Chronic Non-Cancer Pain--An Organizational Approach to Best Practice

Chronic Non-Cancer Pain--An Organizational Approach to Best Practice


Donna Spevakow, RN, MSN
Lisa Hamilton, RN,MSc


Chronic Non-Cancer Pain (CNP) is a clinically complex and common phenomenon in the older adult. Data suggest that CNP is undertreated in older adults who are likely to suffer from arthritis, back problems and joint disorders. Left untreated, CNP in the older adult can lead to depression, sleep disturbances and decreased socialization.

Recently, the problem of untreated CNP was investigated at the Toronto Rehabilitation Institute, a tertiary rehabilitation centre and a teaching hospital of the University of Toronto. A survey to determine pain prevalence and severity was conducted in a patient population consisting of complex continuing care, geriatric, acquired brain injury and stroke rehabilitation. One hundred and ten patients were able to verbally respond to the survey questions, and results showed that 47% of the patient population experienced CNP and 39% of those with pain rated it as severe. At that time, no structures were in place within the organization for the assessment and management of CNP.

This evidence led to the creation of a clinical interprofessional CNP task force which had the goals of establishing a patient-centred, interprofessional approach to CNP rehabilitation using "best practice" evidence, preventing unnecessary suffering and improving outcomes in rehabilitation.

Clinical practice guidelines included information on cultural consideration in pain assessment and management, an initial pain assessment form, and a pain flow sheet to evaluate effectiveness of interventions. Pain assessment scales were made available in 14 languages. Three categories of therapeutic approaches were identified within the guidelines: pharmacological, physical and psychoeducational. These guidelines were then developed into policies.

In order to achieve consistent use in the clinical practice setting, all clinical staff needed to be knowledgeable about the guidelines and policies. To this end, the CNP task force developed an innovative teaching tool--a colourful poster that serves as a quick reference guide for both physicians and patients.

In addition, an educational program was developed for front-line staff. Staff attended a one half-day workshop where, using a case study, they reviewed the pain assessment forms. A second half-day workshop on specific physical modalities was offered to the Registered Nurses who had attended the previous workshop, and to physiotherapists. A full-day workshop was offered by an expert in guided imagery.

Patient and family education is also a crucial component in management of CNP. Recognizing this need, the task force developed an educational booklet entitled "Chronic Pain and You," available in four languages: Chinese, Portuguese, Italian and English.

Other outcomes of the initiative are that links have been established with the Comprehensive Pain Program at Toronto Western Hospital, University of Toronto Centre for the Study of Pain, and that a medical pain specialist is now available on-site for consultation.

We hope that this issue of Geriatrics & Aging will update our readers on the management of pain in the elderly. We have a series of excellent articles including an overview of the biology of pain, a summary of pain management and assessment in the elderly, the principles of palliative care and the management of pain in patients with dementia. We also have a summary of the Toronto Western Hospital's Chronic Pain Program. Topics for our regular columns include 'Syncope in the elderly' (Cardiology column) and chronic lymphocytic leukemia (Cancer column). Enjoy!


Donna Spevakow is a CNS at Toronto Rehabilitation Institute and Lisa Hamilton is a CNS at York Central Hospital. They were Co-Chairs of this Initiative. Toronto Rehab received the Health Care Papers National Best Practice Award at the Ontario Hospital Association Convention, November 2000 for this interprofessional Non-Cancer Pain initiative.