The Queen Square GP Seminars – “Pain Management and Neuromodulation” – May 2016
On Wednesday May 4th 2016, Queen Square Private Healthcare hosted the second event of its 2016 GP seminar series, again in partnership with our colleagues of the National Hospital for Neurology and Neurosurgery. We were pleased to welcome a record attendance of GPs and charitable organisations to this seminar, the topic of which was Pain Management with a special emphasis on the use of neuromodulation therapy techniques.
The evening was opened by Peter Sutton, Queen Square Private Healthcare’s Manager for Marketing and New Business Development, who explained the vital role that the organisation plays within Queen Square, providing high quality clinical services whilst also creating a vital income stream for the UCLH Charity. He explained that the topic of this month’s seminar was particular apt, since grants from the UCLH Charity had been fundamental in the construction of the new Pain Management Centre of the National Hospital for Neurology and Neurosurgery at their new Cleveland Street site.
Dr Ash Shetty, Consultant in Neuro-anaesthesia and Pain Medicine, opened the evening’s presentations by giving a comprehensive overview of the mechanisms of chronic pain, and a discussion around current, and future treatment pathways. The audience contributed a great deal to the discussion and Dr Shetty’s presentation benefitted from some lively debate. Dr Shetty explained that chronic pain management using neuromodulation techniques is one of the newest, but fastest growing areas of modern medicine. However, only 5 percent of patients who would benefit from this form of therapy are currently receiving it, and large groups of referrers (more than 50%) are either unaware of its availability, or do not feel that they understand it sufficiently to consider its use.
Dr Shetty proceeded to explain that recognition of chronic pain as a disease, rather than as a symptom, is key. Understanding of the mechanisms behind chronic pain is now improving, and it is now understood that chronic pain is not necessarily ‘hard wired’. Instead, glial cells, cells which have been previously overlooked in the pain pathway, are now thought to play a key role in amplification and sensitisation of pain signals. Various medications are available for neuropathic pain, although only around 50% will have any beneficial effect. Therefore, Dr Shetty explained that alternative therapies are required in order to provide the patient with relief from this often debilitating condition. Neuromodulation (any technique which modulates brain chemistry to alter pain pathways) is one such technique. Dating back to Ancient Egypt, neuromodulation using electrical stimulation is now an established and rapidly developing therapeutic tool.
Dr Shetty then proceeded to describe various forms of neuro-stimulation (both central and peripheral) and the work that is currently being undertaken to improve understanding and confidence in the technique.
Spinal Cord Stimulation (SCS) is one of the most commonly known techniques, a technique where an adjustable, non-destructive electrical current is applied direct to the spinal cord, most commonly for the treatment of neuropathic pain. This IED-type device can be used to provide stimulation at various spinal levels, chosen specifically to target the source of the pain. For example, the first use of SCS was for angina pain where stimulation could be performed at the cervico-thoracic junction. Dr Shetty explained that unfortunately, no tool exists to scan a patient and discover the exact cause of chronic pain in each individual patient. However, literature is now emerging which gives evidentiary support for the use of SCS in specific cases. NICE guidelines now exist for the use of SCS in:
- Neuropathic pain
- Back Pain
- Radicular Pain
- Pelvic and Visceral pain (with the use of sacral nerve stimulation)
- Facial and Cranial pain (with the use of occipital nerve stimulation)
Long term outcomes have now been published which support the effectiveness of SCS in cases of post laminectomy (failed back) syndrome, and trials comparing outcomes of SCS compared to coronary artery bypass graft for angina have shown comparable results. Chronic regional pain syndrome is also a condition which would warrant early specialist referral, as early treatment with SCS has been shown to produce better outcomes.
After a lively discussion, Dr Anna Mandeville, Consultant Clinical Psychologist, then took the stage to discuss her work with sufferers of chronic pain, and how psychological input now has increasing importance in the treatment of physical illness such as chronic pain syndrome.
Dr Mandeville explained that 7.8 million people are affected by pain in the UK, a burden which equates to an annual spend of £584million for the NHS. The psychological burden of pain is great, with 25% of sufferers losing employment as a result of their pain, and the majority having some difficulty with normal daily activity at some point.
Pain can only be described by the patient, and cannot be described by physical appearance or tissue damage. Therefore, the potential problem that every patient may face is that they may feel judged if there is a lack of a physical/organic explanation.
Dr Mandeville explained that involving the patient in discussions about the physical manifestation of their pain, and using medical imaging and simplified explanations of the mechanism of pain, can often help the patient understand their condition. Whilst an improved understanding of their pain may still not be desirable to the patient, there can at least be some comfort found in an understanding of the ‘science’ behind what they are experiencing. This improved understanding can often assist the patient in developing coping mechanisms.
It is also crucial that the emotion involved in chronic pain is not overlooked. Mood has been shown to affect pain, and it is often the disabling effect of pain which affects the patient’s normal behaviour which then exacerbates that patient’s experience of their pain. Dr Mandeville explained that pain processing is always more than simply a physical sensation. Instead, interpretation of pain and the emotion that accompanies it, play a key role. In cases where sensation pathways cannot be altered to remove pain, then psychology has a real role to work with the patient on changing their perception of pain, making it more manageable and less disabling.
Dr Mandeville explained that psychology now plays a key role in the multidisciplinary team, particularly when neuromodulation is being considered. Psychological assessment is key to identifying those patients who may benefit, creating understanding and realistic expectations, and developing pain management skills. For this reason, psychological input is valued at all stages of the neuromodulation pathway, from pre-implant to post implantation follow up. The patient can be guided throughout the entire process and psychology used to maximise how the patient uses their device and the comfort they can achieve from it.
After a fascinating and often lively debate, the attendees were invited to meet the presenters and the staff of Queen Square Private Healthcare at a drinks reception held at the Queen Square Private Consulting Rooms. Both Dr Shetty and Dr Mandeville hold regular clinics for private patients at the Consulting Rooms, and contact details can be found at queensquare.com/consultants.
The next GP seminar will be held on Tuesday July 5th 2016, and will feature Dr Sanjeev Rajakulendran who will be providing a practical clinical guide to Epilepsy. Details for registration will be published in the coming weeks.