Ramping Up Our Knowledge Of Pain Management

Stephen Barrett DPM FACFAS

No matter what surgical procedure or even rudimentary treatment you offer, the patient outcome is only as good as what the patient “thinks” about the result. You know what I’m talking about. You just did an incredible piece of work, the foot looks great and you’re ready to send off the X-rays for inclusion in the next edition of McGlamry’s Comprehensive Textbook of Foot Surgery.

Suddenly, the air gets sucked out of your chest faster than it takes to blink and the patient says: “I don’t think it looks that good, Doctor!”

“What?” you reply while trying to hold your emotions in check and try to keep from screaming, “Are you kidding me?”

“Yes, doesn’t it look swollen to you?” (She’s two weeks post-Lapidus by the way.)

This happens every day in clinical practice. If it doesn’t, there are two possibilities to explain this. One, you are not doing enough work. Two, you are the best educator in our profession and take an inordinate amount of time explaining not only the surgical process but the postoperative process, and still are not doing enough work. We have talked about this before but I have been thinking that we need to integrate more tools from some other disciplines to help us with this time-consuming aspect of clinical practice.

Practical Pain Management is a trade publication for practitioners from multiple specialties who deal with pain. I recommend that you get on the mailing list to receive this wonderful publication. It is so refreshing for me to read something totally different, written by numerous different specialists ranging from true pain management physicians to physical therapists, etc. When I read it, I always have a certain patient flash across my mind. “Maybe that’s what I can do for Nancy.”

In the November/December 2011 issue, the publication focuses on insomnia and chronic pain.1 How many of you ask your patients, especially post-op patients, how they are sleeping? Remember that the brain down-regulates with those little chemical treasures like serotonin and norepinephrine, and the brain stockpiles these guys while the patient is asleep. No sleep equals less down-regulator magic dust in their noggin. Simple as that. Your job just became far more difficult.

Making A Call For Podiatric Pain Management Fellowships

Pain is a tricky thing to deal with and chronic pain is far trickier than you can imagine. I have been using some screening tools to see if we can identify those patients who will be more likely to have problems postoperatively from a mental health perspective but these tools are spotty at best. I can’t wait for the machine to come along that looks like the glass one at the Transportation Safety Administration checkpoint that we all go through with our hands in the air, and it tells you “yea” or “nay” if you should do the patient’s surgery.

Pain is subjective. How do you measure it. Do you go by Visual Analogue Scale scores or how pain affects the quality of activities of daily living? There is no “one” magic scale that we can use between different subsets of patients like a hemoglobin value.

This is really dicey stuff. When you are working with these patients, you have to have some quantifiable measure charted before your treatment. Perhaps it is determining how long the patient can walk or stand. Then when the patient comes back in three months after medical and surgical management, and says there is no improvement, you ask the patient again: “How long can you walk now?”

“About two hours,“ the patient answers. “Then it really starts to hurt.”

A-ha! You quickly look back in the chart and see that when the patient started with you, he or she could only stand or walk for 10 minutes. Bring that up to the patient. Show the patient she or he has had improvement. Remember that the patients you have taken from a “10” on the pain scale down to a “3” after a few weeks now perceive their “3” as their new “10.” Granted, there is a lot of numbers and I know I’m confusing you, but these folks will confuse you as well.

Here is what I propose we do as a profession: let us start some podiatric pain management fellowships. They should be real fellowships with multidisciplinary team approaches to managing these chronic pain patients. Have the fellow rotate in anesthesia pain management programs, psychiatry clinics and peripheral nerve surgical specialty areas. Have a strong emphasis in pharmacologic management of pain. Remember that many of these chronic pain patients have primary pedal pathology but they now have spinal stimulators, peripheral nerve stimulators, are on numerous meds and still need treatment by specialists with our “lenses” with this expanded knowledge and grasp of multiple approaches.

These are difficult patients to deal with and there are many out there. They need our help.


1. Available at http://www.practicalpainmanagement.com/issue/1111 .


I am a second-year Midwestern student and I would be the first in line to fill that fellowship. I think pain management is something that podiatry needs to incorporate into our education. So where do I need to sign?

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