The challenging field of pain management nursing: caring for patients with persistent pain is complex and challenging and requires specialist skills.

CHRONIC PAIN management is a demanding field of nursing that challenges nurses to develop new skills. Some pain specialists now prefer the term persistent pain, as they feel chronic implies the pain has to have been present a long time. Patients with persistent pain have complex needs that can be addressed in several ways. Nurses working in pain management can work in a clinical role requiring extended knowledge of medications and interventions, or they can be experts in the use of psychological techniques for pain management.

I have worked as a specialist nurse in the Pain Management Centre at Burwood Hospital in Christchurch for five and a half years. When I first joined the multi-disciplinary team, I had little appreciation of the complex problems facing health professionals caring for patients with persistent pain. Unlike patients in acute pain, patients suffering persistent pain often cannot see an end to their pain. Sometimes there is no obvious cause for the pain, just a history of a precipitating event, often many years ago. A recent study found the incidence of persistent pain in New South Wales to be one in five people. There is no reason to expect New Zealand statistics to differ. (1,2)

Many patients are sceptical we can help and sometimes they are not interested in the interventions we can offer. Patients are frequently angry because they feel misunderstood by health professionals, family, friends and funders, eg the Accident Compensation Corporation (ACC). Patients may feel health professionals have not accepted the degree of pain they suffer. Many have unresolved issues with ACC, as some ACC staff can be sceptical about claims of persistent pain, long after the normal healing time has passed. This can lead to increased stress, exacerbating the pain cycle.

Multidisciplinary pain centres were set up to cope with the medical and psychological aspects of persistent pain. (3,4) The centre where I work has three nurses. Alison Middlemiss is skilled in pain management, patient education, and has specialised in psychosocial aspects of pain management, such as biofeedback and relaxation. I coordinate the anaesthetic procedure clinics and have also specialised in interventional therapies such as spinal cord stimulation (SCS) and implanted intrathecal drug pumps. An enrolled nurse Linda McMullan works part-time, assisting in the procedure clinics. Our part-time medical pain specialists include four anaesthetic consultants, a rheumatologist, a musculoskeletal physician, an occupational physician, psychiatrist and an anaesthetic registrar undertaking the anaesthetic training programme. Allied health professionals include two physiotherapists, two occupational therapists, two psychologists, a social worker and a vocational guidance counsellor. A service manager and three full-time secretaries complete our team.

'Complex condition'

Persistent pain is a complex condition. It is often started by an injury but can include migraines and neuropathic pain following viral infections. A combination of neurobiological changes in the central and peripheral nervous systems cause a disruption to the inhibitory pathways resulting in persistent pain. (5,6) Latest research suggests the indicators for long-term pain can be present soon after the precipitating event or injury. (6) For some, the perception of pain, a fear that activity will damage the affected part, and social attitudes result in "pain behaviors", eg avoidance of activities, limping or solicitous behaviour by family and care givers (see illustration). These behaviours may exacerbate the problem rather than help it. (7) Because education to help patients overcome their fears is as essential to rehabilitation as medical interventions, a combination of therapists are involved in our centre. As well as endeavouring to improve patients' ability to cope with pain, we also aim to help restore normal functioning and increase patients' confidence in their ability to do activities of daily living.

The physical changes in the central nervous system associated with persistent pain are complex and not completely understood. There have been recent advances in pharmacology, with new drugs such as Gabapentin, Tramadol or the Cox 2 inhibitors, that may improve some pain, eg some types of neuropathic pain, but there are no medications that can remove all persistent pain. To accept a pain management approach, it is important patients realise their pain may not be cured. We hope, with a collaborative multidisciplinary approach, they will learn to better manage their pain so it does not rule their lives.

Psychological and clinical input

Nurses specialising in persistent pain management can work with psychological techniques or clinical Procedures, or a combination of both. My colleague is an expert in assessing patient suitability for cognitive behavioural programmes. She undertakes psychosocial evaluations. She also teaches within the programmes and takes patients for individual sessions, if they cannot cope with a group setting. She carries out individual and group relaxation and has been getting positive results with biofeedback therapy for migraine sufferers.

My primary role at the centre is coordinating and running procedure clinics, where minor day procedures such as steroid epidurals, nerve blocks, intravenous infusions, chemical lumbar sympathectomies and intrathecal pump refills, are performed. Up to 18 pain clinics are held a month. After the patient's initial assessment with an anaesthetist, they are referred to me to arrange funding and to book the procedure. The initial phone call to book the procedure is a useful opportunity to answer questions about the procedure and any prescribed medications, as well as to establish that day admission is appropriate for the particular patient.

Running the day procedure clinic involves ensuring all drugs and equipment are available. This entails liaising with various hospital departments, eg x-ray, operating theatres and recovery ward, as well as outside medical supplies firms.

As all the doctors work part-time for the centre, I follow up the patients after their procedure. Some patients contact me when the effect of the previous treatment has worn off so I can assess them for suitability for a repeat procedure. The ACC contracts with the hospital require me to gain funding approval for ACC patients before booking any interventions.

Another aspect of my position is coordinating the neuromodulation screening team. Our screening team consists of a pain consultant, a psychologist, physiotherapist, vocational consultant and myself. At Burwood we assess chronic pain patients suitability for spinal cord stimulation (SCS). This involves implanting an electrode lead on the dorsal column of the spinal cord, which is then powered by an implanted pulse generator (IPG) implanted subcutaneously in the abdomen. Electrode placement on the cord depends on the area to be stimulated, eg lumbar for leg pain or high thoracic for chest pain. By programming the IPG with a computer, the electrode impulses block or reduce pain signals. Careful patient selection is essential to get optimum use from the device, as poor patient selection would be of little benefit to the patient and waste health resources. As well as diagnostic indications such as neuropathic leg pain or chronic refractory angina, positive indicators of success with SCS are a willingness to combine SCS with other self management approaches to pain and continued activity despite pain.

As part of pre-operative education, I discuss the practicalities of living with an implanted device. A recent paper presented to the scientific meeting of the Australian Pain Society, highlighted the importance of preoperative counselling by nurses in successful long-term treatment with SCS. (8) Counselling helps patients move from an unrealistic fear of having an electrical foreign body, to a realistic appraisal of the pain relief measures it can provide. The study showed nurse counselling increased the success of SCS treatment by reducing postoperative patient non-compliance. During the operation, a high level of patient feedback is required to ensure the proper lead placement. The counselling sessions also allow time for thorough explanation of the procedure and to discuss patient expectations.

When I see a patient to programme their SCS, or to refill their implanted drug pump, I see the patient and their social background as a whole. I am assessing their pain in the context of their general health, lifestyle and family situation. I am observing as well as listening, and looking for signs or symptoms that may indicate any change in their condition that may require specialist intervention, eg a deteriorating medical condition. A large part of the consultation is spent on education, not only on use of the device but how to make lifestyle changes to get the best health outcome.

There has been concern within the profession that, as nurses embrace technological skills, they may lose the essence of nursing. As an individual nurse, it is up to me not to lose my nursing focus and to apply my expertise in the care of technical devices to enhance patient care.

Because SCS and implanted intrathecal pumps are new in New Zealand, it is important patients and clinicians have someone they can contact. As some patients are seeing several specialists at one time, eg a cardiologist, a neurosurgeon and a GP, as well as the pain specialist or myself, I need to liaise with each specialist on their patient's progress.

I regularly field questions about neuromodulation and other pain management interventions from clinicians, nurses and ACC officials around the country, either about a patient with an existing implant, one who may be considering an implant or a patient being considered for referral to our centre.

Due to the complexity of persistent pain, the ongoing challenge is to find more effective treatments. Why does one person respond to a treatment when another with the same condition does not? Research into new treatments is essential, as well as audits of current treatments. I am sure in 20 years we will understand more, but for now, the challenge is to find time in an over committed day to do research. Several of us at the Burwood Centre will soon be publishing the results of research into the use of Pamidronate in complex regional pain syndrome. This bisphosphonate is commonly used in Pagets Disease. We are also undertaking an audit of other conditions that respond to this treatment.

Pain management nursing is a field where, as a nurse, I have developed specialist skills that have enabled me to practise autonomously, with a collegial environment with other nursing, medical and allied health colleagues. The continuing research and increasing recognition of the importance of pain medicine and nursing make it a dynamic and stimulating field to work in.

REFERENCES

(1) Crowe, S., (2000) Health service fails sufferers from chronic pain. University of Sydney News 7 September 2000. http://www.used.edu.au/publications/news/2K0907News/0709_pain.html 23/06/02.

(2) NSW Health Survey, (1997) Persistent pain. http://www.health.nsw.gov.au/public-health/hs97hst_ppl.htm 23/06/02

(3) Turner, J.A. and F.J. Keefe (1999) Cognitive behavioral therapy for chronic pain. Pain 1999. An Updated Review, refresher course syllabus. Edited by M. Max, IASP Press, Seattle. 523-533.

(4) Linton, S. (1999) Cognitive behavioral interventions for the secondary prevention of musculoskeletal pain. Pain 1999, An Updated Review, refresher course syllabus. Edited by M. Max, IASP Press, Seattle. 535-544.

(5) Dickenson, A.H. (1996) Pharmacology of pain transmission and control. Pain 1996 An updated review. IASP Press, Seattle. 113-121.

(6) Cousins, M. (2002) Evidence for persisting pain as a disease entity: clinical implications. Paper presented at Australian Pain Society Conference, Sydney. March.

(7) Vlaeyen J.W. and Linton, S.J. (2000) Fear--avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain; 85: 3, 317-332.

(8) Helou, A. and Just, A. (2000) The significance of counseling in successful long-term treatment with Spinal Cord Stimulation. Paper presented to the Australian Pain Society Scientific Meeting, Melbourne, Australia. March.

Jenny Sandom, RN, DipHealth Sci, is a specialist nurse in the Pain Management Centre, Burwood Hospital, Christchurch. She is also secretary of the New Zealand Pain Society, PO Box 5303, Lambton Quay, Wellington.