This is the text of a presentation delivered by Associate Professor Atkinson at the Annual Scientific Congress of the Royal Australasian College of Surgeons in Hong Kong in 2008.

Multi-disciplinary rehabilitation pain clinics have an important role to play in the management of patients with persistent pain.

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During the first half of the 20th Century patients with challenging pain conditions were usually referred to neurosurgeons. One of the foremost neurosurgeons in this area was William Sweet, Professor at Harvard University in Boston. He published this forty-year experience mainly of anecdotal studies of patients treated uring that time. I visited him in 1969.

But it was in 1975 that I visited Hong Kong with Bill Noordenbos, seen in the picture to the right with H.L. Wen, the father of Hong Kong neurosurgery. By this time, thanks to the basic research scientists such as Patrick Wall, our understanding of pain patho-physiology began to change. There was seldom a simple surgical solution. In Noordenbos's excellent book, "Post-herpetic Neuralgia", this became evident.

In the early 80's John Bonica, seen in the picture below with our guest, Michael Cousins, and also with Issi Pilowsky, began to emphasise the importance and value of multidisciplinary pain clinics. These vulnerable patients with chronic pain needed to be assessed by specialists with different skills. 

Since then the epidemiology of persistent pain has identified the burden of pain in our communities. In Australia in 2001, Fiona Blyth and Michael Cousins identified a prevalence of 17% in males and 20% in females. In England, Nicola Torrance found the prevalence of 8.2%. Rob Helme and others identified a prevalence of neuropathic pain of 51% in the elderly and Von Korffe earlier (1998) identified a prevalence of 41% of patients with back pain in the population.

The pain patient presents us with a complex problem involving biological, sychological and social problems.

There is the basic malfunction in the nervous system due to an injury. Complex micro-anatomical and patho-physiological changes occur particularly in the dorsal horn of the spinal cord.

However, it would be simplistic to consider that we should address the issue of the injury alone. This injury is shrouded by the patient's perception, cultural background and thought processes about pain. John Loeser from Seattle has developed these Loeser rings which help to expand our understanding of the pain process. 

There is the additional affective component. This includes the great suffering that these patients have and the numerous losses - losses of work, of dignity, of money, of friends and normal marital relations. Not surprisingly, when litigation and workers' compensation come into play there are additional features of illness behaviour. Patients take on a sick role for the advantages of being treated as a sick person.

In the multi-disciplinary pain clinic it is necessary to firstly exclude any progressive disease. Investigations need to lead to a diagnosis. Often the patients attending this clinic have particular traits including pain out of proportion to the disease process, an inappropriate use of substances and medications, excessive depression following the pain experience, general physical deconditioning due to fear and avoidance often, superstitious beliefs about bodily functions and, lastly, a failure to work or carry out the expected physical and cognitive activities that a person of that age might be expected to do. (J. Loeser, Surgical Management of Pain, Burchiel, 2002)

For the multi-disciplinary pain program to be effective, not all patients can be admitted to the program. Not all can benefit. There will be exclusions particularly those with dementia, active psychosis and with an excessive medication intake (e.g. opioid intake more than 50mg of Oxycontin equivalent daily). Lastly, patients with active litigation often respond poorly.

The treatment program then includes the initial assessment to exclude progressive disease. Following that it is important to focus on the education of the patient so that they clearly understand the cause of the pain. Often this concept is poorly understood.

In addition, the diet of the patient is important. Obesity and physical deconditioning are a problem. Many drink excessive amounts of coffee and Coca Cola. There tends to be a big focus on rewards such as smoking cigarettes. These patients tend to have an irregular sleep pattern and that needs attention if they are going to cope with the persistent pain.

Intervention procedures need to be considered including peri-neural injections of Marcain and Cortisone, radiofrequency lesions to the lateral facet joints, dorsal column stimulators and intra-thecal delivery of narcotic drugs. Patients need to know the limitations of these procedures.

Medication management is a major issue. Many of these patients are over-dosed with opioid drugs. Opioid drugs often don't work well on neuropathic pain and, as a result, the patients tend to escalate the dosage resulting in dependency and even addiction. There is a place for multi-modal treatment of the neuropathic pain problem but excessive doses of narcotics need to be contained.

In the end the whole program is orientated towards a return to work or a return to an appropriate level of self-care and independence. This may well mean that patients require to develop coping skills and this might need the assistance of a psychologist.

Lastly, while the program is managed by a group of professionals, the group interaction of the patients is important. While numbers in the program vary between five and fifteen, a group of six or eight is probably optimal. The chemistry in this group approach to treatment is most important. The membership of the program includes psychologists, nurses, physiotherapists, occupational therapists, exercise therapists, dietician and support staff brought together by a pain medicine or rehabilitation specialist.

All of this is to no avail unless there are successful outcomes. This can be difficult to prove, although John Loeser again in Seattle has published very clear outlines of his results. The pain self-rating by the patients decreased by 30%; opiate levels decreased by 60%; visits to physicians decreased by 60% while physical activities increased by 300% and gainful employment occurred in 60% followed up over a period of twelve months. (J. Loeser – The Role of Multidisciplinary Pain Clinics, Page 237 – 242, Surgical Management of Pain, Burchiel, 2002)

In conclusion, there is a major role for multi-disciplinary rehabilitation pain clinics in the treatment of the injured patient or the patient recovering from surgery. To be successful these patients must be referred within the first six months.