Managing Pain IE - Q2 - May 2019

Q2 / 2019 AN INDEPENDENT PUBLICATION DISTRIBUTED ON BEHALF OF MEDIAPLANET WHO TAKE SOLE RESPONSIBILITY FOR ITS CONTENTS

IRISH PAIN SOCIETY The societal impact of pain on Irish society and the loss associated with long-term pain. » p2

MIGRAINE ASSOCIATION OF IRELAND Migraines affect people in different ways. Keeping a migraine diary can help you track your symptoms. » p4

EXPERT PANEL How a multidisciplinary approach is needed in helping patients to manage their pain. » p6

Managing Pain

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Pain can affect everyone – it doesn’t discriminate Most people will experience an episode of severe pain at some point in their life. For 20% of adults,1 this pain is persistent and associated with loss; loss of function, identity, in some cases mental health, and in many, loss of the life they had.

JOANNE O’BRIEN President, Irish Pain Society

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revalence rates for Irish p e ople s u f fe r i n g w it h chronic pain range from 13–35.5% of the population.2 Access to pain treatment is a fundamental human right and society needs to act collectively to provide integrated, multidisciplinar y, ev idenced-based care to pain sufferers.

What is chronic pain?

Chronic pain persists longer than three months, either continually or episodically and has no useful function. It can be a result of an injury, an ongoing pathology (e.g. arthritis), involvement of the nervous system (e.g. post herpetic neuralgia (shingles)) or from an unknown or uncertain cause (e.g. fibromyalgia).

Many people in Ireland suffer with severe chronic pain that can affect their work, daily activities and relationships. It has a huge personal and societal impact.

Access to treatment is a fundamental human right Since the Declaration of Montreal (2010), access to pain management is considered a fundamental human right. We know that pain is the primary reason people seek help from healthcare providers and is the main complaint in general practice, pharmacy practice and in the emergency room.

Who treats chronic pain?

Chronic pain is often challenging to treat and general practitioners are usually the first doctors to treat pain in patients.

Patients may be referred to: • An orthopaedic surgeon with joint pain • A rheumatologist with inflammatory or autoimmune associated pain

DR TADHG LYNCH Consultant Pain Specialist, Kilkenny and Dublin

• A neurologist with neurological issues such as migraine/headache • A spinal surgeon due to neck, back or radiating pain like sciatica • A consultant pain specialist or a pain clinic for chronic pain management What treatment is available for chronic pain?

Patient-centred care may include medication, diagnostic and therapeutic minimally-invasive procedures, and multidisciplinary care including physiotherapy and psychological therapy.

A patient who has persistent and severe pain, that has not responded to or is not suitable for surgery or medical treatment by other specialists, should be referred to a pain specialist. Pain specialists are consultant medical doctors whose training

and qualifications are approved by the Faculty of Pain Medicine of the College of Anaesthesiology.

A pa i n sel f-m a n agement programme can help patients develop tools to enjoy life, such as pain education, medication management, activity pacing, graduated exercise and psychological tools including cognitive behavioural therapy, relaxation techniques and others.

Diet and nutrition advice from a dietitian and work and activity advice from an occupational therapist can also be very helpful.

Pain treatment in Ireland is under-resourced Unfortunately, treatment of pain in Ireland is under-resourced, with prolonged waiting times for sufferers to gain access to specialised pain.3 Healthcare costs associated with pain in Ireland have been estimated at up to €5.34 billion (or 2.86% of GDP) per year,4 posing a significant burden on the individual and on the economy.

EFIC The Irish Pain Society is a non-profit organisation of multidisciplinary healthcare professionals and scientists dedicated to research, and educational and clinical aspects of pain management.

As a chapter of the European Pain Federation (EFIC), we collaborate with colleagues across Europe to improve the lives of people with pain. We believe there is an urgent need in Ireland for integrated, cost-effective, multidisciplinary primary and secondary care services for patients with pain, and for increased support for pain research. We are delighted to support the ‘Managing Pain Campaign’.

1: Breivik et al. 2006 2: Breivik et al., 2006; Raftery et al., 2011 3: Fullen et al., 2006 4: Raftery et al., 2012

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Patients’ perspectives: LOUISE O’SULLIVAN 29 years old. Works in residential sales, Cork

MEL FARRELL 32 years old. Lecturer and researcher, County Longford

SUSAN HADDON 40 years old. Works in Sales, Dublin

“I use yoga and breathing techniques to tackle my migraines.”

“Migraine isn’t a women’s-only illness.”

“My migraines turned out to be genetic.”

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You have no control when a migraine hits You have very little – if any – control of when a migraine will strike. You could be in work, driving or in a social setting. That would immediately make me panic: ‘How will I cope? How will I get home? What about the task I need to finish for work? My anxiety raced all the while my body was trying to process the migraine itself.

The migraine aura makes me feel nauseous just to think of In my younger days, the migraine aura looked like a colourful version of ‘TV static’ – flickering, colourful snowy blotches that I would see in my peripheral vision. In adulthood, it more accurately resembles zigzag, pulsating lines, expanding from the centre of my vision outwards. Just thinking about it here is making my stomach feel sick. It’s absolutely horrible.

Once a migraine has set in, the pain is so bad, I can only text, ‘Migraine’ if people try to get in touch. Then it’s several hours of nausea and vomiting.

ear, panic, nausea, numbness and throbbing pain. For me, that’s what my first migraine felt like. It took me a long time to understand the connection between the mind and the body, and how it can help me deal with my migraines. I’ve battled with intense anxiety for most of my life, but I’ve learned to manage it with counselling and yoga. The knock-on effect this has had on my migraine has been hugely beneficial.

My migraine routine However, many migraines later, I’ve managed to level off my fear at the onset of attacks with a ritual that I stick to.

Once I feel the visual aura starting, I immediately take my medication. I get plenty of water and find a space that’s as quiet and private as possible. Once I’ve managed this much, I sit down, close my eyes and very simply try to breathe deeply in and out.

I reassure myself, sip water, and just breathe to distract myself as much as possible from the physical symptoms.

Once my mind is calm I find that I’m far better equipped to manage the migraine itself.

Although focusing your attention away from the physical symptoms is challenging, with practice it can become a powerful skill and one I definitely recommend integrating into in the battle against migraine.

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have found that many people see migraine as a ‘female condition’. While it is more prevalent in women (8:1 ratio), men do suffer migraine and it has an equally debilitating effect on our lives. Some individuals have even said quite disapproving things to me about it, basically questioning my manliness.

There are friends in my life who simply do not understand.

By a comment or look you sort of know that is one barrier that won’t ever come down.

Teenage hormones can increase the intensity and frequency of migraines The years between ages 7-15 were the worst of my life in terms of migraine attacks. Very few people understood what I was going through, which caused a lot of additional stress. In hindsight, I realise I was depressed.

Even onions can trigger a migraine!

Triggers for me include extreme changes of weather or barometric pressure, humidity, lack of routine, long gaps between meals, dehydration and, bizarrely, the smell of onions.

Thankfully, I’ve had fewer severe migraines since 2017.

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have suffered ‘headaches’ since I was about three years old. I used to complain to my mother about pains in the back of my head. It was alarming for her since I was so young and, being adopted, I had no family medical history to work with.

In my early 20s, I contacted my birth family and discovered a strong genetic link to migraine. It was only then that I was formally diagnosed at the Migraine Clinic in Beaumont Hospital. The wait to access this clinic was over a year at the time, but the care I received there was second to none. And once you’re in the system, it seems easier to access follow-up care.

There seems to be a migraine-shaped gap in GPs’ knowledge Unfortunately, many GPs seem either uninterested or uneducated about the finer aspects of migraine. It leaves many patients in the dark about the condition in general and how to manage it.

Organisations like The Migraine Association of Ireland (MAI) are vital to help sufferers understand more about the condition and connect with others who can give hints and tips on how best to manage your migraines.

I now have a really good GP who helps me manage with prophylactic and acute treatments, but migraine sufferers desperately need more migraine clinics made available to them. And there definitely needs to be more neurologists who have an interest in migraine in public hospitals – all over the country.

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Doctors’ perspectives:

The benefits of a migraine diary Migraine is the most common headache disorder seen by doctors. It is estimated to cost the Irish economy €252 million a year.1 A migraine diary can be hugely beneficial to patients and their healthcare providers.

DR MARTIN RUTTLEDGE Consultant Neurologist, Beaumont Hospital

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he ICGP Migraine Quick Reference Guide, which was co -aut hored by Dr Ruttledge, Dr Mary Kearney and Ms Esther Tomkins was developed to, “help give doctors a greater understanding of migraine, and improved tools in the assessment of headaches which will help them identify cause of headache,” says GP, Dr Mary Kearney.

The pea k preva lence is for women between the ages of 15-49 years. The life-time prevalence is 42% in females. 2 Some patients experience relatively infrequent attacks during their lifetime, while the average patient gets one to two attacks per month. Approximately 10% of all patients get weekly attacks.

Dr Martin Ruttledge, Consultant Neurologist at Beaumont Hospital,

DR MARY KEARNEY GP and co-author, the Migraine Quick Reference Guide

says: “Migraine is a very common and often debilitating neurological disorder that is underdiagnosed/undertreated by doctors a nd hea lt hca re professiona ls worldwide.”

At t he lau nch of t he ICGP Migraine Quick Reference Guide, Dr Ruttledge said: “Our statistics are getting worse and worse as time goes on. We think there’s probably about three quarters of a million migraineurs in Ireland.”

The more detailed the diary, the better The ICGP M ig ra i ne Q u ick Reference Guide says: “When a patient presents to a general practitioner with recurrent headaches, they should be advised to keep a detailed daily diary. This should include details about the severity of

the headaches, associated features, acute treatments used, effect on lifestyle and possible triggers.

This provides very useful clinical information and can help confi rm the diagnosis. In addition, the diary often demonstrates the benefits of acute and/or other therapies. The diary should include, at the least, symptoms, duration, severity, medication taken and its effect for each attack.”

“It’s all about just sitting and talking to the patients,” says Dr Ruttledge.

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1: Steiner TJ, Stovner LJ, Vos T, Jensen R, Katsarava Z. Migraine is first cause of disability in under 50s: will health politicians now take notice? J Headache Pain 2018 Feb 21; 19(1):17-018-0846-2. 2: Frederick IO, Qiu C, Enquobahrie DA, Aurora SK, Peterlin BL, Gelaye B, et al. Lifetime prevalence and correlates of migraine among women in a pacific northwest pregnancy cohort study. Headache 2014 Apr; 54(4):675-685.

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The role of physiotherapists in helping to treat migraine JULIE SUGRUE Clinical Specialist Physiotherapist, Beaumont Hospital

Using physiotherapy for neck pain to manage migraine Phy s io t h e r ap i s t s c o m m o n l y encounter people with migraine and neck pain. In fact, more than three quarters of people with migraine experience neck pain.

This is due to the anatomical connections between nerves from the upper part of the neck, and nerves from the head and face.

The physiotherapist will ask questions about your neck pain and migraine, and will use a hands-on assessment to determine if the neck stiff ness and pain may be a potential migraine trigger.

Neck pain may be one trigger of many The treatment of migraine is u n ique a nd t he physiot herapist will take into account that your neck will only ever be one trigger of many. The management of neck-related symptoms in m ig raine usua l ly involves hands-on treatment and exercises.

However, all other triggers and lifestyle factors such as hormonal changes, sleep patterns, stress, sk ipping mea ls, dehydration,

obesity and not exercising need to be recognised and managed for overall successful migraine management.

Keeping a migraine diary can pinpoint triggers A physical assessment will raise the physiotherapist’s suspicion that the neck may be acting as a trigger, but it is only through a trial of treatment that the physiotherapist will be sure.

The best thing to do is to keep a detailed headache and migraine diary for at least one month before you star t physiot herapy, and then to continue to record your symptoms during your treatment.

If there is no significant change in the number of days you are getting headache or the severity of your symptoms, then physiotherapy is not working for you.

Focusing on lifestyle changes a nd me d ic at ion i s of te n a n essential addition to treatment, and again a detailed diary will show the areas of management that are most beneficial.

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EXPERT PANEL How different healthcare professionals can help you in your pain management journey.

Often, what patients hear is that it’s, ‘all in their head.”

Emotional impacts of pain DEIRDRE RYAN Chair of Chronic Pain Ireland and Pre-Accredited Psychotherapist

Chronic pain can impact every facet of everyday life, resulting in low self-esteem and loss of meaning.

Patients often question what this new life with chronic pain will look like.

Research shows a high comorbidity of chronic pain with depression and anxiety, but one, often overlooked issue, is grief.

Many of those we support mention what they ‘used to’ be able to do and compare life with pain with life before.

For example: ‘I was always the one everyone came to for help. How will I ask them?’ Or: ‘I used to be able to weed the whole garden, but now I can only manage 10 minutes, then I can’t do anything else

for the rest of the day’.

There are huge losses associated with any chronic health condition. Loss of hopes and dreams of the future, loss of identity or role in the family or at work, loss of physical capacity and dignity are just a few.

While treating the physical problem is usually the main approach, chronic pain is complex and usually involves a psychological component. Often, what patients hear is that it’s, ‘all in their head’.

But what we think and feel impacts how we perceive pain, and life with chronic pain will impact our mental health. It’s vital that anyone with chronic pain addresses their mental health and allows themselves the time to grieve and adjust to life with a chronic condition.

Your pharmacist should be your first port of call if you are in pain SINÉAD RYAN Limerick-based, Community Pharmacist

Pharmacists have a central role in counselling and educat ing pat ients in pain management. When pain killers are taken correctly, they can provide a useful option for responsibly managing pain. Pharmacists are experts in medicines and one of the first ports of call should be your local pharmacy if you are experiencing pain.

The ‘Pain Ladder’ recommends that patients always begin with the lowest form of appropriate pain-relief for the shortest amount of time for their symptoms in order to reduce the incidence of side effects and dependence, for example a simple paracetamol in the first instance.

Pharmacists can provide advice on the strength and type of painkiller that is best for you depending on the type of pain you are experiencing.

Pharmacists provide advice on your condition, give directions for treatment use, outline the recommended dose and explain the precautions for use, while checking it is suitable with your current medicine. They will also advise if an over-the-counter or prescription product should not be taken.

Your pharmacist can help if you are not experiencing any relief from your symptoms after a number of days. Or, if you are experiencing side effects from taking painkillers, you can revisit your pharmacist who will recommend a suitable alternative or refer you to the doctor.

Acknowledging the biological, psychological and social contributors to pain NIALL HALLIDAY Physiotherapist (MSc Pain Science), Chairperson, Chartered Physiotherapists in Pain Management group

Persistent pain is a complex condition. It is best understood by considering the biological, psychological and social factors that contribute to the perpetuation of pain. Physiotherapists play an important role in helping people understand their pain and developing strategies to improve their condition.

International guidelines for numerous pain conditions identify physiotherapists as playing a key role in helping people successfully manage their condition.

At its simplest, the role of a physiotherapist is to listen to the person in front of them and identify the specific factors that are affecting the person in pain. By using their k now le d g e of

pain biology, exercise, goal-setting and problem-solving, a physiotherapist can help the person in pain understand their condition and develop a meaningful plan of action.

It is important for a physiotherapist to explain the significance of the many tests and scans people may have had, ensuring that the management plan in place is the right one.

Developing fitness, education and management strategies take time for people in all walks of life and it is no different for those suffering with long-term pain. A strong relationship between the person in pain and the physiotherapist is key to a positive outcome.

The role of acupuncture in treating chronic pain

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Acupuncture analgesia, in combination with neuroimaging research, offers medicine a physiological understanding of chronic pain treatments with acupuncture. Acupuncture is widely recognised for its effectiveness in the treatment of pain, with substantial research into the effects on a wide range of conditions.

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ver 1.5 billion people suffer from chronic pain conditions worldwide, according to the World Health Organization (WHO) and the National Center for Health Statistics (US).

A systematic review, funded by the National Institute for Health Research, shows that acupuncture is superior to ‘usual care’ and ‘sham acupuncture’ in pain treatment for musculoskeletal conditions, knee osteoarthritis and chronic headaches, including migraine pain.

Acupuncture also shows promise as an adjunct therapy to control symptoms in the treatment of cancer, alleviating pain, fatigue and nausea caused by chemotherapy.1,2,3,4,5 What is acupuncture?

Acupuncture practice is a branch of Traditional Chinese Medicine (TCM). It is a medical treatment that involves the insertion of very thin

needles into specific points on the body’s meridian network. The theory is that invigorating these points releases or redirects the body’s natural energy or ‘Qi’. Qi is the vital life force and illness and pain result from blockages or imbalance within the meridian pathways.

The science behind acupuncture Neu rosc ient i st s have be en studying how acupuncture affects the brain. Brain scans during acupuncture treatments showed changes in patients’ brain activity caused by the pain of inserting needles into the skin. Professor Hugh McPherson, an acupuncture researcher at the University of York, summarises that needle insertion seems to reduce activity in areas of the brain normally associated with pain.6,7 Leonard Goldstein, DDS,PhD, states that pain relief with acu-

puncture comes from inactivating the source of pain by modulating endorphin levels.8 Neuroscientist Richard Harris at the University of Michigan used PET scans to detect opioid receptors targeted by endorphin molecules.

The trials during and after acupuncture treatments showed an increase of endorphins in opioid receptors, preventing the cell from sending pain signals.9 Recent studies in electroacupuncture application for carpal tunnel syndrome, by neuroscientist Vitaly Napadow at the Martinos Center for Biomedical Imaging in Massachusetts, presented improvements in nerve transmission and pain reduction. Patients still felt these improvements three months after the treatment.10 While there is still much to learn about the mechanisms of acupuncture, we can safely say that acupuncture is an viable alternative

JUTTA BRASSIL Chairperson, Acupuncture Council of Ireland

to pharmaceutical options in pain reduction and pain management.

Acupuncture for painrelated conditions Chronic pain sufferers often highlight the side effects of their pain, which impact their life quality. Pain preventing adequate sleep, resulting in tiredness, more pain, fatigue, emotional distress and depression is very common. Acupuncture is also an excellent treatment modality in relieving these symptoms, helping to increase physical energy, calm the mind and support sleep. The WHO endorses acupuncture for pain conditions and many more health disorders.11 Is acupuncture safe?

Research continues to demonstrate a low rate of adverse effects of acupuncture, making it a feasible and safe treatment.12,13 The Acupuncture Council of Ireland

(ACI) believes patient safety is paramount. The ACI is responsible for the regulation and maintenance of a Register of Acupuncturists.

ACI members are required to meet and maintain the standards for safe acupuncture practice set out in its Code of Safe Practice and Code of Ethics.

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https://discover.dc.nihr.ac.uk/content/signal-000426/acupuncture-shown-to-have-benefits-for-treatment-of-some-chronic-pain 2https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2666860/ 3https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5676441/ 4https://www.journalslibrary.nihr.ac.uk/ pgfar/pgfar05030#/abstract 5https://consensus.nih.gov/1997/1997Acupuncture107pdf.pdf 6https://www.journalslibrary.nihr.ac.uk/pgfar/pgfar05030/#/full-report 7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1193550/ 8 ‘Acupuncture for Pain Relief’ in Practical Pain Management 9https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2757074/ 10https://www.theguardian.com/global-development-professionals-network/2017/sep/07/pains-and-needles-brain-scans-point-to-hidden-effects-of-acupuncture 11https://www.iama.edu/OtherArticles/acupuncture_WHO_full_report.pdf 12 https://www.evidencebasedacupuncture.org/safety/ 13https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121068/ 1

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