European Pain Federation

Core Curriculum for

the European Diploma
in Pain Medicine
SEPTEMBER 2023
Second Edition
 Dedication

This curriculum is dedicated to the millions of people

throughout Europe who suffer pain,
and the scientists and health care professionals
who seek the best ways to help them.

Endorsements

This curriculum is endorsed by the following organisations:

• European Society of Anaesthesiology and Intensive Care Medicine (ESAIC)

• European Academy of Neurology (EAN)
• European Psychiatric Association (EPA)
• European Society of Regional Anaesthesia (ESRA)
• World Organisation of National Colleges, Academies and Academic
• Associations of GPs/Family Physicians, European Branch (WONCA EUROPE)
• European Cancer Organisation (ECO)
• European Region of World Physiotherapy (ER-WCPT)
• European Association of Hospital Pharmacists (EAHP)
 Foreword

Foreword from the President

Education for all clinicians is one of the key priorities of the European Pain Federation EFIC. With
the core curriculum for the European Diploma in Pain Medicine (EDPM), EFIC sets the standard for
medical education on pain in Europe. The core curriculum was first launched in 2016, and through
my time on the Executive Board and as President, I have seen it flourish under the leadership of
EFIC pain medicine educators; Prof Bart Morlion, Dr Andreas Kopf, Prof. Frank Huygen, Dr Daniele
Battelli, Dr Liam Conroy and Dr Chris Wells.

The core curriculum has been brought to life via EFIC’s EDPM Examination, e-learning materials on
the EFIC Academy platform, the biennial Virtual Pain Education Summit and in various live-teaching
environments including the EFIC Pain Schools. The curriculum is the reference point for European
pain educators, and we have seen a concerted effort to map educational activities to the learning
outcomes set out in this document. I would like to thank all the educators within the EFIC community
for their dedication to this task.

Along with the direct provision of assessment and teaching by EFIC, a wider goal for the core
curriculum is to influence other educators across Europe in the development of their educational
programmes, whether in a formal academic setting or informally. Likewise, the recognition of the
curriculum and Examination by educational authorities is part of EFIC’s strategic objectives which we
are striving towards.

As a physiotherapist, I helped establish EFIC’s European Diploma in Pain Physiotherapy (EDPP)

and championed the development of EFICs European Diploma in Pain Nursing (EDPN) exam.
Interprofessional and multidisciplinary pain practice is central to EFIC’s philosophy. Prof. Morlion
is the strongest supporter of this ideal and it has been a pleasure to work together to champion
the development of pain medicine education within a broader interprofessional framework with
physiotherapy, psychology and nursing .

Dr Brona Fullen

President, European Pain Federation EFIC®

September 2023

Curriculum for the European Diploma in Pain Medicine 5

Foreword

Foreword from the Curriculum Chair

The European Pain Federation EFIC first decided to establish a core curriculum for pain medicine in
2015. This pivotal moment led to the establishment of a broad and ambitious educational framework,
covering not only medicine but also various other allied professional fields, including physiotherapy,
psychology and nursing. The European Diploma in Pain Medicine (EDPM) plays a central role, and
pain medicine professionals continue to make up the largest share of professionals working in pain
management.

The core curriculum is multidisciplinary, for all clinicians across Europe (and beyond, for those
interested). Whilst some European countries have their own pain management qualification, many
do not at this time. Even when a qualification is available it is often aimed at one specialty, or even
a subsection of that specialty (for example, interventional management). The core curriculum aims to
show that the Fellow has a firm grounding in the basic skills and knowledge needed to assess and
manage the many patients whose pain requires attention in all types of clinical scenario.

This curriculum is a dynamic instrument and will be reviewed and updated on a regular basis,
sensitive to advances in pain medicine and in medical education and also feedback from educators
and learners.

Feedback on the 2016 curriculum has been overwhelmingly positive, and it continues to direct
learning in existing educational projects and institutions. This review has been undertaken as a
substantial amount of time has passed since the initial launch, though much of the content remains
relevant. Rather than an overhaul of the previous curriculum, revisions reflect small updates in scientific
understanding and clinical management concepts.

Significant developments on the original version include reference to the latest version of the
International Classification of Diseases (ICD-11) and chronic primary pain, a new section on digital
medicine (now mainstreamed since the COVID-19 pandemic), and updates in response to concerns
on non-responsible opioid prescribing and opioid use disorder.

The review of the curriculum has been supported by many colleagues, including examiners for the
EDPM Examination, EFIC Academy Board members, EFIC Pain School directors, EFIC Education
Committee members and various other experts consulted for their subject-matter expertise. The full list
of acknowledgments can be found at the back of this document.

We remain grateful to the Faculty of Pain Medicine of Australia and New Zealand for allowing us to
use their curriculum as a basis for ours. This has been modified to suit the diversity in pre- and post-
graduate training in pain medicine across Europe and in line with our desire to cover all factors of
relevance to all medical disciplines involved in the assessment and treatment of those in pain.

Professor Bart Morlion, Curriculum review chair, European Diploma in Pain Medicine

Past President, European Pain Federation

September 2023

6 Curriculum for the European Diploma in Pain Medicine

 Table of Contents

Table of Contents
Introduction 8
Section One: Foundations of Pain Medicine
1.1 Background 12
1.2 Fundamental Concepts 12
1.3 Terminology used in Pain Medicine 13
1.4 Neurobiology of Pain 14
1.5 Research Methodology of Pain 15
1.6 Bio-psychosocial Aspects of Pain 17
1.7 Assessment of Pain 21
1.8 Management of Pain 22
Section Two: Pain Medicine Roles in Practice
2.1 Clinician 26
2.2 Professional 33
2.3 Scholar 35
2.4 Communicator 36
2.5 Collaborator 38
2.6 Manager (and Leader) 39
2.7 Health Advocate 40
Section Three: Managing Different Types of Pain
3.1 Acute Pain 44
3.2 Neuropathic and related Pain 48
3.3 Cancer-related Pain 50
3.4 Musculoskeletal Pain 55
3.5 Neck and Back Pain 57
3.6 Fibromyalgia Syndrome and Chronic Widespread Pain 61
3.7 Headache and Orofacial Pain 64
3.8 Visceral Pain 68
3.9 Complex Regional Pain Syndromes, Type I and II 70
3.10 Pain in Hereditary Connective Tissue Disorders 72
Section Four: Special Patient Populations
4.1 Pain in Older Adults 76
4.2 Pain in Infants, Children and Adolescents 82
4.3 Pain and Problem Substance Use 85
Section Five: Interprofessional Working and Learning
5.1 Interprofessional Working and Learning .. 88

Acknowledgements 89

Curriculum for the European Diploma in Pain Medicine 7

Introduction

Introduction
Chronic, unrelieved pain is a major unsolved healthcare problem worldwide. It is universal, with
no age, race, social class, national or geographic boundaries. It has enormous associated costs –
financial, as well as being a tremendous burden in terms of reduced quality of life for the patient, their
family and wider society. Rough estimates place the cost of chronic pain, as a disease state, in the
very substantial category of cardiovascular disease and cancer. The incidence of chronic pain tends to
increase with age; with the success of curative and preventative medicine, and the consequent increase
in average life spans, the problem of chronic pain is likely to increase for the foreseeable future.

Pain is the most common reason for patients to see their family doctors, and is a frequent reason for them
seeing a specialist. Although clear guidelines exist for assessing and managing acute and cancer pain,
these are not always applied, leading to unnecessary suffering. Understanding and managing chronic
pain is more difficult, and problems arise because of the lack of understanding of the biopsychosocial
approach, and also the undertreatment by some, and overtreatment by others, of the patient.

In recent years “Pain Medicine” has emerged as a distinct academic discipline with delineated borders
and aims. It focuses on management of complex pain problems, typically using a multidisciplinary
approach. Healthcare authorities in several countries in Europe have begun to establish programs for
specialist training and certification in the field of Pain Medicine. The time has come to broaden the
scope of pain specialization to cover the whole of Europe using uniform, agreed-upon standards of
training and certification for pain specialists.

Pan-European standards of training and certification, once in place, will ensure higher professional
quality, uniformity and care. Such standards will also promote recognition among specialists and non-
specialists alike, of the boundaries at which patients with complex chronic pain ought to be referred
to a pain specialist for treatment. Finally, they will create a body of trained professionals qualified to
provide guidance and leadership in the areas of therapeutic modalities, resource allocation, research,
ethical considerations and public policy concerning chronic pain and its management.

The European Pain Federation EFIC® is a multidisciplinary professional organisation in the field of
pain research and medicine, consisting of the 38 Chapters of the International Association for the
Study of Pain (IASP®), which are the IASP approved official national Pain Societies in each country.
Established in 1993, EFIC®’s constituent Chapters represent Pain Societies from 38 European countries
and close to 20,000 physicians, basic researchers, nurses, physiotherapists, psychologists and other
healthcare professionals across Europe, who are involved in pain management and pain research.
Further information is on our website, http://www.efic.org .

We recognize that most clinicians see people with pain, and feel it is important that all have the
knowledge to better assess and manage this pain. We also realise the vital importance of the
multidisciplinary management of pain; hence, we have developed this curriculum for all physicians
who see and treat pain patients.

In providing a pathway towards specialisation in pain medicine, EFIC has created a core curriculum in
pain medicine that establishes the knowledge and competences required for basic proficiency in pain
management. The next step would be to establish the core areas of practical training via a ‘common
training framework’ for the development of pain as a ‘supra-speciality’; accessible to a wide variety of
disciplines relevant to pain.

8 Curriculum for the European Diploma in Pain Medicine

 Introduction

The scope of pain medicine practice

The specialty of pain medicine is concerned with the study of pain from a biopsychosocial perspective.
Clinically this incorporates the evaluation, treatment and rehabilitation of persons with pain. The field
spans three major clinical areas:

• Acute pain – post-operative, post-trauma, acute episodes of pain in medical conditions.

• Cancer-related pain – pain due to tumour invasion or compression; pain related to diagnostic
or therapeutic procedures; pain due to cancer treatment; pain present after treatment and in
survivorship.

• Chronic non-cancer pain – including more than 200 conditions described in the IASP Taxonomy.

• The purpose of the curriculum is to define the required learning, teaching and assessment
necessary for the acquisition of a Diploma in Pain Medicine, as the culmination of training
programs for physicians across Europe.

The curriculum aims to:

• Articulate the scope of practice required by a specialist pain medicine physician including
breadth and depth of knowledge, range of skills and professional behaviours necessary for
quality patient care.

• Guide supervisors of training and other Fellows involved in the training programme with respect
to suitable learning experiences for trainees.

• Foster trainees’ self-directed learning by providing clear requirements.

• Promote regular and productive interaction between trainees and supervisors, through formative
workplace-based assessments and feedback.

• Provide consistency of standards and outcomes across different training settings and countries
in Europe.

• Enable comparison with international training programmes with respect to standards of

experience, education and assessment.

• Outline foundation knowledge and skills required to ensure that trainees are ready to commence
the training programme.

• Provide a framework to inform the scope of continuing professional development activities.

The sections of the curriculum are:

1. Foundations of Pain Medicine

2. Pain Medicine Roles in Practice

3. Managing Different Types of Pain

4. Special Patient Populations

5. Interprofessional Working and learning

Curriculum for the European Diploma in Pain Medicine 9

Introduction

The section on Foundations of Pain Medicine has been developed to inform applicants and trainees
about the knowledge and skills that underpin learning during the training programme. Trainees may
have, or may be training toward, a primary Fellowship in anaesthesia, psychiatry, rehabilitation
medicine, physician and surgical specialties (e.g. Neurology, Rheumatology, Orthopaedics,
Neurosurgery etc.) or general practice. Attainment of learning outcomes within the Foundations
of Pain Medicine will ensure that trainees are prepared similarly to build on their current specialist
medical abilities.

A key principle in designing the curriculum has been an emphasis on trainees’ development across all
professional roles. Using the CanMEDS framework from the Royal College of Physicians and Surgeons
of Canada as a base, the Pain Medicine Roles in Practice have been designed to emphasise a
biopsychosocial orientation to practice, rather than a narrow biomedical one. The section includes
the titles of Clinician, Professional, Scholar, Communicator, Collaborator, Manager (and Leader) and
Health Advocate. The clinician role, which articulates the skills and attitudes required of a specialist
pain medicine physician when working with patients and the knowledge to perform these skills, is the
focus of outcomes within the next section, Managing Different Types of Pain.

The section Managing Different Types of Pain directs teaching and learning in relation to specific
topic areas in pain medicine. The themes in this section were chosen as areas in which the expertise
of the specialist pain medicine physician should be paramount. They are not intended to be a
comprehensive coverage of the discipline of pain medicine but rather to be integrative. For example,
the themes in “Neuropathic and related Pain” pervade all areas of pain medicine practice, while
there is much clinical overlap between the “Neck and Back pain”, ‘Fibromyalgia Syndrome and
Chronic Widespread Pain’ chapters. It is important that the topics in this section are studied in
conjunction with the Pain Medicine Roles in Practice.

The section about Special Patient Populations addresses the two extreme age groups, older adults
versus infants, children and adolescents and the management approaches which are unique to each
of these populations. Problem substance use is an emerging field and is also included in this section.

European Diploma in Pain Medicine

The Education Committee of EFIC® has developed an examination based upon this curriculum.
Physician candidates who wish to achieve the qualification of European Diploma in Pain Medicine of
the European Pain Federation will be assessed by this examination. Further details on the examination
and how to prepare can be found on the EFIC website.

10 Curriculum for the European Diploma in Pain Medicine

 Section

Section One:-
Foundations of Pain Medicine

Curriculum for the European Diploma in Pain Medicine 11

Section One: Foundations of Pain Medicine

1.1 Background
The topics in the chapter on Foundations of Pain Medicine aim to provide trainees with the knowledge
and skills that underpin learning during the training program. It aims to give trainees a roadmap to
gain the basic science and research-related knowledge before they move forward in the program.
This approach is taken, given the diversity of pre- and postgraduate training in pain medicine across
Europe.

1.1.1 Broadly discuss the importance of the CanMEDS roles in relation to the specialist
pain medicine physician comprising:-
• Medical expert/clinician
• Professional
• Scholar
• Communicator
• Collaborator
• Health advocate
• Manager/leader
CanMEDS is a competency framework designed by the Royal College of Physicians and Surgeons of Canada and comprises seven
roles, or thematic groups of competencies, integrated by physicians on a daily basis. For more information refer to http://rcpsc.
medical.org

1.2 Fundamental Concepts

1.2.1 Discuss bioethical principles:-

1. Justice
2. Autonomy
3. Beneficence
4. Non-maleficence
5. EQUITY as a bioethical principle
1.2.2 Critically discuss the International Association for the Study of Pain (IASP)’s definition
of pain
1.2.3 Discuss the distinction between nociception and pain
1.2.4 Discuss the differences between acute and chronic pain
1.2.5 Discuss the evolution of different conceptual models in pain medicine, pain prevention
models and strategies, including the biopsychosocial model

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 Section One: Foundations of Pain Medicine

1.3 Terminology used in Pain Medicine

1.3.1 Define common pain terms according to the International Association for the Study
of Pain (IASP):-
• Allodynia
• Analgesia
• Anesthesia Dolorosa
• Causalgia
• Dysesthesia
• Hyperalgesia
• Hyperesthesia
• Hyperpathia
• Hypoalgesia
• Neuralgia
• Neuritis
• Neuropathic Pain (Central and Peripheral)
• Neuropathy
• Nociception
• Nociceptive Neuron
• Nociceptive Pain
• Nociceptive Stimulus
• Nociceptor
• Nociplastic Pain
• Noxious Stimulus
• Pain Treshold
• Pain Tolerance Level
• Paresthesia
• Sensitization (Central and Peripheral)
1.3.2 Define IASP terms used for different Pain Treatment modalities:-
• Unimodal treatment
• Multimodal treatment
• Multidisciplinary treatment
• Interdisciplinary treatment
1.3.3 Discuss the concepts of placebo and nocebo effect
In referring to the placebo response, address also ‘regression to the mean’
Discuss the relevance of placebo, nocebo and lessebo effects for routine clinical
care
Discuss the difference between a diagnosis (according to the ICD-11 classification)
and a mechanism, and what does it imply

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Section One: Foundations of Pain Medicine

1.4 Neurobiology of Pain

1.4.1 Outline the anatomy and physiology of ascending and descending pathways of
nociceptive modulation in the central nervous system
Refer to the:-
• The somatosensory system
• The autonomic nervous system
• Somatic and visceral peripheral nerves
• Spinal system
• Processing pathways in the brain:-
oo Midbrain and brainstem (including descending inhibition and facilitation)
oo Thalamus and cortex
oo Limbic system
1.4.2 Outline the neuroanatomical and neurophysiological bases for the cognitive and
affective dimensions of the pain experience
1.4.3 Describe mechanisms of transduction, transmission and modulation in nociceptive
pathways
Discuss current concepts of referred pain, including its neurophysiological basis
1.4.4 Understand the changes that occur in the brain during chronic pain and their impact
on pain, mood and cognition
1.4.5 Outline the concepts of peripheral and central sensitisation of nociception including
reference to:-
• Synaptic plasticity
• N-methyl-D-aspartate (NMDA) receptors
• Long-term potentiation/depression
• Neuroimmune signalling, glial cells and sensitisation
• Brain processes involved in sensitisation
• Psychosocial factors contributing to central sensitisation
1.4.6 Outline the mechanisms of acute pain, inflammatory and neuropathic pain
1.4.7 Compare and contrast the anatomical and physiological aspects somatic and
visceral pain
1.4.8 Discuss the physiology of and differences between tolerance, dependence and
addiction with respect to pharmacological agents

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 Section One: Foundations of Pain Medicine

1.5 Research Methodology of Pain

1.5.1 Describe the principles of clinical trial design:-

• Case definitions (inclusion and exclusion criteria)
• Use of data from medical history and clinical examination
• Use of questionnaires
• Use of laboratory tests and imaging
• Hypothesis generation
1.5.2 Address ethical principles guiding research in humans:-
• Social and clinical value
• Scientific validity
• Fair subject selection
• Favorable risk-benefit ratio
• Independent review
• Informed consent
• Respect for potential and enrolled subjects
• Historical review of abuses of medical ethics
1.5.3 Describe the principles of clinical epidemiology, including:-
• Terminology and presentation of epidemiological data
• Different types of epidemiological study design: descriptive/observational
(correlational, case reports/series, cohort, retrospective, cross-sectional survey)
and controlled (interventional, prospective, experimental/clinical trials)
• Difference between statistical significance and clinical relevance (minimally
clinical important difference; substantial benefit and harm)
1.5.4 Demonstrate understanding of fundamental data analysis concepts by discussing the
following:-
• Different data types (parametric/non-parametric, continuous/interval, ratio,
categorical, dichotomous), and their relevance to statistical analysis
• Concept of clear and efficient organization of raw or summary data in tables
and graphs
• Concepts of normal and non-normal data distributions as relevant to statistical
testing, and the use of normalizing transformations such as logarithms
• Descriptive statistics, including calculation and interpretation of a 95 per cent
confidence interval of a mean or a proportion
• Concept of probability testing, sample distributions and the importance of
appropriate sampling techniques
• Concepts of different types of epidemiological study design: descriptive/
observational
1.5.5 Describe basic power, effect size, and significance concepts by addressing the
following concepts:-
• Power and power calculations
• Importance of effect size in respect of power calculations and evaluating the
necessary levels of evidence
• Concepts of significance and power when testing an hypothesis, that is, type
one and type two errors and their relationship to sample size
• Influence of sample size on derived indices such as a proportion or a mean

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Section One: Foundations of Pain Medicine

1.5.6 Describe and demonstrate understanding of single and multiple study results:-
• Concept of minimal clinically important difference
• Concept of regression analysis to examine relationship between dependent
variable and multiple explanatory variables (including ability to control for
confounding variables)
• Appropriate use of tests of relationships between continuous data, such as
Pearson and Spearman correlation coefficients
• Application, limitations and interpretation of tests used to analyse single studies
and meta-analyses: specifically t-test and ANOVA (including repeated measures
versions), linear regression, chi-squared test, odds ratios, logistic regression,
Receiver Operating Characteristic (ROC) methods, effect size and statistical
power, survival curves and number-needed-to-treat (NNT) and number-needed-
to-harm (NNH)
• Appropriate use of methodologies for assessing inter-test session and inter-
tester precision of tests, particularly with regard to clinical relevance, such as
determination of repeatability and minimal clinical difference (MCD)
• Appropriate use of methodologies for determining quantitative agreement
between different clinical test methods or instruments, such as Bland-Altman
methods and intra-class correlation
• Concept of summary statistics in meta-analysis (effect sizes, standardized mean
differences and odds ratios)
1.5.7 Explain the concepts of:-
• Reliability
• Validity
• Sensitivity
• Specificity
• Predictive value
1.5.8 Explain the concept of design of studies to logically examine specific hypotheses,
with special regard to appropriate counterbalancing and controls, tests of placebo
and related effects, and randomization methods for minimizing bias
1.5.9 Describe the principles of assessing scientific evidence, including:-
• Grades of evidence and methodologies and difficulties of combining evidence
as in systematic reviews and meta-analyses
• Cochrane database of systematic reviews
• Influence of bias, chance, multiple comparisons and confounding variables in
studies, and methods to reduce them
• Publication bias
• Principles of assessment of qualitative studies including systematic reviews of same

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 Section One: Foundations of Pain Medicine

1.6 Bio-psychosocial Aspects of Pain

1.6.1 With reference to the biopsychosocial model of pain, the specialist pain medicine
physician (SPMP) in close collaboration with the general practitioner should:-
• Critically discuss the concept of assessment and management of patients with
pain
• Demonstrate understanding of the integrated role of specialist disciplines in
the biopsychosocial management of pain including clinical psychology,
physiotherapy, occupational therapy, nursing, social work
Patient Triage
1.6.2 The SPMP should be able to:-
Demonstrate the process of triaging patients with respect to their underlying
diagnosis, natural history and prognosis, urgency, complexity and facilities required,
and psychosocial risk factors for ongoing chronicity
1.6.3 Critically discuss situations when referral to specialist team members is appropriate.
Being able to screen and diagnose and refer for treatment comorbid psychiatric
disorders commonly associated with chronic pain such as depression, suicidality
and anxiety disorders
1.6.4 Discuss ICD-11 classification in relation to high-impact chronic pain
Discuss the application of the World Health Organisation (WHO) International
Classification of Functioning, Disability and Health (ICF).
Assessment Principles
1.6.5 The SPMP should be able to:-
Demonstrate understanding that pain in any one patient may attract different
concurrent descriptors, and therefore, different inferred mechanisms
1.6.6 Demonstrate ability to infer mechanism(s) of production of pain on the basis of
clinical examination, irrespective of pre-existing diagnostic label(s)
1.6.7 Discuss the process of integrating multiple sources of information towards a multi-
axial formulation of diagnosis – physical, psychological and psychosocial context
1.6.8 Identify and explore patients’ issues, concerns, beliefs, goals and expectations with
respect to their pain experience and pain treatment
Patient Assessment
1.6.9 The SPMP will describe how to carry out a focused biomedical assessment including
but not limited to:-
• Response to current and post treatments
• Nutritional status
• Sleep function
• Sexual function
• Pharmacological management
• General health indicators
• Psychological function (depression, anxiety, fear)

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Section One: Foundations of Pain Medicine

Physical Assessment
1.6.10 Demonstrate skills to undertake a physical assessment including levels of activity
function and sleep
1.6.11 Identify all Red, Yellow, Blue, Black and Orange flags
1.6.12 Show understanding of the role of physiotherapy and when it is appropriate to refer
for further specialist assessment and treatment
Psychological Assessment
1.6.13 Elicit and interpret a detailed history of the concerns and beliefs of the patient
regarding their pain: experience and consequences of the pain
1.6.14 Perform a focused assessment regarding but not limited to: home situation, eating,
support, family and roles, employment and occupational factors, financial status,
recreational activities, cultural beliefs, mobility
1.6.15 Demonstrate an understanding of the detailed specialist assessment a clinical
psychologist will undertake relating to:-
• History of physical, emotional and sexual abuse history
• Family medical and psychological history
• Personal psychological history
• Past and current lifetime events
• Personal psychological history
• Family medical and psychological history
• Identification of lifetime, current and daily stresses
• Current psychological symptoms
• Cognitive impairment
• Resources: coping strategies, self-efficacy, support/lack of support from family & friends
• Beliefs and anxieties about pain and cause of pain
• Expected prognosis
• Interference with life
• Changes to lifestyle and identity
Psychological Management
1.6.16 Demonstrate an understanding of the behavioural and psychodynamic therapies
available and delivered by clinical psychologists including but not limited to:--
• Education
• Reduction of fear avoidance
• Hypnosis
• Relaxation/guided imagery
• Biofeedback
• Balancing/regulating rest and activities
• Behavioural analysis
• Operant aspects
• Solution focused brief therapy
• Mindfulness-based cognitive behavioural therapy
• Acceptance and commitment therapy
• Mindfulness-based stress reduction
• “Pain neuroscience” education

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 Section One: Foundations of Pain Medicine

Physical Management
1.6.17 Demonstrate an understanding of the range of treatment options that a chartered
physiotherapist can offer including:-
• TENS
• Paced and graded activity
• Physical activity and fitness
• Goal setting
• Neurodynamics
• Manual therapy, and their level of integration (peripheral, spinal, supraspinal)
Demonstrate an understanding of the range of treatment options that occupational
therapy can offer:-
• Energy conservation
• Pacing
• Relaxation
Demonstreate an understanding of the importance of integrating physiotherapy
programme to work and leisure
Social Management
1.6.18 Demonstrate an understanding of the role of work, occupational factors, career,
finances, housing, recreational and leisure activities
Validated Tools for assessing and monitoring Treatment
1.6.19 Demonstrate critical selection of appropriate physical and psychological assessment
and outcome measures across International Classification of Functioning, Disability,
and Health (ICF) domains (mood, quality of life, beliefs about pain, pain self-efficacy,
physical function, sleep, health literacy)
1.6.20 Demonstrate ability to assess psychosocial factors that elicit and maintain pain
disorders with somatic causes [Multiaxial Pain Classification – Psychosocial
Dimension (MASK-P)]
1.6.21 Show ability to choose appropriate and validated tools to assess and monitor
treatment in specific populations such as:-
• Older adults
• Neonates and Children
• Patients from linguistically or culturally diverse backgrounds
• Patients who are cognitively impaired
• Patients with behavioural issues
Implementing a biopsychosocial Management Plan
1.6.22 Discuss the process of explaining the diagnostic formulation and the proposed
management plan to the patient, taking into account the patients’ health literacy level

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Section One: Foundations of Pain Medicine

1.6.23 Demonstrate the process of negotiating a therapeutic alliance with the patient
towards implementation of the management plan. Differentiate those patients who
require:-
• Multimodal approach from one practitioner
• Interprofessional/multidisciplinary approach from a team
• Referral to other medical specialists and/or allied healthcare professionals
1.6.24 Discuss the process of applying interprofessional/multidisciplinary treatment
principles in pain management programs. Demonstrate ability to adapt plans to the
specific needs of patient groups, including but not limited to:-
• Pregnant women
• Older adults (including those with dementia)
• Patients with mental health disorders
• Opioid-tolerant
• Opioid-naïve
• With active or past substance use disorders
• Patients with intellectual and/or physical disabilities

20 Curriculum for the European Diploma in Pain Medicine

 Section One: Foundations of Pain Medicine

1.7 Assessment of Pain

1.7.1 Broadly describe how the following factors may influence the patient’s experience
of illness and pain:-
• Social
• Cultural
• Psychological
• Physical
• Genetic
• Age
• Gender
• Caregivers
• Role of health literacy (patient’s ability to seek, understand and implement health
related information to manage their health)
• Religion
• Traditional medical practices
• Patients’ and family wishes, motivations, goals and strengths
1.7.2 Broadly describe patient’s and family’s different responses to the experience of pain
and illness including affective, cognitive and behavioural responses
1.7.3 Outline the current Diagnostic and Statistical Manual of Mental Disorders (DSM) and
International Classification of Diseases (ICD) framework for classification of mental
disorders with particular reference to anxiety, substance misuse, different somatic
symptom disorders, and depressive disorders
1.7.4 Demonstrate understanding of the concept of coloured flags: red (biomedical), yellow
(psychosocial predictors), blue (social and economic factors) and black (occupational)
1.7.5 Perform a basic medical assessment of a patient including:-
• General history-taking
• General physical examination
• Quantitative Sensory Testing
• Psychological function /Mental state examination
1.7.6 Interpret the following basic investigations, including but not limited to:-
• Full blood count
• Biochemical screening including liver function tests and myeloma screening
• Arterial blood gases
• Thyroid function tests
• Electrocardiograms
• Plain radiographs
• MRI and fMRI
• CT
1.7.7 Interpret the following basic screening questionnaires for psychological and somatic
symptom burden, including but not limited to
• Patient Health Questionnaire 4
• Patient Health Questionnaire 9
• Hospital Anxiety and Depression Scale
1.7.8 Demonstrate basic problem-oriented synthesis of clinical information

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Section One: Foundations of Pain Medicine

1.8 Management of Pain

1.8.1 Generally discuss the following treatment principles that may be used in the
management of pain:-
• Psychological
• Physical
• Pharmacological
• Interventional
1.8.2 Broadly discuss the principles of pharmacokinetics, pharmacogenetics and
pharmacodynamics
1.8.3 Describe and give examples of pharmacogenetic variation in relation to a range of
drugs, including but not limited to:-
• Tramadol
• Tricyclic antidepressants
• Non-steroidal anti-inflammatory drugs
1.8.4 Describe the:-
• Mechanism(s) of action
• Potential adverse effects (including toxicity)
• Indications, precautions, and contraindications for use
• Interactions with other drugs
• Site of action
Of the following drugs
• Paracetamol
• Metamizole (dipyrone) – in countries where used
• Nefopam – in countries where used
• Non-steroidal anti-inflammatory drugs, selective and un-selective
• Opioid agonists, partial agonists, agonist-antagonists and antagonists
• Methadone
• Tramadol and tapentadol
• Antidepressants
• Anticonvulsants
• Benzodiazepines
• Local anaesthetics
• Corticosteroids
• Botulinum toxin
• Capsaicin
• Alpha 2 adrenoreceptor agonists
• Cannabis-based medicines and medical cannabis

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 Section One: Foundations of Pain Medicine

1.8.5 Discuss the principles of analgeisc and opioid equivalence, including but not limited to:-
• Buprenorphine
• Codeine, dihydrocodeine
• Fentanyl
• Hydromorphone
• Methadone, Levomethadone
• Morphine
• Oxycodone
• Tapentadol
• Tramadol
1.8.6 Describe pharmacokinetic and pharmacodynamic differences between the different
systemic routes of administration of drugs (for example, onset/offset of action,
efficacy, adverse effects), including:-
• Oral
• Sublingual
• Buccal
• Rectal
• Transdermal
• Topical
• Inhaled
• Intranasal
• Subcutaneous
• Intramuscular
• Intravenous
• Intra-articular
• Spinal (epidural and intra-thecal)

Curriculum for the European Diploma in Pain Medicine 23

Section One: Foundations of Pain Medicine

1.9 Digital medicine and telehealth

1.9.1 Understand the principles and theoretical foundations of digital medicine, including
artificial intelligence, in pain management
1.9.2 Evaluate the benefits, limitations, and ethical considerations of digital technologies
in pain medicine
1.9.3 Utilize evidence-based approaches to implementing telemedicine, artificial
intelligence, remote consultation, in pain management including patient education
and self-management through digital platforms
1.9.4 Identify and select appropriate health apps and digital tools (e.g., wearables) for
pain assessment, monitoring, and treatment
1.9.5 Apply data security and privacy principles in the context of digital medicine,
including artificial intelligence in pain management
1.9.6 Collaborate effectively with interdisciplinary teams in utilizing digital technologies
for comprehensive pain care and integrate electronic health records and digital
platforms for comprehensive care; patient-reported outcomes, patient-relevant
outcomes, digital biomarkers
1.9.7 Evaluate the impact of digital medicine, including artificial intelligence, on patient
outcomes, satisfaction, and quality of life
1.9.8 Stay updated with the latest advancements and trends in digital medicine and their
relevance to pain management

24 Curriculum for the European Diploma in Pain Medicine

Section Two:-
Pain Medicine Roles in Practice

Curriculum for the European Diploma in Pain Medicine 25

Section Two: Pain Medicine Roles in Practice

2.1 Clinician
As a clinician, the specialist pain medicine physician dynamically applies high-level knowledge, skills
and professional attitudes in the practice of pain medicine across stable, unpredictable and complex
situations. The clinician role describes in particular the skills to be acquired during the course of
pain medicine training. It also contains aspects of knowledge that are considered to permeate and
transcend all aspects of the discipline.

By the end of training, the Specialist Pain Medicine Physician will be able to:-

Clinical Assessment and Formulation

2.1.1 Triage referred patients with respect to urgency, complexity, risk factors for ongoing
chronicity, facilities required
2.1.2 Elicit and interpret a detailed history of:-
• The patient‘s biopsychosocial backgound
• The pain experienced by the patient
• The consequences of the experience of pain for the patient, with particular
regards to concerns and beliefs about the pain
2.1.3 Discuss the application of the World Health Organization (WHO) International
Classification of Functioning, Disability and Health (ICF) concepts to people
experiencing pain:-
• Functioning and disability
oo Body functions and body structures
oo Activities and participations
• Contextual factors
oo Environmental Factors
oo Personal factors
• Select appropriate outcome measures across the ICF domains
2.1.4 Perform a focused psychological and sociological assessment
See Section One: Foundations of Pain Medicine/1.6.14 Bio-psychosocial Aspects
of Pain
2.1.5 Perform a focused biomedical assessment, including but not limited to:-
• Response to treatment(s) to date
• Nutritional status
• Sleep function
• Sexual function
• Pharmacological management
• General health indicators

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 Section Two: Pain Medicine Roles in Practice

2.1.6 Perform and interpret a pain-orientated physical examination, incorporating:-

• Documentation of pain qualities and symptoms
• Assessment of Musculo-skeletal and articular functions
• Assessment of clinical tests and signs for pain-oriented diagnosis formulation
• Assessment of nervous system functions
oo Pain oriented sensory testing (POST)
oo Assessment of motor functions
oo Assessment of autonomic functions
• Relevant systems

Knows the role and limitations of use of ultrasounds in bedside patient evaluation
and treatment for:-
• Musculoskeletal pain
• Peripheral neuropathies
• Other pain conditions
• US-guided procedures
2.1.7 Use appropriate and validated assessment techniques to specific populations such as:-
• Older patients
• Neonates, Infants and Children
• Patients from linguistically or culturally diverse backgrounds
• Patients who are cognitively impaired
• Patients with opioid use disorders
2.1.8 Recognise that pain in any one patient may attract different concurrent descriptors
and therefore different inferred mechanisms
2.1.9 Demonstrate ability to infer mechanism(s) of production of pain on the basis of
clinical examination, irrespective of pre-existing diagnostic label(s)
2.1.10 Critically review existing investigations and interpretations, including but not limited
to bone scans, computed tomography (CT) scans, magnetic resonance imaging
(MRI), positron emission tomography (PET) scans, and electrodiagnostic techniques
2.1.11 Make judicious and resource-sensitive decisions about obtaining further investigative
options
2.1.12 Integrate multiple sources of information towards a multi-axial formulation of
diagnosis-function-context
Identify and explore the patient’s issues, concerns, beliefs, goals and expectations
with respect to their pain experience and the pain treatment
2.1.13 Evaluate and arrange if necessary whether further specialised assessment and/
or management is required in sociological, psychological, cultural, religious or
biomedical dimensions
2.1.14 Develop understanding of the person and their family, in relation to their pain-
associated limitations, losses and distress, but also strengths, motivators and resilience

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Section Two: Pain Medicine Roles in Practice

Preparing Management Plans

2.1.15 Synthesize, justify and negotiate with the patient an individualized management plan
and options, based on evidence and the context in which the patient’s experience
of pain occurs
2.1.16 Recognise and respond to the uncertainty inherent in the practice of pain medicine,
including but not limited to:-
• Accommodating unpredictability
• Managing risk in complex patient care situations
• Varying practice according to contextual and cultural influences
2.1.17 Adapt plans to the specific needs of the following patient groups experiencing pain:-
• Pregnant women
• Patients with hepatic and/or renal function impairment
• Elderly patients (including those with dementia)
• Patients with mental health disorders, cognitive or neurodevelopmental impairment
• Opioid-tolerant patients
• Patients with active or past substance abuse problems
• Patients from diverse socio-economic, ethnic and cultural backgrounds
• Patients with allergies
2.1.18 Understand the principles and application of placebo and nocebo theory in patients
with pain
2.1.19 Critically discuss evidence-based psychological therapies related to pain medicine,
including:-
• Solution focused brief therapy
• Cognitive and behavioural therapies
• Mindfulness-based cognitive behaviour therapy; acceptance and commitment
therapy; mindfulness-based stress reduction
• Systemic (couple and family) therapy
• Hypnosis/guided imagery
• Biofeedback, relaxation techniques such as progressive muscle relaxation and
autogenic training

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 Section Two: Pain Medicine Roles in Practice

2.1.20 Discuss in detail clinical pharmacotherapy, the evidence base for the efficacy and
adverse effects in pain medicine, including but not limited to the use of:-
• Paracetamol
• Non-steroidal anti-inflammatory drugs
• Opioids, strong and weak
• Tramadol and tapentadol
• Cannabinoids
• Capsaicin
• NMDA-receptor antagonists
• Local anaesthetic agents
• Anticonvulsants
• Antidepressants
• Benzodiazepines
• Neuroleptics
• Alpha-2 adrenergic agonists
• Anti-emetics
• Laxatives
• Vitamins and electrolytes supplementations
• Biologic drugs

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Section Two: Pain Medicine Roles in Practice

2.1.21 With respect to opioids:-

• Compare and contrast rational of use in acute, chronic non-cancer and cancer-
associated pain
• Critically discuss the evidence base for their efficacy in non-cancer pain
• Critically discuss commonly used dose equivalents for oral, parenteral,
transdermal and neuraxial (epidural, intraspinal) routes of opioid administration
• Describe the pharmacokinetic and pharmacodynamic differences between
immediate-release and slow-release oral opioid formulations
• Discuss the rationale for opioid rotation
• Describe the use and idiosyncrasies of methadone and buprenorphine
• Critically discuss opioid-induced hyperalgesia
• Discuss the assessment, prevention and symptomatic relief of adverse effects of
opioids with particular reference to:-
oo Constipation
oo Nausea and vomiting
oo Sedation
oo Confusion or delirium
oo Pruritus
• Discuss the long-term effects of the use of opioids including, but not limited to
their immuno-modulatory, endocrine and psycho-cognitive effects
• Detail the factors that need to be considered if patients are discharged
from hospital with opioids for ongoing management of acute pain including
dispensation and disposal of unused drugs
• Negotiate a plan for withdrawal from opioids, where appropriate
• Know the different metabolic pathways of opioids, including when used in
patients with liver or kidney function impairment
• Know and know how to discuss with the patient issues related to opioids such
as:- length of treatment, dependency, loss of efficacy with time, impact on
driving, general function
• Know the principles of deprescribing, tapering and stopping opioids
2.1.22 Critically discuss physical treatment modalities related to pain medicine, including
but not limited to:-
• Principles of physical activity
• Principles of pacing and graded activity
• Passive and active therapy
• Role of physiotherapy
• Know how to adapt physical treatments to different pain states
• Exercise prescription

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 Section Two: Pain Medicine Roles in Practice

2.1.23 Critically discuss indications, efficacy, complications, management and patient

follow-up for procedural treatment modalities related to pain medicine, including but
not limited to:-
• Peripheral injections
oo Soft-tissue
oo Intra-articular
• Neuraxial injections
• Ablative techniques: chemical OR electrical/thermal
• Non-invasive neuromodulation
oo Transcutaneous- and Percutaneous Electrical Nerve Stimulation
(e.g. TENS, PENS, rTMS, tDCS, tACS)
• Electroacupuncture
• Intradiscal techniques
• Ablative techniques
oo Chemical
oo Electrical/thermal
• Neuromodulation
oo Spinal Cord Stimulation
oo Dorsal Root Ganglion (DRG) stimulation
oo Intrathecal drug delivery
• Epiduroscopy
• Surgical interventions
oo MRI-, US-, laser- guided ablations
oo Deep brain, motor cortex, transcranial magnetic stimulation
oo Stereotactic surgical techniques
oo Cordotomy
oo Dorsal root entry zone (DREZ)
oo Other CNS surgical techniques for pain treatment
2.1.24 Critically discuss the use, evidence, efficacy and potential interactions and adverse
effects of complementary and alternative medicine (CAM) used in the community for
the treatment of pain, including, but not limited to:-
• Acupuncture
• Homeopathy
• Herbal, botanical, and dietary supplements,
• The conceptual framework of Integrative pain medicine and Salutogenesis
2.1.25 Describe the application of interprofessional and multidisciplinary treatment principles
in pain management programmes
See Section One: Foundations of Pain Medicine/1.6 Bio-psychosocial Aspects of Pain
Implementing Management Plans
2.1.26 Discuss and agree with the patient and their significant others the diagnostic
formulation and the proposed management plan
2.1.27 Build a therapeutic alliance with the patient and their significant others towards
implementation of the management plan, using ‘plain language’, the teachback
method to ensure patient’s understanding, and establishing common expectations

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Section Two: Pain Medicine Roles in Practice

2.1.28 Discuss the role of shared decision when choosing treatment

2.1.29 Evaluate efficacy of intervention, through reassessment of key indicators (reflecting
International Classification of Functioning, Disability and Health)
2.1.30 Discuss the role of adherence
2.1.31 Demonstrate the ability to differentiate between those patients who require:-
• Multimodal approach from one practitioner
• Interprofessional and multidisciplinary approach from a team
• Referral to other medical specialists and/or allied healthcare professionals
2.1.32 Consult and collaborate with colleagues and other healthcare professionals to
optimise patient wellbeing and enhance patient outcomes
2.1.33 Demonstrate the skills required to lead a interprofessional/multidisciplinary team
(across health and social care) in the implementation of a pain management plan,
including communication skills
2.1.34 Incorporate as part of a comprehensive pain management plan, where indicated:-
• Risk assessment
• Identification of vulnerable adults and appropriate safeguarding referral
• Consider use of an independent patient advocate
• Psychological treatment, physiotherapy and social needs evaluation in an
interprofessional and multidisciplinary setting
• Rational pharmacotherapy
• Appropriate interventional treatment modalities
• Patient education
• Involvement in supported self-management, in voluntary and community
organisations
2.1.35 Demonstrate ability to rationalize, supervise and individualize complex
pharmacotherapy in patients experiencing pain, also in light of their co-morbidities
as well as discuss pharmacotherapy with hospital pharmacist
2.1.36 Consider the use of alternative therapies to meet patient needs
2.1.37 Arrange appropriate follow up and proper outcome measurement. Discuss de-
prescribing strategies, specifically for opioids, risks and mitigation plans
2.1.38 Discuss the role of PROMs (patient-reported outcome measures) and PREMs (patient-
reported experience measures) as measures of the well-being of patients in clinical
practice and research

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 Section Two: Pain Medicine Roles in Practice

2.2 Professional
As a professional, the specialist pain medicine physician (SPMP) has a unique role arising out of
their advanced knowledge of the sociobiology of pain and its complex effects on people. Such
work requires mastery of a complex skill set and the knowledge underpinning this, in addition to
the art of medicine. The SPMP is committed to the health and wellbeing of individuals and society
through ethical practice, characterised by high personal standards of behaviour, accountability and
leadership.

By the end of training the SPMP will be able to:

Ethical Practice
2.2.1 Exhibit professional behaviours in practice, including honesty, integrity, commitment,
compassion, respect, and altruism
2.2.2 Exhibit understanding of principles of confidentiality, including access to, content of,
and security of records
2.2.3 Discuss the principle of informed consent without coercion and shared decision making
2.2.4 Explain the concepts of competence, contract and negligence
2.2.5 Demonstrate professional relationships with colleagues and patients and their
significant others
2.2.6 Accept the responsibilities involved in continuing care of people with complex
conditions
2.2.7 Recognise and respond to ethical issues encountered in practice
2.2.8 Recognise limitations of expertise and seek appropriate guidance
2.2.9 Demonstrate professional integrity, probity and ethical conduct in response to industry
marketing strategies
2.2.10 Recognise and manage conflicts of interest
Cultural Awareness and Sensitivity
2.2.11 Demonstrate an understanding of how personal beliefs, cultural bias and biopsycho-
social factors may influence pain diagnosis, management, rehabilitation and
interactions with others
2.2.12 Demonstrate respect for differences in cultural and social responses to health and
illness in general, and to pain in particular
2.2.13 Incorporate health beliefs of the individual/community into management modalities
in a culturally sensitive manner
Legal and regulatory Environment
2.2.14 Adhere to professional, legal and ethical codes of practice
2.2.15 Fulfill regulatory and legal obligations required of current practice
2.2.16 Respond to requests for medico-legal and coroner’s opinion, especially in
compensation settings

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Section Two: Pain Medicine Roles in Practice

2.2.17 Demonstrate accountability in considering access, clinical efficacy and quality when
making patient-care decisions
2.2.18 Recognise and respond to others’ unprofessional behaviour, which may include
notification to regulatory authorities
2.2.19 Recognize conflicts of interest in choice of provider
2.2.20 Demonstrate detailed knowledge of regulations with respect to controlled substances
in the relevant jurisdiction(s)
2.2.21 Be aware of the restrictions regarding the use of cannabinoids in the relevant
jurisdiction(s)
2.2.22 Recognise the features of substance abuse in the patient and in the healthcare
professional
Health and sustainable Practice of Specialist Pain Medicine Physicians
2.2.23 Identify risks to personal physical and mental wellbeing
2.2.24 Adopt strategies to enhance personal and professional awareness and insight, such
as developing a mentor relationship
2.2.25 Recognise and respond to other professionals in need

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 Section Two: Pain Medicine Roles in Practice

2.3 Scholar
As a scholar, the specialist pain medicine physician (SPMP) demonstrates active commitment to
learning, to the creation, dissemination, application and translation of knowledge relevant to pain
medicine, and to the education of their patients, students, colleagues and within the community.

By the end of training, the specialist pain medicine physician (SPMP) will be able to:-

Ongoing personal Learning

2.3.1 Identify opportunities for further personal development and learning
2.3.2 Participate in relevant professional and educational development in pain medicine
and apply insights in practice
Critical Appraisal and clinical Application of medical Information
2.3.3 Access established and evolving knowledge in the clinical and social sciences
relevant to pain medicine
2.3.4 Participate in practice evaluation and quality improvement activities, apply insights
from own learning to medical practice
2.3.5 Determine the validity and risk of bias in a wide range of scholarly sources
2.3.6 Critically appraise scientific literature and translate evidence into decision-making
about the care of patients with pain using national high-quality guidelines
2.3.7 Describe the principles, application and limitations of evidence-based medicine
2.3.8 Participate in audit of specific areas of practice
Teaching and Learning of others, with Respect to Pain and Pain Medicine
2.3.9 Identify the learning needs of others and prioritise learning outcomes
2.3.10 Demonstrate effective teaching strategies to facilitate learning
2.3.11 Provide meaningful feedback to others
2.3.12 Provide inter-professional mentorship to colleagues and other health professionals by
leading education sessions related to pain medicine
New Knowledge and Practices in Pain Medicine (Contribution to Innovation)
2.3.13 Describe principles of research ethics as applied to human and animal research in
pain medicine
2.3.14 Contribute to clinical trials and/or research projects and to education/teaching
activities of students/peers, for example teaching courses, clinical education etc.
2.3.15 If appropriate, stimulate scholarly interdisciplinary collaborative research in the area
of pain medicine in an international context

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Section Two: Pain Medicine Roles in Practice

2.4 Communicator
As a communicator, the specialist pain medicine physician (SPMP) offers the patient a relationship
with a professional who has particular interest and expertise in the pain, which is the focus of their
concern and suffering. The SPMP is able to listen, interpret and explain the predicament and concerns
of the patient in a broad bio-psychosocial framework.

By the end of training, the specialist pain medicine physician (SPMP) will be able to:-

Therapeutic Relationships
2.4.1 Establish therapeutic relationships with patients, their families and carers, and foster
their involvement as partners in their care
Be able to assess a patients level of ‚activation’ and health literacy and be able to
tailor information giving appropriately
2.4.2 Communicate using a person-centered approach that encourages patient trust and
autonomy, and is characterised by empathy and respect
2.4.3 Demonstrate effective communication skills, including but not limited to:-
• Active listening
• Encouraging discussion
• Reinforcing key messages
• Attending to verbal and non-verbal cues
• Respecting patient difference and diversity
• Adapting communication skills to individual patients
• Recognising and addressing miscommunication
• Apply the “Teach-back method” to ensure patients understanding of condition
and therapeutic instructions
• Motivational interviewing
2.4.4 Acknowledge and validate the patient’s experiences of pain
2.4.5 Optimise the physical environment for patient comfort, dignity, privacy, engagement
and safety
2.4.6 Recognise and negotiate challenging communication situations, including conflict or
culturally related situations
2.4.7 Identify and manage emotionally charged situations
Obtaining relevant Information
2.4.8 Gather, prioritise and synthesise information about the patient’s medical condition,
including beliefs, anxieties, expectations and experiences, from a variety of sources
2.4.9 Utilise appropriate personnel and resources to facilitate communication with patients
from culturally and linguistically diverse populations
2.4.10 Elicit a patient’s understanding of their referral to a pain service and correct
misconceptions
Sharing Information with Patients and significant others

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 Section Two: Pain Medicine Roles in Practice

2.4.11 Advise patients about the risks and benefits of treatment options, specifically the
limitations of evidence, to help with informed choices
2.4.12 Facilitate discussion with patients and their families to ensure a common understanding
of the problems and plans, using appropriate developmental tools for children (e.g.
videos, drawings, pictures)
2.4.13 Respect diversity and difference and the impact these have upon decisionmaking
2.4.14 Encourage active involvement in shared decision-making
2.4.15 Provide patients with “plain language” information regarding model of care,
discharge and follow up
2.4.16 Explain unanticipated complications to patients, their families and other healthcare
providers
2.4.17 Assist patients and others to identify and make use of information and communication
technologies to support their care and manage their health
Sharing Information
2.4.18 Demonstrate effective written and verbal communication skills tailored to audience,
purpose, intent, and context
2.4.19 Comprehensively and succinctly document the assessment and agreed management
plan for the individual patient with pain
2.4.20 Develop skills for communication in medico-legal settings and with administrative
bodies
2.4.21 Develop skills for communication with consumer groups and the broader community

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Section Two: Pain Medicine Roles in Practice

2.5 Collaborator
As a collaborator, the specialist pain medicine physician (SPMP) effectively works in a healthcare
team to achieve optimal patient care.

See Section 5: ‘Interprofessional Working and Learning’

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 Section Two: Pain Medicine Roles in Practice

2.6 Manager (and Leader)

As a manager, the specialist pain medicine physician (SPMP) has the ability to make and manage
decisions about resource allocation as may apply personally, professionally and at an organizational
level, to provide leadership and to contribute to the effectiveness of the healthcare system. The SPMP
is able to look outward from the clinic to collaborate with other sectors, design local (not just within
the service) systems for optimal delivery of healthcare.

By the end of training, the SPMP will be able to:-

Organisational Work Practice

2.6.1 Define the characteristics underpinning the provision of quality patient-centred pain
management services that are safe, effective, efficient, and timely
2.6.2 Contribute to the processes of quality assurance, quality improvement and
accreditation activities within their department/practice
2.6.3 Use and adapt systems to learn from adverse events and critical incidents, and to
inform regulatory agencies when needed
2.6.4 Apply legislative/regulatory requirements and service policies, for example, adverse
outcomes reporting
Personal Work Practice
2.6.5 Describe their own scope of practice, responsibilities and line of reporting
2.6.6 Identify the operational structure and their role in the pain management service/
practice
2.6.7 Organise, prioritise and delegate tasks in order to achieve balance between
professional requirements and personal life
2.6.8 Demonstrate self-reflection to appraise and improve efficiency and effectiveness in
the workplace
2.6.9 Use information technology to optimise patient care
Equitable Allocation of finite Health Resources
2.6.10 Understand the general principles of organisational and healthcare funding
2.6.11 Optimise cost-appropriate care in pain medicine
2.6.12 Demonstrate leadership in the management and allocation of tasks and resources
Participation in Administrative and Leadership
2.6.13 Develop leadership skills in interdisciplinary and administrative settings
2.6.14 Contribute to clinical governance forums as appropriate
2.6.15 Participate in committees and meetings at various organisational levels, as appropriate
2.6.16 Understand the financial, administrative and human resource requirements in order
to manage a pain management unit or private practice

Curriculum for the European Diploma in Pain Medicine 39

Section Two: Pain Medicine Roles in Practice

2.7 Health Advocate

As a health advocate, the specialist pain medicine physician (SPMP) responsibly uses their expertise
and influence to advance the health and wellbeing of patients and caregivers, colleagues, communities
and populations.

By the end of training, the SPMP will be able to:-

Patient Advocate
2.7.1 Work with patients experiencing pain to address relevant determinants of health
2.7.2 Identify opportunities for advocacy, promotion of health and improvement in quality
of life for patients with pain
2.7.3 Advocate for access to evidence-based treatments for pain
2.7.4 Advocate for access to controlled medicines including opioids for management of
pain as a human right
2.7.5 Advocate for patient-centred management options, including in palliative and end-
of-life contexts
2.7.6 Identify circumstances where advanced care directives or plans, particularly with
respect to management of pain, should be formulated by the patient and their family
2.7.7 Promote strategies regarding the recognition of pain in patients with other conditions
and in patients from different cultural backgrounds
2.7.8 Promote patient self-advocacy for access to health-related resources
Community Advocate
2.7.9 Work with a community or population to identify those determinants of health such
as cultural influence on pain belief that might influence the experience of pain
2.7.10 Advocate for, and contribute to, the generation of adequate population-based
statistics on pain in the general population
2.7.11 Promote the availability and the appropriate and safe use of therapeutic substances
for pain treatment within the population
2.7.12 Understand a public health approach to pain management and palliative care as
essential in resource-poor settings
2.7.13 Describe the role of specialist pain medicine physicians in advocating for improved
resources locally, nationally and internationally in order to improve access for and
management of patients with pain
2.7.14 Promote the position of pain medicine within the spectrum of medical professions
2.7.15 Support establishment of personalized pain medicine
2.7.16 Understand health care systems and determinants of access to pain management

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 Section Two: Pain Medicine Roles in Practice

Personal Advocate
2.7.17 Identify risks to personal, physical and mental wellbeing, help in understading non
familiar situations related to cultural differences
2.7.18 Advocate for the health, wellbeing and safety of colleagues and assist or intervene
if required

Curriculum for the European Diploma in Pain Medicine 41

42 Curriculum for the European Diploma in Pain Medicine
Section Three:-
Managing Different Types of Pain

Curriculum for the European Diploma in Pain Medicine 43

Section Three: Managing Different Types of Pain

3.1 Acute Pain

The specialist pain medicine physician (SPMP) will be asked to assist in the management of patients
with acute pain. The advice requested will often relate to management of complex patients, such as
those who have pre-existing chronic pain or are opioid tolerant, or, have a substance abuse disorder
or a significant medical comorbidity. This requires that the SPMP will have a thorough knowledge
of medications, techniques and equipment used in acute pain management and an understanding
of their efficacy as well as recognition and management of their adverse effects and complications.
An important aspect is understanding risk factors and mechanisms involved in transition of acute to
chronic pain and possible ways to mitigate this process.

By the end of training, a trainee will be able to:-

Background
3.1.1 Discuss the role of Acute Pain Services (APS). The SPMP should be able to broadly
describe the two main APS models: physician-based and specialist nurse-based,
physician supervised
3.1.2 Discuss the role of acute pain management in primary care
3.1.3 Discuss general requirements that enable safe and effective delivery of acute pain
management techniques in hospitals including: education of staff and patient
monitoring requirements (assess and document pain as the “fifth vital sign”); responses
to inadequate or excessive medication; use of “standard orders”; equipment used
3.1.4 Discuss the issues related to the ongoing management of acute pain following
discharge from hospital, including patients undergoing ambulatory surgery
3.1.5 Evaluate the role of acute pain management in rehabilitation, including enhanced
recovery or “fast-track” surgery
3.1.6 Understand the evidence for acute pain management and promotion of enhanced
recovery and rehabilitation in prevention of chronic pain
3.1.7 Discuss the risk factors and mechanisms involved in the transition of acute to chronic
pain, and critically evaluate the evidence for measures that may reduce (mitigate)
that transition
Discuss the potential role of a ‘transitional pain service’
Applied Foundation Knowledge
3.1.8 Describe the pharmacokinetics and pharmacodynamics of opioids and local
anaesthetics administered into the epidural space or cerebrospinal fluid; also
perineural and infiltrative techniques (infusions in wounds, joints, peritoneal,
subfascial, subacromial etc.)
3.1.9 Describe the physiological consequences of a central neuraxial (epidural or
intrathecal) block with local anaesthetics and/or opioids
3.1.10 Describe the adjuvant agents that may be used to enhance the quality or extend the
duration of central neuraxial or other regional analgesia blocks, and discuss their
mechanisms of action, risks and benefits

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 Section Three: Managing Different Types of Pain

3.1.11 Discuss the contribution of maladaptive psychological coping skills, mental disorders,
psychological distress, psychiatric illness and socioenvironmental and further culturally
related factors to the experience of acute pain (pain ratings, opioid use) and the risks
of persistent pain and prolonged opioid use after discharge from hospital
3.1.12 Critically discuss the importance of regular institutional audits to ensure that the goals
of effective analgesia and patient satisfaction are being met and also to serve as a
benchmarking tool
Clinical Assessment of Acute Pain
3.1.13 Discuss assessment of acute pain (including acute neuropathic pain) in the adult
patient, including the nonverbal patient and those from diverse socieeconomic,
ethnic, or other, linguistic- and cultural backgrounds, and the relevance of functional
assessment
3.1.14 Discuss assessment of acute pain in the older patient (especially those with dementia)
including challenges in communication, relevance of functional assessment and use
of other pain evaluation methods that do not rely on verbal ability
3.1.15 Discuss assessment of acute pain in infants, young children and adolescents including
the developmental and practical challenges, relevance of functional assessment and
use of appropriate and validated paediatric pain scales, including those for children
with neurodevelopmental impairment
3.1.16 Recognise causes of delirium in the acute pain setting and the effect this may have
on assessment and treatment of the patient with acute pain
Management of Acute pain
3.1.17 Compare and contrast the evidence for efficacy and adverse effects in the
management of acute pain by using analgesics:-
• Paracetamol, metamizole, nefopam
• Non-steroidal anti-inflammatory drugs (COX-1 and COX-2 inhibitors)
• Strong and weak opioids
3.1.18 Critically discuss the evidence-base for the indications, efficacy and adverse effects of:-
• NMDA-receptor antagonists
• Anticonvulsants
• Antidepressants
• Alpha-2 adrenergic agonists
• Inhalational agents
• Corticosteroids
• Systemic lidocaine

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3.1.19 Assess and manage adverse effects related to pharmacological therapies in acute
pain management, including but not limited to:-
• Opioid induced:-
oo Nausea and vomiting
oo Respiratory depression
oo Excessive sedation
oo Pruritus
oo Constipation
oo Congnitive dysfunction
3.1.20 Describe the complications that may be associated with neuraxial analgesia and
other regional analgesia (including secondary to needle/catheter insertion and
drug administration) and how these may be mitigated and managed
3.1.21 Outline a plan to transition patients from patient-controlled analgesia (PCA),
intravenous or regional, to oral administration
3.1.22 Discuss the use of ultrasound imaging in the performance of regional analgesic
techniques
3.1.23 For patients receiving:-
• Intravenous PCA
• Epidural analgesia (including epidural PCA)
• Sublingual PCA (using sufentanil)
• Intrathecal analgesia
• Anlagiesia by major peripheral nerve blocks nest
• Plexus analgesia/Paravertebral block and other interfascial blocks
Outline:-
1. Risks versus benefits
2. Monitoring of efficacy
3. Safety considerations
3.1.24 Discuss issues specific to the management of acute pain in patients with:-
• Spinal cord injury
• Burns
• Trauma
• Crush injuries and ischaemic limbs with a risk of compartment syndrome
• Patients with obstructive sleep apnoea
• Patients who are pregnant or breast-feeding
• Patients with renal impairment (including those on dialysis)
• Patients with chronic pain
• Opioid-tolerant patients and patients with past or present substance abuse disorder
3.1.25 Discuss the management of patients who are taking anticoagulants or anti-platelet
agents and who have or are about to receive catheters in situ for neuraxial or major
peripheral nerve analgesia
3.1.26 Discuss the potential complications specific to the concurrent use of anticoagulant
and antiplatelet agents in patients undergoing central neuraxial and major regional
nerve blockade

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3.1.27 Discuss the management of patients undergoing repeated painful procedures

including use of EMLA, NO2 or psychological treatment (distraction, hypnosis)
3.1.28 Discuss the management of acute pain by using nonpharmacological methods
e.g. hot/cold pack, TENS, low-laser therapy and psychological strategies (e.g.
distractions and breathing techniques) and psychological support for patients before
and after surgery
3.1.29 Evaluate efficacy of key interventions through assessment of key clinical and patient
reported outcomes

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3.2 Neuropathic and related Pain

The recognition that disease of damage to the somatosensory nervous system itself can be associated
with the experience of pain has been a major insight. The recent change in the definition of
“neuropathic” pain and its role as a descriptor, has prompted a reappraisal of how to deliver this
topic. Technically, “neuropathic pain” is pain of neurological disease or damage.

By the end of training, a trainee will be able to:-

Background
3.2.1 Critically discuss the main descriptors of pain and other pain-related terms as in the
International Association for the Study of Pain (IASP) Taxonomy
3.2.2 Distinguish between use of terms in relation to pain syndromes, such as nociceptive,
neuropathic, mixed, hypersensitivity and sensitization
Applied Foundation Knowledge
3.2.3 Outline the neurobiological (functional and structural) basis of allodynia, hyperalgesia
and hyperpathia
3.2.4 Describe possible mechanism(s) leading to the experience of pain in the following
examples of damage to the somatosensory nervous system:-
• Brain injury
• Spinal cord injury
• Traumatic peripheral nerve injury, including that incurred during surgery
• Compression neuropathy
• Amputation of a limb
See also Section 3.3 Pain related to Cancer
Clinical Assessment of Neuropathic and related Pain
3.2.5 Describe purpose, scoring, interpretation and limitations of common tools to assess
presumed neuropathic pain:-
• Douleur Neuropathique (DN4)
• pain DETECT
• Leeds Assessment of Neuropathic Symptoms and Signs (LANSS)
• Neuropathic Pain Questionnaire (NPQ)
• Others

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3.2.6 Describe the different presentations of pain and clinical findings in the following
primary neurological diseases:-
• Stroke
• Complex Regional Pain Syndrome type II
• Trigeminal neuralgia
• Parkinson’s disease
• Multiple sclerosis
• Syringomyelia
• Peripheral neuropathies: diabetic, HIV-associated, toxic (alcohol, chemotherapy)
• Acute herpes zoster infection and post-herpetic neuralgia
• Phantom limb
• Guillain-Barré syndrome
• Neurofibromatosis
• Erythromelalgia
Management of Neuropathic and related Pain
3.2.7 Critically discuss the general management of neuropathic pain in a biopsychosocial
context
3.2.8 Critically discuss the pharmacological treatment of neuropathic pain
3.2.9 Critically evaluate the evidence for the efficacy and adverse effects for drugs used
in the treatment of neuropathic pain:-
• Antidepressants
• Anticonvulsants
• Topical lidocaine and capsaicin
• Opioids
• Others (e.g. NMDA-receptor antagonists, intrathecal drug delivery)
3.2.10 Critically discuss the clinical decision making in the pharmacological treatment of
neuropathic pain:-
• Associated therapeutic goals (e.g., sleeping disorder, depression)
• Comorbidity, adverse effects
• A mechanism based versus a disease based approach
3.2.11 Critically discuss the non-pharmacological approaches in the treatment of neuropathic
pain:-
• Neuromodulation
• Physiotherapy (e.g., mirror therapy for phantom limb pain)
• General multimodal, interprofessional/ multidisciplinary principles of chronic
pain management

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3.3 Cancer-related Pain

Thirty per cent of patients with cancer will have pain at diagnosis. Seventy per cent will have moderate
to severe pain by the time their disease is advanced. Despite this high prevalence, the outcomes
for management of cancer pain are often poor. Management of cancer pain uses management
techniques from both acute and chronic pain but also brings in additional challenges due to the
presence of a terminal illness. This topic also addresses chronic pain experienced by patients who
are cancer survivors.

By the end of training, a trainee will be able to:-

Background
3.3.1 Identify age and sociocultural influences on the perception and experience of cancer
and of cancer- related pain
3.3.2 Compare and contrast the assessment and management of persons with cancer
pain and those with chronic non-cancer pain
3.3.3 Recognize the problems faced by cancer survivors who have persistent pain
3.3.4 Discuss the meaning and significance of the World Health Organization (WHO)
analgesic guidelines for pain in cancer
3.3.5 Discuss the choice of analgesics in the WHO ladder and critically evaluate the
evidence base
3.3.6 Discuss the differences between application routes (oral, transdermal, subcutaneous,
intravenous, intrathecal)
3.3.7 Discuss the management of opioid analgesics including the role of opioid rotation
in patients with inadequate pain relief or severe side effects
3.3.8 Critically discuss situations in which changing the route of analgesic administration
may be required
3.3.9 Discuss the use of opioids in the patients with impaired renal or liver function
3.3.10 Discuss the options for the management of breakthrough cancer pain
3.3.11 Discuss the management of opioid-related adverse events
3.3.12 Be aware of and discuss clinical practice guidelines addressing the management of
end-of-life symptoms including but not limited to:-
• Pain
• Nausea/vomiting
• Respiratory symptoms
• Fatigue
• Itch
• Emotional distress
3.3.13 Recognise the essential role of close collaborations between the various teams
involved in the care of cancer patients – for example pain specialist, oncologist,
surgeon, palliative care, hospital pharmacist, physiotherapist, nurse and family
physician

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Applied Foundation Knowledge

3.3.14 Discuss the neurophysiological mechanisms contributing to the experience of pain:-
• Nociceptive pain related to cancer and cancer treatment
• Neuropathic pain related to cancer and cancer treatment
• Visceral pain related to cancer and cancer treatment
Adress specific mechanisms including pain:-
• Arising from a solid viscus
• Arising from a hollow viscus
• Directly related to cancer (tumour invasion, compression, metastases etc.)
• Indirectly related to cancer (pressure areas, osteoporosis, acute herpes zoster
infection, worsening back pain due to poor mobilisation)
• Related to cancer treatments (surgery, radiotherapy, chemotherapy, hormone
therapy or immunotherapy)
3.3.15 Recognise interactions of medications, particularly the anti-cancer drugs, with the
cytochrome P450 enzyme system and how this might influence analgesic treatments
3.3.16 Discuss the analgesic benefits of cancer-modifying treatments such as:-
• Surgery
• Chemotherapy
• Radiotherapy
• Hormone therapy
Clinical Assessment of Cancer Pain
3.3.17 Define and distinguish between:-
• Breakthrough pain and persistent background pain
• Incident pain and incompletely relieved background pain
3.3.18 Apply a mechanism-based approach to identifying the origins and contributing
factors to pain in cancer patients:-
• Bone pain
• Soft tissue
• Visceral pain
3.3.19 Discuss assessment and management of cancer pain in special populations such
as older adults, children, adults with learning difficulties and those with substance
abuse problems.
See Section Four: Special Patient Populations
3.3.20 Discuss the presentation of emergencies in the patient with cancer- related pain,
including but not limited to:-
• Acute spinal cord compression
• Life-threatening increased intracranial pressure
• Gastrointestinal obstruction and perforation of a viscus
oo Bleeding from tumour
oo Airway obstruction from tumour or post radiotherapy
• Hypercalcaemia
• Long bone fracture

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3.3.21 Discuss the role of cancer therapies in the management of cancer-related pain,
including but not limited to:-
• Radiotherapy
• Radiopharmaceuticals
• Chemotherapy
• Immune therapy
• Surgery
3.3.22 Discuss the management of acute pain in cancer patients, including:-
• Diagnostic interventions
• Therapeutic interventions
3.3.23 Discuss the management of post-chemotherapy and post-radiotherapy pain
3.3.24 Discuss the management of mucositis
3.3.25 Outline the changes in pain management when a patient is:-
• No longer able to swallow
• Unconscious or delirious
• Likely to die within days
3.3.26 Critically discuss the use of adjuvant analgesics in cancer pain including but not
limited to:-
• Bisphosphonates
• Denosumab
• Corticosteroids
• Ketamine
• Antidepressants
• Anticonvulsants

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3.3.27 Discuss the role of interventional procedures in the management of cancer pain that
is unresponsive to non-invasive treatment, including but not limited to:-
• Neuraxial and intracerebroventricular administration of medications
• Neurolytic blocks, with particular reference to:-
oo Saddle block
oo Coeliac plexus block
• Surgical procedures
oo Cordotomy
oo Vertebral procedures
3.3.28 Discuss the evidence base for other analgesics in the management of pain and other
symptoms in patients with terminal disease for example:-
• Cannabinoids
• Ziconotide
3.3.29 Evaluate efficacy of key interventions through reassessment of key clinical and patient
reported outcomes

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Management of Pain associated with Cancer

3.3.30 Discuss the different goals of care for a pre-terminal patient compared with those for
a terminally ill patient
3.3.31 Address management of pain and other symptoms at the end of life
3.3.32 Outline the value of palliative care regarding structure and process of care

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3.4 Musculoskeletal Pain

Musculoskeletal (MSK) pain is one of the most frequent pain conditions and a major clinical problem. It
comprises most of the nociceptive pain conditions seen, and also has major social and psychological
influences. Peripheral and central sensitization are important mechanisms for MSK pain conditions.
Further research into peripheral and central neurobiological mechanisms is required to improve
understanding, diagnosis and management. The incidence of MSK is increasing; this is linked to
ageing, obesity and sedentary life style.

The sections on ‘Neck and Back pain’ and ‘Fibromyalgia syndrome and widespread pain’ address
many topics related to MSK pain: they should be considered in conjunction with this section.

By the end of training, a trainee will be able to:-

Background
3.4.1. Understand the pathophysiology of joint pain, muscle pain and bone pain
Applied Foundation Knowledge
3.4.2 Recognise the stages of acute and chronic MSK pain and discuss the development
and prevention of chronicity
3.4.3 Recognise causes and treatments of joint pain
3.4.4 Recognise causes and treatment of bone pain
3.4.5 Recognise the role of movement in causation of MSK pain
3.4.6 Recognise the influence of repetitive injuries in MSK pain
3.4.7 Discuss the role of work and its relationship with MSK pain
3.4.8 Discuss sleep disorders and their relationship to MSK pain
3.4.9 Recognise the poor correlation between symptoms and imaging findings
Clinical Assessment of Musculoskeletal Pain
3.4.10 Outline the importance of assessment of function together with pain
3.4.11 Differentiate inflammatory and mechanical pain
3.4.12 Assess the impact of MSK pain on activities of daily living
Management of Musculoskeletal Pain
3.4.13 Discuss the evidence base for employing the following strategies to manage MSK:-
• Self management
• Exercise
• Education
• Rehabilitation
• Pharmacology
• Regenerative Medicine
• Nonpharmacological approaches
See also Sections 3.5 Neck and Back Pain and 3.6 Fibromyalgia Syndrome and
Chronic Widespread Pain

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3.4.14 Evaluate efficacy of key interventions, through assessment of key clinical and patient
reported outcomes

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3.5 Neck and Back Pain

Neck and Back Pain (spinal pain) is a major contributor to lost productivity. Low back pain, which
affects 9 % of the world’s population, and neck pain, which affects 5 % of the world’s population,
are major contributors to global non-fatal health burden (years lived with disability). Definitions and
approaches to assessment and management of spinal pain vary according to the belief systems of the
diverse group of healthcare providers involved. It is essential that specialist pain medicine physicians
develop a comprehensive, integrated approach to reduce its impact on the patient and society at
large.

By the end of training, a trainee will be able to:-

Background
3.5.1 Compare and contrast the current International Association for the Study of Pain
(IASP) Classification of Spinal Pain with other classification systems
3.5.2 Discuss controversies in diagnostic terminology in spinal pain
3.5.3 Discuss the public health dimensions of the problem of spinal pain, including but not
limited to:-
• Prevalence
• Demography
• Personal and societal costs including but not limited to:-
oo Effects on quality of life
oo Ability to work
oo Social function
oo Disability and sickness benefits
oo Lost productivity
3.5.4 Recognise major risk factors, including psychosocial, for transition of acute to chronic
low back pain
3.5.5 Recognise risk factors for transition of acute to chronic neck pain following “whiplash”
injury
3.5.6 Discuss factors predictive of chronicity after acute spinal pain, including but not
restricted to the “flag” system
Applied Foundation Knowledge
3.5.7 Describe the neuroanatomy and function of the spine and identify potential structures
that can be associated with pain
3.5.8 Critically appraise the value of epidural injections, zygo-apophyseal joint blocks,
medial branch blocks and denervation as part of a long-term plan and as part of
the diagnostic process
Clinical Assessment of Neck and Back Pain
3.5.9 Discuss initial evaluation of spinal pain, including risk assessment and risk stratification
tools, e.g. STarT Back

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3.5.10 Discuss the rationale and use of questionnaires for assessing dimensions of chronic
spinal pain, e.g.:-
• Oswestry Low Back Pain Disability Questionnaire
• Roland Morris Disability Questionnaire
• Assessment of mood, anxiety, catastrophising
• PainDETECT
3.5.11 Identify the potential specific causes of acute and chronic spinal pain including but
not limited to:-
• Infection
• Trauma
• Neoplasia
• Metabolic bone disease
• Inflammatory disease
• Pain hypersensitivity/augmentation
• Degeneration and rheumatic disease
3.5.12 Distinguish between radiculopathic and referred pain, with respect to limb girdle or
limb pain associated with spinal pain. Identify neuropathic components of spinal pain
3.5.13 Critically interpret commonly used physical examination tests for upper and lower
limbs, for example, Lasegue/straight leg raise test, slump test, etc.
3.5.14 Perform a gait analysis
3.5.15 Recognise the clinical presentation of symptomatic spinal stenosis
3.5.16 Recognize ‘red flag’ pathologies: e.g. cauda equina syndrome and neoplasm
3.5.17 Distinguish between acute and acute-on-chronic episodes of spinal pain
3.5.18 Reinterpret pre-existing investigations and opinions in the light of clinical findings
3.5.19 Know and discuss when to order investigations including imaging and how to
interpret images and reports
Management of Neck and Back Pain
3.5.20 Critically discuss the evidence base for management of acute low back pain with
or without radicular pain
3.5.21 Describe national, European and international guidelines for the management of
acute and chronic low back pain
3.5.22 Discuss the importance of self-management and how it may be implemented

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3.5.23 Discuss the efficacy of psychological therapies in chronic spinal pain including, but
not limited to:-
• Cognitive
• Behavioural
• Acceptance commitment
• Biofeedback
• Mindfulness
• Relaxation therapies
• Hypnosis
• Combined psychological and physical approaches
3.5.24 Discuss principles of activity prescription in the management of neck and back pain
3.5.25 Generally discuss the evidence for efficacy and adverse effects of treatment
approaches in spinal pain, including but not limited to:-
• Graded exercise exposure
• Aerobic exercises
• Stretching/strengthening
• Biomechanics
• Hydrotherapy
• Alexander technique
• Massage
• Acupuncture
• Electrical stimulation, Transcutaneous- and Percutaneous Electrical Nerve
Stimulation (TENS, PENS)
• Laser therapy
3.5.26 Critically discuss the evidence base for the efficacy of pharmacological treatments
for chronic spinal pain including:-
• Paracetamol
• NSAIDS
• Weak opioids, including in combination
• Strong opioids
• Adjunct medications including antidepressants and anticonvulsants
• Antibiotics for modic disc changes

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3.5.27 Critically discuss the evidence base for the indications, efficacy and complications of
interventions used for chronic spinal pain, with or without radicular pain including:-
• Injections
oo Epidural/caudal steroids
oo Medial branch injections
oo Prolotherapy
oo Trigger point injections
oo Botulinum toxin
oo Intra-articular steroids (apophyseal and sacro-iliac)
• Radiofrequency and electrothermal treatment (including evaluation)
oo Facet joint
oo Intervertebral disc
oo Sacro-Iliac joint
oo Dorsal root ganglion
• Central neuromodulation including spinal cord stimulation
• Peripheral nerve stimulation
• Intrathecal drug infusion
• Epiduroscopy
3.5.28 Critically discuss the evidence base for the indications, efficacy and limitations of
surgical interventions for chronic spinal pain with or without radiculopathy:-
• Decompression/laminectomy
• Discectomy
• Disc replacement
• Fusion
3.5.29 Critically discuss the evidence base for the efficacy and complications of
complementary and alternative medicine in spinal pain, for example, acupuncture,
chiropractic
3.5.30 Evaluate efficacy of key interventions through assessment of key clinical and patient
reported outcomes

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3.6 Fibromyalgia Syndrome and Chronic Widespread Pain

Physicians who see people with pain will be expected to assess and manage patients who have
diffuse pain that is not well understood by medical science. Such presentations are marked by
incomplete knowledge and/or uncertainty as to causation. However, in this chapter fibromyalgia
syndrome (FMS) should be considered as a well defined clinical entity, with national and international
recommendations for its management. Pain (CWP) is a symptom described by many patients.

By the end of training, a trainee will be able to:-

Background
3.6.1 Demonstrate understanding of historical speculations about the nature of pain that
is poorly understood, the shortcomings of these speculations and the medical and
social outcomes that have arisen as a result of the adoption of these concepts. These
include but are not limited to:-
• Symptoms as psychological by default (DSM-V and ICD-10)
• Symptoms as injury (for example, “repetitive strain injury”)
• Symptoms as disease entity (for example, “fibromyalgia syndrome”)
• Symptoms according to different age groups, e.g. adolescents, adults and
older adults
3.6.2 Be aware of developments in the field of nociceptive signal processing in the brain
and descending control systems
Applied Foundation Knowledge
3.6.3 Critically discuss the concepts of somatisation and hypervigilance
3.6.4 Discuss the “diagnostic” category of somatic symptom disorder and related disorders
(according to DSM-V or ICD-10), including but not limited to:-
• Somatic symptom disorder
• Illness anxiety disorder
• Psychological factors affecting other medical conditions
• Central sensitization disorders
• Small nerve neuropathy
• Chronic Pain Disorder with somatic and psychological factors
3.6.5 Recognise the potential contributions of sources of somatic and visceral nociception
to the experience of widespread pain including CNS processing and descending
controls
Clinical Assessment of FMS and CWP
3.6.6 Outline the heterogeneity of clinical presentations of CWP
3.6.7 Critically interpret the clinical finding of “tenderness”
3.6.8 Critically evaluate the constructs of “myofascial pain” and “fibromyalgia syndrome”
3.6.9 Evaluate the role of a mental health care specialist in providing a formulation and
assessing risk of suicide

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3.6.10 Understand the condition of FMS and its historical and more recent definitions,
including the current American College of Rheumatology definition, revised in 2011
3.6.11 Know the incidence, including relative occurrence according to gender, and
understand the societal impact
3.6.12 Discuss and critique the criteria for diagnosis including:-
• Widespread pain
• Tender points
• Fatigue
• Sleep problems
• Mood disturbance, including depression and anxiety
• Cognitive effects, including loss of concentration, memory
• Associated conditions including irritable bowel syndrome (IBS), headache,
cystitis, chronic fatigue syndrome (CFS)
• Absence of other conditions to explain symptoms
3.6.13 Discuss the possible aetiologies for FMS and CWP such as:-
• Chemical changes in the brain
• Central sensitisation
• Small fibre neuropathy
• Altered descending inhibition
• Sleep disturbance
• Injury (including trauma and litigation)
• Infection
• Sympathetic
• Viral disorder
• Growth hormone deficiency
• Genetic predisposition (gene abnormalities)
• Immune system disorder
• Lyme disease
• Neuropathic pain
• Psychological disturbance
• Somatoform disorder
• Arteriovenous shunt (Albrecht)
• Malingering
Management of FMS and CWP
3.6.14 Discuss reasons for the paucity of quality evidence in the management of CWP
3.6.15 Appreciate the need to provide an interprofessional/multidisciplinary approach
including explanation, acceptance, graded activity and social adaptations stressing
the importance of movement, rehabilitation and self-management. Critically review
medications used for FMS (see below)

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3.6.16 Discuss treatment of FMS according to National and International Guidelines

including the evidence base and the place of:-
• Self-management
• Graded exercise
• Medications, including duloxetine, milnacipran, antidepressants, pregabalin,
tramadol, simple analgesics only in short term usage
oo Other than tramadol, opioids should not be used
• Cognitive Behavioural Therapy (CBT) and the use of appropriate alternative
techniques to reduce symptoms and encourage increased activity and better
function
3.6.17 Educate the patient on the role of the key interventions and evaluate the efficacy of
key interventions through assessment of key clinical and patient reported outcomes
(PROs)

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3.7 Headache and Orofacial Pain

Headache and orofacial pain are among the most common pain disorders. Almost half of the adult
population have a headache at least once a year. More than 10% of the population have migraine
and medication overuse headache may affect up to 5% of some populations. About 10% of the
population suffers from chronic orofacial pain. Temporomandibular disorders are the most common
causes of orofacial pain and are often associated with other chronic pain conditions. Headache
and orofacial pain disorders are associated with the major personal and societal burdens of pain
and disability and have a significant psychological impact including depression and anxiety. In spite
of their high prevalences, only a minority of people with headache and orofacial pain disorders
are appropriately diagnosed, indicating that this is an underestimated and undertreated problem
throughout the world. A number of specific headache and orofacial pain disorders may be identified
based on careful clinical assessment.

By the end of training, a trainee will be able to:-

Background
3.7.1 Appraise the International Classification of Headache Disorders and compare to
IASP’s
3.7.2 Generally discuss accepted definitions of terms associated with headache disorders
and orofacial pain conditions
3.7.3 Describe a taxonomy of orofacial pain such as International Classification of
Orofacial Pain (ICOP)
Applied Foundation Knowledge
3.7.4 Describe the anatomy of the cranial and upper cervical nerves and the innervation
of the scalp, sinuses and teeth
3.7.5 Describe potential neurobiological mechanisms for:-
• Primary and secondary headaches
• Orofacial pain
• Dental pain
3.7.6 Discuss the pathophysiology of trigeminal neuralgia and trigeminal autonomic
cephalagias (TAC)
3.7.7 Discuss the pathophysiology of:-
• Migraine
• Medication Overuse Headache
• Post-dural puncture headache
Clinical Assessment of Headache and Orofacial Pain
3.7.8 Perform a cranial nerve examination
3.7.9 Perform an examination of the face including the temporomandibular system and
intraoral examination
3.7.10 Perform an examination of the cervical spine
3.7.11 Detail the critical factors for assessing life-threatening headache

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3.7.12 Demonstrate awareness of potential causes of headache that may be overlooked on

initial assessment including:-
• Idiopathic intracranial hypertension
• Low cerebrospinal fluid (CSF); low pressure headache; intracranial hypotension
• Post-craniotomy headache
• Space-occupying lesions
• Vascular disease, especially temporal arteritis
• Cervical artery dysfunction
• Pathology in the eyes and ears
• Sinus pathology
Headache
3.7.13 Distinguish between the clinical features of the following primary chronic daily
headache syndromes:-
• Migraine (with and without aura)
• Tension-type headache
• Trigeminal autonomic cephalalgias (cluster headache, paroxysmal hemicrania,
short-lasting unilateral neuralgiform headache attacks, hemicrania continua)
3.7.14 Distinguish between the clinical features of the following secondary chronic daily
headache syndromes:-
• Medication-related
oo Medication overuse headache
oo Medication-induced side effects
• Post-traumatic
oo Headache attributable to head injury
oo Headache attributable to neck injury or whiplash trauma
• Disorders of intracranial pressure
oo Increased intracranial pressure
oo Decreased intracranial pressure
• Headache referred from other structures
oo Cervicogenic headache
Orofacial Pain
3.7.15 Recognise the clinical features of:-
• Trigeminal neuralgia and its variants
• Secondary trigeminal neurlagia – e.g multiple sclerosis, tumour
• Glossopharyngeal neuralgia
• Post-herpetic neuralgia
• Trigeminal neuropathic pain related to past trauma
• Post stroke pain
• ”Burning mouth” syndrome
3.7.16 Describe the use of investigations such as MRI for trigeminal neuralgia
3.7.17 Apply a differential diagnosis approach to determining the anatomical origin of
persistent idiopathic facial pain

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3.7.18 Distinguish pain of odontogenic (especially cracked tooth) and non-odontogenic

origin and appreciating the role of the dentist in ruling out odontogentic causes
3.7.19 Describe the spectrum of diagnostic criteria for temporomandibular disorders as
defined by the 2014 International Research Diagnostic Criteria for Temporomandibular
Disorders consortium and the findings of the large OPPERA study in the USA
3.7.20 Discuss the importance of psychosocial factors as predictors of chronicity in
temporomandibular disorders
Management of Headache
3.7.21 Discuss the evidence base for non-drug interventions in primary and secondary
headaches:-
• Education and information (counseling), including the importance of
oo Keeping a pain diary
oo Relaxation
oo Aerobic exercise
oo Sleep hygiene
oo Diet
• Cognitive-behavioural therapy
• Biofeedback
• Physiotherapy
• Role of patient support groups
3.7.22 Discuss the evidence base for pharmacological treatment of acute migraine:-
• Paracetamol
• Non-steroidal anti-inflammatory drugs
• Antiemetics
• Triptans
• Ergotamines
• GEPANTS
• DITANS
• IV lidocaine/ketamine
3.7.23 Discuss the evidence base for pharmacological prophylaxis of migraine in adults:-
• Beta-blockers
• Calcium channel blockers
• Sodium valproate
• Tricyclic agents
• Topiramate
• Other agents including selective serotonin-noradrenalin reuptake inhibitors
(SNRIs), gabapentin, pizotifen
• GEPANTS
• CGRP monoclonal antibodies
3.7.24 Discuss the evidence base for and the role of botulinum toxin in the prophylaxis
management of chronic migraine
3.7.25 Discuss the limited number of invasive treatment options for migraine and cluster
headache (e.g. greater occipital nerve (GON)-injection and neuromodulation for
cluster headache)

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3.7.26 Describe management of cluster headache including, but not limited to : Sumatriptan
s.c. / oxygen; verapamil/topiramate/lithium; gon-injection/neurostimulation
3.7.27 Discuss the treatment options available in the management of medication-overuse
headache
Management of Orofacial Pain
3.7.28 Discuss the evidence base, recommendations and side effects for pharmacological
treatment of trigeminal neuralgia with:-
• Carbamazepine
• Oxcarbazepine
• Lamotrigine
• Gabapentin and pregabalin
• Clonazepam
• Baclofen
• Levetirazetame
• Angiotensin II receptor antagonists
• Others
3.7.29 Discuss the efficacy and complications of surgical options for trigeminal neuralgia:-
• Neurovascular decompression
• Radiofrequency ablation
• Balloon compression
• Gamma irradiation
• Glycerol rhizotomy
• Partial rhizotomy
• Sterotactic radiosurgery
3.7.30 Discuss the evidence base for managemant of painful trigeminal neuropathy with
trigeminal ganglion stimulation
3.7.31 Discuss the evidence base behind these treatments for temporomandibular disorders:-
• Education and information (counseling)
• Cognitive behavioural therapy
• Jaw exercises
• Occlusal appliances
• Physiotherapy (e.g. massage)
• Other approaches (e.g. acupuncture)
• Temporomandibular joint arthroscopy
• Temporomandibular joint surgery
3.7.32 Appreciate the need to manage temporomadibular disorders early and holistically
to prevent chronicty
3.7.33 Discuss the evidence base for management of ”burning mouth” syndrome
3.7.34 Discuss the evidence base for management of presistent idiopathic facial pain
3.7.35 Discuss the evidence base for management of facial deafferentation with motor
cortex Stimulation
3.7.36 Evaluate efficacy of key interventions through assessment of key clinical and patient
reported outcomes

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3.8 Visceral Pain

Visceral pain can arise from the chest, abdomen or pelvis and is a common symptom in the population.
Pain affecting the viscera can be severe. Injury and inflammation can be particularly problematic, as
organs become highly sensitive to any kind of stimulation, as in inflammatory bowel disease.

By the end of training, a trainee will be able to:-

Background
3.8.1 Describe the taxonomy of primary (functional) and secondary (organic) visceral
disorders
3.8.2 Discuss the differences between somatic and visceral pain syndromes
3.8.3 Describe the epidemiology of principle visceral pain conditions and their social
impact
Applied Foundation Knowledge
3.8.4 Outline the definition and classification of visceral pain
3.8.5 Demonstrate an understanding of the following with respect to chronic visceral pain:-
• Neuroanatomy
oo Central pathways
oo Peripheral pathways
oo Innervation of viscera within: thorax, abdomen & pelvis
With particular reference to:-
»» Stellate ganglion
»» Splanchnic nerves
»» Coeliac ganglion
»» Hypogastric plexus
»» Ganglion impar
»» Pudendal nerve
• Neurophysiology
oo Visceral sensitization
oo Visceral nociceptors
oo Visceral pain & hyperalgesia
oo Visceral hypersensitivity
oo Neurophysiological basis of referred visceral pain
oo The gut-brain-axis
• Biopsychosocial issues of visceral pain
Clinical Assessment of Visceral Pain
3.8.6 Outline features for evaluating the clinical history of suspected visceral pain syndromes
3.8.7 Outline features of a pyschosocial assessment
3.8.8 Outline features of a physical examination

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3.8.9 Distinguish clinically between:-

• Active visceral nociception
• Visceral hyperalgesia
• Referred pain with and without hyperalgesia:-
oo Viscero-somatic
oo Viscero-visceral (cross-organ sensitization)
3.8.10 Interpret laboratory tests and imaging
3.8.11 Identify ‘red flag’ features that suggest active visceral disease
3.8.12 Demonstrate a mechanistic approach for identifying non-visceral causes of thoracic,
abdominal and pelvic pain. This would include myofascial, thoracic and abdominal
wall pain, and post-surgical neuropathic pain
Management of Visceral Pain
3.8.13 Discuss the principles of pharmacotherapy to manage visceral pain
3.8.14 Discuss the evidence base for the indications, effectiveness and adverse effects of
the following therapies:-
• Physiotherapy
• Other approaches (e.g. acupuncture)
• Non-invasive neuromodulation (e.g. TENS, rTMS, tDCS, tACS)
• Invasive therapies
»» Radiofrequency techniques
»» Neuromodulation
»» Intrathecal techniques
»» Electrical stimulation
»» Neurolytic techniques
3.8.15 Discuss the evidence base for the indications and effectiveness of psychological
interventions used for management of chronic visceral pain
3.8.16 Discuss treatment options for the management of:-
• Functional pain syndromes such as: irritable bowel syndrome, chronic functional
abdominal pain, painful bladder syndrome and functional chest pain
• Organic visceral pain disorders such as in chronic pancreatitis and inflammatory
bowel diseases
• Abdominal wall pain
• Anorectal pain
• Pelvic pain syndromes
3.8.17 • Evaluate efficacy of key interventions through assessment of key clinical and
patient reported outcomes

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3.9 Complex Regional Pain Syndromes, Type I and II

Complex Regional Pain Syndromes, types I and II, are challenging in terms of understanding the
mechanisms of the disease and approaches to management. The specialist pain medicine physician
should gain expertise in identifying presenting signs and symptoms, diagnosis and differential diagnosis
of these conditions. It is also important to gain knowledge of the pathophysiology, natural history and
evidence-based approaches for prevention and treatment.

By the end of training, a trainee will be able to:-

Background
3.9.1 Discuss the historical progression of terminology used to describe CRPS Syndromes,
type I and II, towards the current use of clinical and research New IASP criteria.
Address also, sensitivity, specificity and positive predictive value of the current
diagnostic criteria
3.9.2 Know that there are differences between adult and paediatric CRPS in terms of
presentation, disease course and management and prognosis
Applied Foundation Knowledge
3.9.3 Discuss proposed pathophysiological mechanisms of CRPS, types I and II.
3.9.4 Critically discuss “sympathetically maintained pain”
3.9.5 Explain the rationale for programs of:-
• Desensitisation
• Graded mobilisation
Clinical Identification and Assessment of CRPS
3.9.6 Generate a differential diagnosis of more common conditions for a patient with
presumed CRPS and know how to use the New IASP criteria
3.9.7 Perform a functional assessment of the CRPS-affected limb including:-
• Comparison with the contralateral side
• Performance of activities of daily living
• Motion analysis, where relevant
• Deep somatic structures (bone, joints)
• Vasomotor changes, sudomotor changes, trophic changes and sensory changes
See also Section 3.5. Neck and Back Pain

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Management of CRPS
3.9.8 Outline the role and the elements of the following strategies in achieving improved
function and/or recovery in patients with CRPS:-
• General:-
oo Patient information and education
• Psychological (cognitive behavioural therapy), including but not limited to:-
oo Coping skills
oo Relaxation techniques
oo Addressing critical life events and abuse
oo Management of anxiety and/or depression
• Physical, including but not limited to:-
oo Graded motor imagery
oo Mirror visual feedback
oo Occupational therapy
oo Graded paced exercise and activity
oo Desensitization with tactile and thermal stimuli
• Pharmacotherapy depending on the stage of the disease including
oo Neuropathic pain medication
oo Bisphosphonates
oo Steroids
• Invasive treatment options in selected patients
oo Neuromodulation
oo Neuraxial application of analgesics
oo Sympathectomy
• IV infusions
3.9.9 Evaluate efficacy of key interventions through assessment of key clinical and patient
reported outcomes

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3.10 Pain in Hereditary Connective Tissue Disorders

Pain in hereditary connective tissue disorders (HDCT) is a major contributor to lost productivity. Several
pain patterns are recognized in these disorders such as neuropathic pain including entrapment
neuropathies, arthralgia, low back and neck pain, luxation or subluxation. Dysautonomia and
psychological disturbances are another important clinical issue. HDCT is a non homogenous group of
conditions that includes Ehlers Danlos Syndrome (EDS), Joint Hypermobility Syndrome (JHS), Marfan
Syndrome, Osteogenesis Imperfecta and other related syndromes. HDCT affects 2 % of the world’s
population. These conditions are major contributors to global non-fatal health burden (years lived with
disability). Definitions and approaches to assessment and management of HDCT vary according
to the etiology and clinical presentation. It is essential that the Specialist Pain Medicine Physician
develop a comprehensive, integrated approach to this burden on society.

By the end of training, a trainee will be able to:-

Background
3.10.1 Compare and contrast the current definition of HDCT Rheumatoid Arthritis/Juvenile
RA, Bechterew/Ankylosing Spondylitis, Systemic Lupus Erythematosus (SLE), Osteo
Arthritis, Fibromyalgia syndrome, ‘Growing Pain‘, Migraine, Multiple Sclerosis,
Painful Peripheral /Entrapment Neuropathies, Restless Legs, Low Back Pain
3.10.2 Discuss controversies in diagnostic terminology of HDCT
3.10.3 Discuss the public health dimensions of the problem of pain in HDCT, including but
not limited to:--
• Prevalence
• Demography
• Personal and community costs
Applied Foundation Knowledge
3.10.4 Describe the connective tissue structure and function and identify potential structures
that may be associated with pain
Clinical Assessment of Pain in HDCT
3.10.5 Discuss the rationale and use of psychological and functional questionnaires for
assessing these chronic pain conditions
3.10.6 Identify the potential specific causes of acute and chronic pain in HDCT
• Dislocation/subluxation
• Trauma
• Skin and tissue fragility
3.10.7 Distinguish between radiculopathic and referred pain with respect to limb girdle or
limb pain associated with spinal pain, or peripheral or central entrapment entrapment
disorders
3.10.8 Critically interpret commonly used physical examination tests, for example, Beighton
score, 2017 criteria for EDS diagnosis and myofascial pain syndrome tests
3.10.9 Perform a gait analysis, bedside neurological examination, orthostatic blood
pressure test, joint/muscle examination

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3.10.11 Recognise the clinical presentation of symptomatic dysautonomia mast cell activation
syndrome
3.10.12 Distinguish between acute and acute-on-chronic episodes of pain
3.10.13 Reinterpret pre-existing investigations and opinions in the light of clinical findings
Management of Pain in HDCT
3.10.14 Critically discuss the evidence base for management of acute and chronic pain
according to the pain etiology
3.10.15 Discuss the efficacy of psychological therapies in chronic musculoskeletal pain,
including but not limited to:-
• Cognitive
• Behavioural
• Acceptance and commitment
3.10.16 Discuss principles of activity prescription in the management of pain in HDCT
3.10.17 Generally discuss the evidence-base for efficacy and adverse effects of physiotherapy
in chronic HDCT pain, including but not limited to:-
• Graded exercise exposure
• Stabilization/strengthening
• Posture training, proprioceptive training
• Hydrotherapy
• Feldenkrais technique
• Manual therapy
• Massage
• Biofeedback
• TENS
3.10.18 Critically discuss the evidence base for the efficacy of pharmacological treatments
for chronic pain and dysautonomia in HDCT
3.10.19 Critically discuss the evidence base for the indications, efficacy and complications
of interventions used for chronic HDCT pain, including:-
• Injections
• Epidural/caudal steroids
• Medial branch injections
• Trigger point injections
oo Botulinum toxin
oo Intra-articular steroids
3.10.20 Broadly appreciate the evidence base for the efficacy and complications of
complementary and alternative medicine for management of HDCT pain, for
example, acupuncture and chiropractic medicine

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Section Four:-
Special Patient Populations

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4.1 Pain in Older Adults

While previous evidence suggests that chronic pain typically affects those of working age, there is
growing evidence to demonstrate that chronic pain continues to increase into the oldest old. Although
older people experience a decrease in non-disabling back pain, they experience an increased
prevalence of disabling back pain and this can continue to increase into the oldest of the elderly.

The aetiology of back pain in the working population is relatively well known, risk markers are well
established, and include, female gender, lower social class, poor psychological well-being and
occupational physical and psychosocial factors. The aetiology of back pain may differ in older
people, however there are few large-scale prospective studies in this area and so information is
sparse.

There are substantial differences in the population, methods and definitions used in published research
which make it difficult to compare across studies and determine the prevalence of pain in older
people. The reported effect of age on pain prevalence in older people is inconsistent, with some
studies reporting an increase in prevalence with age and others reporting a decrease in prevalence
with age. This section aims to describe the intricacies around the prevalence and onset of pain in
older adults, to allow a fuller understanding of how pain might be better assessed and managed.

Background
4.1.1 Demonstrate an understanding of the prevalence of pain in later life
4.1.2 Demonstrate an understanding of the onset of pain in older adults
4.1.3 Demonstrate an understanding of the burden pain has both on the individual and
to society
4.1.4 Demonstrate an understanding of the key risk factors both associated with, and
predictive of, pain in older adults
4.1.5 Discuss the prognosis for pain in older adults

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Applied Foundation Knowledge

4.1.6 Demonstrate an understanding of the anatomical and pathophysiological processes
involved in the distribution and perception of pain in the older person, addressing:-
• Alterations to anatomical structures and physiological processes associated
with ageing and how these alterations impact upon the presentation and
normal physiological response to pain and its treatment
• Changes in pharmacodynamics and pharmacokinetics
• Site of pain
• Physical comorbidities
• Thresholds of pain
• Physiological processes in the Central Nervous System related to:-
oo Injury
oo Ischaemia
oo Neurodegenerative disorders:
a. Alzheimer’s disease and other dementias
b. Parkinson’s disease
• Changes in neurotransmitters
• Physiological processes in the Peripheral Nervous System related to:-
oo Injury
oo Degeneration
oo Neurotransmitters
4.1.7 Address the multifactorial nature of pain, including:-
• Emotional and behavioural components
• Mood
• Sleep
• Functional ability
• Agitation and anxiety
4.1.8 Demonstrate knowledge of alterations to physiological and metabolic processes
associated with ageing and how these alterations impact upon the metabolic and
physical response to the pharmacological management of pain addressing:-
• General physical ageing
• Gastrointestinal
• Hepatic: structural and metabolic
• Renal system: structural and functional
4.1.9 Demonstrate an understanding of conceptualisations of attitudes and beliefs and
their relationship to behaviour
4.1.10 Demonstrate an understanding of the impact of beliefs held by health professionals,
care givers and family
4.1.11 Demonstrate an understanding of the impact the beliefs health professionals, care
givers, and family have on the support and interventions offered to older people
4.1.12 Demonstrate an understanding of the impact the beliefs health professionals, care
givers, and family have on older people’s responses to pain

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4.1.13 Show an understanding of the pharmacokinetics, pharmacodynamics, tolerance,

and dependence of drugs upon the older person with and without identified
comorbidities. Describe:-
• Pharmacokinetics
oo Drug absorption
oo Drug distribution
oo Renal drug excretion
oo Drug metabolism
• Pharmacodynamics
oo Receptor properties
oo Homeostatic mechanisms
• Tolerance
• Dependence
4.1.14 Describe some of the common conditions/diseases in older people and presenting
with specific pain, including:-
• Bone pain (secondary to metastasis or osteoporotic fractures)
• Chronic neuralgic pain (from nerve compression or radiculopathy)
• Chronic visceral pain syndrome (like bladder pain and gastrointestinal pain)
• Include an understanding of the characteristics of visceral pain (in contrast to
somatic pain)
Clinical Assessment of Pain in Older Adults
4.1.15 Demonstrate skills for assessing the intensity of pain in the older population regardless
of aetiology and communication ability
4.1.16 Discuss key topics required for diagnosis of pain in older adults along with the range
of assessment tools available for clinicians to use:-
• To determine the differences between acute and chronic pain
• To identify the assessment tools which can be applied by clinicians to aid
diagnosis and quantify symptoms
a. Brief Pain Inventory
b. Numerical Pain Scales/Verbal Pain Scales
c. NRS/VPS
d. Geriatric Pain Scales
4.1.17 Show ability to identify the impact of pain upon the mood and quality of life of the
older person:-
• Explore tools available to measure anxiety and depression which may be
associated with long term pain (Hospital Anxiety and Depression Scale, Beck
Depression Scale)
• Identify the impact of pain upon quality of life

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4.1.18 Perform a person-centred assessment and establish a management plan:-

• Prioritise facilitation of physical activity/exercise within issues to be addressed
with the person
• Assess physical abilities and capacity, preferences for physical activity/
exercise, and perceived barriers
• Establish goals of physical activity/exercise in collaboration with the person
and, if appropriate, their families, which should consider improvement/
maintenance of social, physical and psychological function; and managing
symptoms
• Establish a person-centred physical activity/exercise plan
4.1.19 Demonstrate ability to:-
• Identify and manage pain in people living with dementia, use of pain tools and
carer involvement
• Describe the effects of pain (e.g. on diet, mood and behaviour) on general
health of people living with dementia
• Outline referral pathways for people living with dementia who experience pain
• Support carers and family of people living with dementia who experience pain
Management of Pain in Older Adults
4.1.20 Discuss the influence of other prescribed medicines and the potential impact of
common comorbidities when considering treatment options for pain
4.1.21 Describe changes in the pharmacodynamics and pharmacokinetics of analgesic
drugs that occur with ageing
• NSAIDs
• Opioids
• Tricyclic antidepressants
• Anticonvulsants
4.1.22 Explain the consequences and implications of physiological and pharmacological
changes on effectiveness, side effects and need for dose adjustment
4.1.23 Monitor effects of pain management approaches to adjust the care plan as needed
4.1.24 Recognise that pharmacological treatments for persistent pain are more effective
when combined with non-pharmacological approaches and that use of analgesic
medicines should aid functional rehabilitation
4.1.25 Recognise that dependence to and misuse of analgesics may occur in older people
and ensure appropriate monitoring

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4.1.26 Show ability to facilitate physical activity/exercise within the practitioner’s defined
scope of practice and expertise:-
• Demonstrate a commitment to facilitating physical activity/exercise in older
people with persistent pain
• Apply knowledge of the clinical, biological, psychological and social sciences
relevant to the practitioner’s discipline, in the context of physical activity/
exercise
• Recognize the breadth of work, leisure, and other activities of daily living
covered by the term ‘physical activity’
• Perform appropriate clinical assessments and provide clearly understandable
recommendations, which may include referral to a health professional from a
more appropriate discipline for physical activity/exercise, e.g. a physiotherapist
• Recognize and respond to the complexity, uncertainty, and ambiguity inherent
in facilitation of physical activity/exercise
4.1.27 Plan and perform facilitation of physical activity/exercise:-
• Determine, in collaboration with the patient, options for physical activity/
exercise, appropriate to their physical abilities/capacity, including discussion
of the possible value of equipment and adaptations to support engagement in
activity
• Explain the risks and benefits of, and the rationale for, a proposed physical
activity/exercise plan
• Consider the priority of the type of physical activity/exercise, taking into
account the person’s functional status and available resources.
oo For example, professional-led rehabilitation focusing on strength, flexibility,
endurance and balance for people with limited function; supervised
activity/exercise for people not yet confident in independent physical
activity/exercise; community-based physical activity/exercise for higher
functioning people  
• Provide clear feedback on the person’s performance of physical activity/
exercise
• Facilitate physical activity/exercise in a skilful and safe manner, adapting to
unanticipated findings or changing clinical circumstances
4.1.28 Establish plans for physical activity/exercise as part of self-management and, when
appropriate, provide provision for timely consultation:-
• Implement a person-centred physical activity/exercise plan that supports self-
management, and provides practical advice about future consultation
4.1.29 Discuss the benefits of minimally invasive interventional strategies in pain management.
Addressing the:-
• Evidence base behind recommending invasive approach in certain conditions
• The different available modalities and when to consider each one

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4.1.30 Discuss current evidence around growing interest in the use of psychosocial
interventions to help older adults manage pain:-
• Demonstrate an understanding of the various psychosocial interventions
available
• Demonstrate an understanding of the evidence on effectiveness of these
interventions in older adults
• Demonstrate an understanding of why psychosocial interventions would be
beneficial for older adults based on the aetiology of pain in this population
4.1.31 Demonstrate an understanding on the key aspects of Cognitive Behavioural Therapy
(CBT) as relevant for pain management in older adults:-
• Demonstrate a knowledge of CBT and what it is
• Demonstrate an understanding of areas where evidence for CBT is strong and
pain research can learn from
• Demonstrate an understanding of the evidence around CBT and its use for pain
management in older adults
4.1.32 Discuss the considerations which must be made when using complementary therapies
with older adults in terms of contraindications, efficacy and side effects:-
• Consider the use of complementary therapies such as acupuncture, TENS and
massage
Palliative Care, Cancer Care and the End of Life
4.1.33 Understand the needs of older adults when receiving cancer care or palliative care
4.1.34 Consider the implications of treatment and side effects
4.1.35 Understand the principles of analgesic use, using the three step, WHO, analgesic
ladder
4.1.36 Anticipate and prevent the risk of side effects associated with strong opioid drugs
4.1.37 Promote evidence based practice
4.1.38 Provide guidelines for the end of life
Nursing Care
4.1.39 Ensure the application of good pain management practice regardless of patients’
age or cognitive ability:-
• Conduct relevant and appropriate pain assessment and documentation using
well validated pain tools according to level of cognitive ability
• Act as a patient advocate throughout the pain management process, ensuring
that the patient receives the best possible care and understands the implications
of such care
• Monitor progress and report any deviations from the pain management process
or any untoward side effects
• Communicate between the patient, their carer and members of the
interprofessional/ multidisciplinary team

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Section Four: Special Patient Populations

4.2 Pain in Infants, Children, Adolescents and Young Adults (AYA)

The section outlines the core knowledge, skills and attitudes for physicians specializing in Pain
Medicine who may be involved in managing a child with pain. The premise of this chapter is that not
all specialist pain medicine physicians will be directly involved in providing pediatric pain services,
however, all need to have an understanding in this area.

Applied Foundation Knowledge

4.2.1 Demonstrate knowledge of developmental neurobiology of pain, including
mechanisms of nociception and hyperalgesia
4.2.2 Show understanding of the long-term neurophysiological consequences of pain in
infancy and early childhood
4.2.3 Outline the of principles of age-related changes in body composition,
pharmacokinetics and pharmacodynamics affecting pain pharmacotherapy,
therapeutics and dosing in infants, children and adolescents
4.2.4 Discuss ethical and legal aspects of prescribing for children including marketing
authorisation and off-label prescribing
Clinical Assessment of Pain in Infants, Children and Adolescents
4.2.5 Discuss developmental, cognitive, contextual, and practical considerations in acute,
procedural and chronic pain assessment in infants, children and adolescents
4.2.6 Demonstrate accurate assessment of acute and chronic pain in infants, children
and adolescents using validated pain measurement tools and diaries, including the
ability to apply to children who are:-
• Cognitively impaired
• From linguistically and culturally diverse backgrounds
4.2.7 Critically discuss the evidence-base on the relationship of mood disorders and early
adverse life events, including prolonged time in the neonatal intensive care unit or
child abuse and pain
Management of Pain in Infants, Children and Adolescents
4.2.8 Critically discuss methods of analgesic delivery appropriate for:-
• Home
• School
• Hospital settings

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4.2.9 Discuss the evidence-base for effective pain treatments in children of different ages
and in different contexts including, but not limited to:-
• Procedural pain, including repeated painful procedures
• Acute pain
• Postoperative pain
• Complex pain conditions including, but not limited to functional abdominal
pain, headache, Complex Regional Pain Syndrome, chronic widespread pain,
neuropathic, visceral and musculoskeletal pain
• Cancer pain and palliative care, including mucositis
• Role of interventional procedures including regional nerve blocks and surgical
procedures
4.2.10 Discuss safe and effective pharmacological management of acute, procedural and
complex pain conditions in children using analgesics and adjuvants
4.2.11 Demonstrate safe and appropriate prescription of analgesia with awareness
of toxicity, interactions and side-effects associated with opioids and other pain
medication
4.2.12 Demonstrate understanding of the principles of interprofessional/multidisciplinary
team management of pain in children and adolescents
4.2.13 Discuss biopsychosocial aspects of pain management in children,family-centered
care, including the role of the family (or carer) and society and influence of diverse
socio-economic, ethnic and cultural backgrounds
4.2.14 Demonstrate understanding of organisational aspects of children’s pain services
including:-
• Acute (postoperative and procedural) pain
• Cancer pain and palliative care
• Complex pain
4.2.15 Critically discuss Child Protection and safeguarding risks and procedures
4.2.16 Outline practices for transitioning from pediatric to adult pain clinics
4.2.17 Demonstrate skills for communication with:-
• Children and families/carers in a setting of cultural diversity
• Other healthcare professionals in primary and secondary children’s care
4.2.18 Discuss the role of Returning To School (RTS) and Staying In School (SIS)
4.2.19 Recognize the family as information provider as well as co-therapist. Examples
include but not limited to allowing for PCA by proxy in small children or by facilitating
breast feeding during immunization
4.2.20 Demonstrate skills for setting adequate and realistic functional goals for management
of complex pain conditions
4.2.21 Outline means to identify children at risk and means to implement local safeguarding
procedures
4.2.22 Critically discuss appropriate skills mix for interprofessional/multidisciplinary
pain management in children of different ages, abilities and social, cultural and
educational needs

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4.2.23 Demonstrate verbal and written communication skills necessary within the
interprofessional/multidisciplinary team
4.2.24 Discuss approaches for integrating the 3 P’s – Pharmacology, Physiotherapy and
Psychology into an interprofessional /multidisciplinary management plan
4.2.25 Outline physical and psychological strategies to manage pain including, but not
limited to:-
• Hot/cold pack
• TENS
• Distractions
• Breathing techniques
4.2.26 Distinguish the role of physiotherapy, including pacing, in chronic pain
4.2.27 Critically discuss the role of psychological therapies in procedural and chronic pain,
including:-
• Cognitive behavioural techniques
• Distraction, guided imagery
• Biofeedback and mindfulness
4.2.28 Discuss the role of complementary and alternative medicine (CAM)

Pain Medicine Roles in Practice

4.2.29 Participate in a local or international pain research and/or pain registry
4.2.30 Participate in teaching relevant pain topics to other health care professionals
including general practitioners, students and nurses
4.2.31 Present a pediatric pain topic at academic rounds or a journal club
4.2.32 Attend at least one local or international pediatric pain conference during the
fellowship
4.2.33 Participate in Continuing Professional Development (CPD) including patient and
colleague feedback
4.2.34 Participate in annual appraisal and revalidation processes

84 Curriculum for the European Diploma in Pain Medicine

 Section Four: Special Patient Populations
Section

4.3 Pain and Problem Substance Use

Pain and substance misuse are often “co-morbid”. The specialist pain medicine physician (SPMP)
must not only be aware of the spectrum of substance abuse in the clinical pain community but also
be equipped to identify, if possible prevent, and institute management of such problems in patients
and in colleagues.

By the end of training, a trainee will be able to:-

Background
4.3.1 Define the following concepts:-
• Tolerance
• Physical dependence
• Psychological dependence
• Classification of clinical states following psychoactive substance use
• Dual diagnosis (Substance Use Disorder as Co- Morbidity with Physical and
Mental Health Problems)
4.3.2 Critically discuss the differences in understanding and use of the terms above
between the disciplines of pain medicine and addiction medicine
4.3.3 Distinguish between inappropriate prescription (inappropriate prescriber behaviour)
and unsanctioned use (unsanctioned user behaviour) of drugs
4.3.4 Describe the impact of the following non-prescription substances on health and pain
experience:-
• Caffeine
• Illicit Heroin
• Nicotine
• Alcohol
• Cannabis
• Methamphetamine and other stimulants
Applied Foundation Knowledge
4.3.5 Describe in detail regulations regarding the prescription, restrictions and monitoring
of controlled substances in your relevant healthcare system
See also Section 2.2.20 – 2.2.22 Professional
4.3.6 Discuss the current DSM 5 or ICD-11 criteria for diagnosis of mental and behavioural
problems due to psychoactive substance use, in particular Opioid Use Disorder;
discuss the appropriateness of ICD-11 criteria of substance use disorder and
dependence for patients receiving opioid therapy
4.3.7 Discuss in detail the role of sedatives, hypnotics, and anxiolytics in acute pain and
chronic non-cancer pain
4.3.8 Describe your understanding of Neonatal Abstinence Syndrome (NAS) – Describe
the relationship between NAS and prescribed opioid analgesia

Curriculum for the European Diploma in Pain Medicine 85

Section Four: Special Patient Populations

Clinical Presentations and Risk Assessment

4.3.9 Recognize the different forms of substance abuse that may be co-morbid with the
experience of chronic pain across all ages
4.3.10 Compare and contrast intoxication and withdrawal syndromes from:-
• Opioids
• Alcohol
• Benzodiazepines
• Amphetamines
• Cannabis
• Other centrally acting substances
4.3.11 Identify risk factors and protective factors for addictive behavior, acknowledge the
individual risk continuum and stratify patients into risk categories when considering
opioid prescription for pain
4.3.12 Critically appraise the tools available to assist clinical assessment of suitability for,
and monitoring of, prescription of opioids for chronic non-cancer pain
4.3.13 Discuss the uses and limitations of urine drug testing and hair analysis
Discuss the ethical aspects of drug testing
Management of Problem Substance Use
4.3.14 Assess and quantify medication use by persons with chronic pain, including assessing
the cumulative effects of multiple substances
4.3.15 Discuss strategies to minimise opioid diversion
4.3.16 Broadly discuss regimens of supervised withdrawal from:-
• Illicit opioids
• Prescribed opioids (including methadone, buprenorphone and others)
• Benzodiazepines
• Alcohol
• Other centrally acting substances
4.3.17 Demonstrate understanding of controlled opioid substitution treatment programs in
your relevant health care system
4.3.18 Demonstrate understanding of the management of patients with problematic substance
use in the context of acute and chronic pain, including monitoring, identification of
the change cycle in which the patient is, the role of support figures, drug therapy
and rehabilitation
4.3.19 Counsel patients, their families and carers, and colleagues regarding the conduct
of withdrawal of opioids and benzodiazepines in chronic non-cancer pain and the
provision of naloxone
4.3.20 Work ethically with general practitioners, addiction services, families and, where
appropriate, employers of patients with co-morbid pain and problematic substance use
4.3.21 Assist in the management of the healthcare professional with problematic substance
use, especially benzodiazepines and opioids; including monitoring, drug therapy
and rehabilitation

86 Curriculum for the European Diploma in Pain Medicine

 Section

Section Five:-
Interprofessional Working and Learning

Curriculum for the European Diploma in Pain Medicine 87

Section Five: Interprofessional Working and Learning

5.1 Interprofessional Working and Learning

A specialist pain medicine physician (SPMP) should function within an interprofessional and multi-
disciplinary pain management team to achieve optimal patient care. The European Pain Federation
EFIC have established complimentary educational pathways for various professions, with a focus on
interprofessional learning and working. By the end of training, the SPMP will be able to:-

5.5.1 Discuss the importance of interprofessional working in pain management along with
potential barriers and facilitators to team-based care
5.5.2 Demonstrate an ability to work respectfully and in partnership with patients, families/
carers, healthcare team members and agencies, to improve patient outcomes
5.5.3 Engage in and create regular opportunities for interprofessional education and
supervision understanding the importance and benefits of interprofessional learning
5.5.4 Critically reflect on own contribution to the interprofessional team and continually
strive to improve interpersonal and team skills, e. g. communication, negotiation,
problem solving, decision-making
5.5.5 Demonstrate understanding of professional perspectives, skills, goals and priorities
of all team members
5.5.6 Negotiate overlapping and shared responsibilities with interprofessional colleagues
for episodic or ongoing care of patients with pain
5.5.7 Respect professional differences, acknowledge misunderstandings and limitations in
oneself and other healthcare professionals that may contribute to interprofessional
tension(s)
5.5.8 Reflect, negotiate and work with others to minimise and resolve conflict and maximise
patient outcomes
5.5.9 Participate in team discussions and implement strategies to improve team-based
care and interprofessional working
5.5.10 Discuss the particular personal and team-related stressors inherent in specialist pain
medicine practice, and seek assistance or provide support as necessary
5.5.11 Convey all relevant information when transferring care of a patient to another
practitioner

88 Curriculum for the European Diploma in Pain Medicine

 Acknowledgements
Section

Acknowledgements
The European Pain Federation EFIC® would like to thank the following individuals and organisations for
their support for the 2023 review of this curriculum:

EFIC® Education Committee

Prof. Frank Huygen, Prof. Harriet Wittink, Prof. Bart Morlion, Prof. Ed Keogh, Felicia Cox, Dr. Morten
Högh, Dr. Andreas Kopf

The Directors of the EFIC Pain Schools-

Dr. Manohar Sharma (Cancer Pain), Prof. Nevenka Krcevski Škvarc (Cancer Pain), Prof. Barbara
Przewlocka (Translational Pain Research), Prof. Luis Garcia Larrea (Neuropathic Pain), Prof. Winfried
Meissner (Acute Pain)

The Board of Examiners for the Examination for the European Diploma in Pain Medicine-
and in particular; Dr. Daniele Battelli, Dr. Hani Hattar, Dr. Aki Hietaharju, Prof. Asbjørn Mohr Drewes,
Dr. María Luz Padilla del Rey, Dr. Samer Narouze, and Dr. Winfried Häuser for their individual contributions.

The EFIC Academy Board

The EFIC® Executive Board-

Dr. Brona Fullen, Prof. Luis Garcia Larrea, Prof. Patrice Forget, Dr. Silviu Brill, Prof. Thomas Tölle, Prof.
Magdalena Kocot Kepska.

Other educators who contributed-

such as Prof. Boris Zernikow, Dr. Cem Yetimoglu, Dr. Staja Booker

The following scientific societies contributed to the review process via the European Pain Forum:
European Academy of Neurology (EAN) – Prof. Martin Rakusa
European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) – Prof. Esther Pogatzki Zahn
European Psychiatric Association (EPA) – Prof. Geert Dom
European Federation of Psychologists Associations (EFPA) – Prof. Borrik Schjødt
European Society of Physical and Rehabilitation Medicine (ESPRM) – Dr. Roberto Casale
European Region of World Physiotherapy (ER-WCPT) – Prof. Carmen Suarez
European Specialist Nursing Organisation (ESNO) – Dr. Adriano Friganović
European Cancer Organisation (ECO) – Prof. Nevenka Krcevski Skvarc
European Society of Regional Anaesthesia (ESRA) – Prof. Eric Buchser
European Federation of Addiction Specialists (EUFAS) – Prof. Cristina Ribeiro
European Headache Federation (EHF) – Prof. Antoinette Maassen van den Brink
Council of Occupational Therapists for European Countries (COTEC) – Dr. Omid Rasouli
European Association of Hospital Pharmacists (EAHP) – Dr. Andras Sule
World Organisation of National Colleges, Academies and Academic Associations of GPs/Family
Physicians (WONCA EUROPE) – Dr. Aleksander Stepanovic

Curriculum for the European Diploma in Pain Medicine 89

European Pain Federation EFIC®
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2nd Edition 2023
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Copyright © 2023 by European Pain Federation EFIC®

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Find the curriculum on the EFIC® website under
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