any significant change in the patient's condition or the need for readmission to hospital. Lines of communication are also maintained by occasional letter cards or a diary with records of daily events. Relatives and friends can assist in the patient's recovery by encouraging outside interests and a return to former activities whenever practicable. Visits by medicosocial workers ensure that home conditions are satisfactory and additional help is summoned whenever necessary. Sometimes treatment is continued on an out-patient basis--as for example, by arrangement with the physiotherapy or occupational therapy department. All these strands of patient care need to be reviewed and integrated at the next visit to the pain relief clinic and appropriate adjustments made to the therapeutic programme. 5. SPACE AND E Q U I P M E N T 5.1. OUT-PATIENTS Although a great deal can be achieved with minimal space and equipment, a fully developed service needs organisation on a wider scale. Out-patients should be received in a pleasant and informal waiting room, where they are greeted individually and put at their ease by a nurse who can answer any preliminary enquiries. Notes, X-rays and other relevant documents are checked by the receptionist. They are available in the consulting room, which needs to have a good light and all the facilities for a comprehensive general medical or neurological examination. Nerve blocks and other minor procedures are conducted in an adjoining fully equipped out-patient theatre. Sterile syringes, needles, towels, galley pots and various solutions for injection are assembled on a tray and scrubbing-up facilities are available for the physician and his assistant. A separate recovery room is needed for recovery, where oxygen and other essential resuscitation equipment are immediately available. Ideally anothe? separate area should be available for noninvasive techniques, such as acupuncture and transcutaneous nerve stimulation, but many practitioners utilise part of the consulting room for this purpose. No-one who has had theatre treatment is allowed home unaccompanied by a responsible adult and when the receptionist or nurse in charge makes an appointment for the next visit, she also arranges suitable transport or notifies the patient of the procedure for hospital admission when this is required. When there is no limitation on space there is a great deal to be said for separate changing rooms and a waiting area for relatives and friends. Proper toilet and kitchen facilities are desirable and in hospitals with a large teaching commitment, it would be very helpful to have a small teaching centre with a library containing essential books on basic pain therapy and illustrations of the common nerve blocks. 5.2. IN-PATIENTS Hospital beds are needed for both emergency and elective pain cases. The use of beds belonging to another consultant is acceptable as a temporary measure but is inconvenient and often impracticable as a long-term arrangement. This is a delicate area for negotiation and requires a great deal of tact, patience and careful statement of need.
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Difficulties are greatest in the formative stage of a pain-relief clinic but lessen as the potential of the service is appreciated and statistics on cost efficiency are a persuasive argument in favour of beds exclusively for this purpose. It can be pointed out. e.g., that the successful rehabilitation of any one patient, who has been receiving health insurance and other state subsidies, more than justifies the cost of a bed and the supporting services. Because the relief of chronic pain is a comparatively new venture there are no figures available for bed occupancy. However, in any district general hospital two beds for the smaller pain relief clinic and six beds for the fully developed regional service would not be an overstatement of need. Beds are needed for investigations and assessment, adjustment of drug schedules and for major pain-relieving procedures. Sometimes a patient has to be admitted for a short period because home care has placed an intolerable burden on relatives who need ~t well-deserved rest. Ideally these beds should be centralized in one ward. not only for the convenience of the physician in charge but also to familiarize nurses with the problems encountered in this work. Nevertheless the privilege of having patients under his cz~re imposes considerable responsibilities on the consultant, who may be an anesthetist with theatre commitments and limited time for writing notes and other mundane tasks usuaIh undertaken by a house surgeon or physician. It is also important for the consultant in pain relief to be available on request or make satisfactory arrangements for a deputy throughout the entire period of hospital admission. The recognition of pain relief in the syllabus for higher training and professional examinations might be the stimulus to encourage younger anesthetists to take their share of this commitment. As the service grows it becomes increasingly necessary to have at least one or t~o theatre sessions with full X-ray facilities for accurate control of major procedures like cordotomy, facet denervation and injections into the spinal canal. The danger of complications and the high risk of medico-legal proceedings in the event of a mishap make it almost mandatory to have all available help when performing complex techniques in the vicinity of the spinal cord. The general practitioner is notified when a patient is discharged, sent a full report of the treatment and given a complete list of drugs required on leaving hospital. It is also sometimes necessary to make suitable arrangements with the district nurse, social worker or indeed anyone who has a part to play in the patient's welfare while he is at home. 6. PERSONNEL The size and composition of the Pain Relief Team varies considerably according to local circumstances, financial resources, time available and the range of clinical conditions encountered. There are no exact figures available but at one end of the scale is the single clinician dealing with investigation, diagnosis and management of every case. This arrangement is unsatisfactory because of the wide spectrum presented by the patient with long-standing pain and no individual has sufficient knowledge to deal with every aspect of this complex phenomenon. In many hospitals there is an informal understanding between two or three interested specialists, who concentrate on different aspects of pain therapy but meet occasionally to discuss problems of a complicated nature. A fully evolved multidisciplinary team might involve up to 30 members, with representatives from the anesthetists, neurologists, general surgeons or physicians, general practitioners. psychologists, psychiatrists, physicians in rehabilitation medicine and specialist groups like orthopaedic, dental and neurosurgeons (Bonica and Butler, 1978). The aims and mission of this group are to work as a coordinated team, encourage independent and collaborative clinical investigations, organize teaching programmes and foster relevant research projects. However, this ideal is unattainable in most places and a compromise is reached somewhere between the two extremes (McEwen et al.. 1965). The team should have access to a wide range of other experts, notably a physicist, radiologist and a pharmacologist, who are not involved in the day to day running of the clinic but whose specialist knowledge is often invaluable. Others involved indirectly with the service are
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physiotherapists, occupational therapists, medico--social workers and occasionally the parish priest. The large numbers involved in the successful running of a pain relief service place a high premium on smooth integration of all these units and efficient organization. Teaching is essential for progress but creates great problems in staffing for non-university departments with heavy service commitments. In practice, detailed instruction can be given only to senior residents and young consultants who wish to take up this work. Large groups are not only impracticable but unfair to the patient who needs personal and confidential attention. Nevertheless, it is permissible to have one or two bystanders who come in the role of interested observers. 6.1. NURSES Nurses have an important part to play in this sphere. They need to be fully conversant with operating theatre routine but, in addition to technical proficiency, must be cheerful, tactful and understand the apparently strange behavior and occasional eccentricities of patients in chronic pain. Outside the consulting room patients sometimes present an entirely different picture, when they no longer need to assume a pose or modify emotions specially for the benefit of the doctor. At times like these the nurse can be a shrewd observer and supply a great deal of useful information regarding the intensity of pain or the personality characteristics of the individual. Continuity is helpful, because it enables the nurse to become familiar with the drugs, methods of treatment and after-care of this particular group of patients. 6.2. SECRETARIALHELP
Secretarial help is essential for correspondence and maintaining lines of communication with other members of the team and doctors outside the hospital. In addition she monitors telephone calls and answers patients' queries. A records or filing clerk, who collects notes, X-rays and other essential documents for the clinic, is another useful member of the team. who can also be of assistance in the storage and retrieval of records for research. The difficulties of assembling these essential links in a pain relief team may seem insurmountable in the beginning. However, it is most important to make a start, even on a modest basis, because help gradually becomes available, particularly at the present time when there is greater understanding of the needs for such a service in every large general hospital. 7. PRESENT POSITION AND FUTURE DEVELOPMENTS The challenge of chronic pain, neglected for so many years, is being met but a great deal remains to be achieved. In Great Britain and Ireland the pain relief service has expanded in the last two decades from a handful of isolated units to nearly 200 centres, but these facilities should be available in every major hospital. The size and complexity of pain relief clinics varies considerably and there is no limit to what can be done by any individual at the periphery, but it should be possible for difficult problems to filter through to a regional centre, where there are staff and specialised equipment to deal with them (Swerdlow et al., 1978). There are also cogent reasons for a national institute for coordination of all activities in the pain field. The Medical Research Council in London has made a start by appointing a sub-committee, representing workers in many varied disciplines, to discuss and integrate developments in the understanding and treatment of pain. A clear definition together with a classification of pain syndromes is a case in point and this needs to be exhaustive with sub-sections which are mutually exclusive (Mersky, 1978). The task is extremely difficult for medicine in general and even more taxing for pain, which is essentially a subjective sensation and less precise in definition. Another useful function is the collection of data on uncommon conditions, like the reflex sym-
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pathetic dystrophies. It is also necessary for a central, authoritative body to enquire critically into the many branches of fringe medicine like osteopathy, chiropractice and radiesthesia (Mehta, 1980). A great deal of money is spent by sections of the general public, disillusioned with conventional methods of treatment and it is important for these patients and their medical advisers to have a reliable opinion on the value of these techniques. Pain is a unique personal experience, which is difficult to quantify in conventional units and yet it is essential to have valid, acceptable criteria for standardization and comparison of drug potency and the efficacy of different modes of treatment. The use of visual analogue scales and a combination of reliable objective tests with the psychophysical approach {Chapman, 1975). in which both the sensory and psychological aspects of pain are considered, are steps in the right direction. More rigid criteria should limit the increasing number of highly acclaimed new drugs and techniques which do not stand the test of time. Progress emanates from better understanding. Despite recent advances there is still a great deal we do not know about basic pain mechanisms and the reasons for the return of original symptoms after an initial period of relief following ablation of the appropriate pathways, as for example after cordotomy. Even more fundamental is better education of doctors and the general public. Medical students conversant with nearly all aspects of acute pain, are seldom taught about the problems and management of the chronic condition. The press and news media in general are reluctant to feature subjects like chronic pain, which often reflect the inadequacies of modern medicine and do not have the glamour and appeal of heart operations or organ transplants. As a result there is a great deal of unnecessary fear and ignorance in the lay mind, certainly about terminal cancer. Reports on epidemiological studies encompassing the overall situation of the patient, with an emphasis on the social and economic environment, would make interesting reading and may be of greater importance than the current preoccupation with individual aspects of disease and the efficacy of a particular method of treatment. Sensibly presented information of this kind would undoubtedly stimulate interest and encourage better financial support for the growth and establishment of pain relief clinics in the future. REFERENCES BOND, M. (1979) Pain, Its Nature, Analysis and Treatment. Churchill Livingstone, Edinburgh, London and New York. BON'ICA, J. J. (1977) Introduction to Symposium on Pain. Arch. Surg. 112: 749. BONICA, J. J. and BUTLER. S. H. (1978) The management and functions of pain centres. In: Relief of Inrractahh' Pain (2nd ed.) pp. 49-64. SWERDLOW, M. (Ed,). Excerpta Medica, Amsterdam. BOULTON', T. B. (1978~ Editorial. Anaesthesia. 33: 225-226. CHAPMAN, C. R. (19751 Ps.~chophysical exaluation of acupuncture analgesia. Anaesrhesiology, 43(5): 501 505. GERBERSHAGEN. H. U , FREY, R., MAGIN. F., SCHOLL, W. and M{)LLER-SUuR (19751 The pain clinic Br. J. Anaesth. 47: 526-529. McEWEN, B. W.. DE WILDE, F. W., DW~ER, B., WOODFORI)E, J. M.. BLEASEL,K. and CONNELEY, T. J. 11965) The pain clinic: a clinic for the management of intractable pain. 3,Ied. J. Aust. l: 6"6-82. MEHTA, M. (1980) Current views on non-invasive methods of pain relief. In: Pain Therapy, SWERDLOW, M. (Ed.). Current Status of Modern Therapy, Vol. 8. M.T.P. Press Ltd. Lancaster. England. (Awaiting Publication.) MERSKEY, H. {1978) Diagnosis of the patient v,'ith chronic pain. J. Human Stress. 4t2): 3-7. MUSHIN, W. W., SWERDLOW, M., LIPTOX, S. and MEHTA. M. D. (1977) The pain centre. Practitioner 218: 439~440. NEWMAN, R. I., PAINTER. J. R. and SERES.J. L. (1978J A therapeutic milieu for chronic patients. J. Human Stress. 4(2): 8-12. NEWMAN, R. 1.. SERF,S. J. L.. YosPE, L. P. and GARLINOTON, B. (1978) Multidisciplinary treatment of chronic pain: Long-term follow-up of low-back pain patients. Pain 4: 283-292. ROVENSl-INE, E. A. and WERTHEIM, H. M. 11942t Present status of therapeutic regional analgesia. N. Y St. d. Med. 42:123 130. SIMPSON, D. A.. SAUNDERS,J. M., RISCHBIETH,R. H. C., BLRNELL, A. W. and CRAMOND, W. A. (19651 Experiences in a pain clinic. Med. J. Aust. I: 671 675. STERNBACH,R. A. (19741 Pain Patients: Traits and Treatment. Academic Press, New York. SWERDLOW, M. (19721 The pain clinic. Brit. J. Clm. Pruct. 26: 403-405. SWERDLOW, M., MEHTA. M. D. and LIPTON, S. (1978t The role of the anaesthetist in chronic pain management. Anaesthesia. 33: 25(~257.