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Preface

      We hope that you enjoy the following edition of Clinics as much as we enjoyed the process and challenge of putting it together. It certainly was a challenge to condense and summarize the vast and ever-expanding field of pain management into the following articles. Each individual article could easily represent an entire textbook's worth of information if designed for the specialty of pain management. We specifically chose these topics with the hope that they would have the most influence and impact on the readers' everyday practices.
      Our particular goals for this edition are threefold. The first is an attempt to spur our profession into taking a more active role in pain management. Because of our training and the era of efficiency in medicine today, the majority of us practice pain management with a passive, symptomatic approach. We hope to show that this strategy is not representative of doing everything possible to improve the overall care of our patients. The second goal is to highlight the need for more pain management education in our formal training. Our passive attitudes generally represent a lack of education during our formative podiatric educational years. The third goal was to make this edition as clinically relevant as possible for the reader. Each article is planned with clinical points of emphasis for immediate implementation within your practices.
      Pain is the primary symptom that motivates people to seek medical treatment, accounting for over 80% of all office visits to physicians in the United States [
      • Gatchel R.J.
      A biopsychosocial overview of pretreatment screening of patients with pain.
      ]. A reflective look at your own daily practices would probably reveal a surprisingly high percentage of pain management issues. In a single podiatric epidemiologic study that evaluated pain, Helfand reported that nearly 75% of patients aged 65 and older presenting during a 12-year period had a primary compliant or history of lower extremity pain [
      • Helfand A.E.
      Foot problems in older patients: a focused podogeriatric assessment study in ambulatory care.
      ]. The National Ambulatory Medical Care Survey data from 2004 showed that over 73,000 office visits were for acute or chronic musculoskeletal pain and that over 100,000 visits were for acute injuries, including fractures, sprains, contusions, and lacerations. Over 73,000 prescriptions were written that year for nonsteroidal anti-inflammatory drugs, as well as over 46,000 prescriptions for narcotic analgesics [
      • Hing E.
      • Cherry D.K.
      • Woodwell D.A.
      National ambulatory medical care survey: 2004 summary.
      ]. This information provides evidence that the majority of our patients are coming to us to manage their form of pain. It is our responsibility as physicians to be as informed as possible to provide the highest level of patient care.
      Despite this, there is a relative lack of pain management education in our formal training. In the podiatric medical schools there is no dedicated pain management curriculum. Isolated lectures can be found across courses including neurology, pharmacology, and podiatric management, for example. Pain management is not a required rotation in our surgical residencies. The national podiatric medical licensing examinations also demonstrate a relative lack of emphasis with regard to the topic of pain management. Approximately 5% of Part I of these Medical Boards covers topics such as the sensory system and pharmacologic analgesics. Parts II and III dedicate roughly 5% to “integrated pain management.” Our national organization meetings are no different. In the last five American Podiatric Medical Association national meetings, no more than 2 hours of a week of lectures was given to the topic of pain management. There has generally been about an hour dedicated at each annual meeting, usually repeating the topics of anti-inflammatory pharmacology, diabetic neuropathy, and complex regional pain syndrome. The annual American College of Foot and Ankle Surgeons meeting has a similar track record. No recent lectures at the annual meetings have covered topics such as operative pain physiology, chronic pain pathophysiology, preoperative preventative analgesia, multimodal pain management techniques, or addiction recognition.
      This issue of Clinics is not simply a regurgitation of textbook information in review article format. The authors of the following articles were all challenged to make their work as clinically relevant as possible. Indeed, it was our goal for this to be a truly clinical Clinics. Each article has points of emphasis for immediate use and implementation within your practices. We wanted there to be something in each article that you can use this week to improve the treatment of your patients and your overall patient care. We offer you a similar challenge to actively read and incorporate this information.
      By the same token, this edition is by no means meant to be comprehensive. It is simply intended to serve as a starting point for you to build on your knowledge of pain management. I have written before that at some point the practice of medicine becomes a job for each of us. Our mindset unconsciously changes from an active quest for knowledge during our training to a situation of passive, business-like efficiency. We should all revert to a time when we attempted to learn as much as possible from as many situations as possible, so that we were better able and more prepared to help the next patient we encountered.
      Again, we hope that you enjoy the following issue. Please do not hesitate to contact us at any time if we can be of any service to you.

      References

        • Gatchel R.J.
        A biopsychosocial overview of pretreatment screening of patients with pain.
        Clin J Pain. 2001; 17: 192-199
        • Helfand A.E.
        Foot problems in older patients: a focused podogeriatric assessment study in ambulatory care.
        J Amer Podiatr Med Assoc. 2004; 94: 293-304
        • Hing E.
        • Cherry D.K.
        • Woodwell D.A.
        National ambulatory medical care survey: 2004 summary.
        Adv Data. 2006; : 1-33