The History of the Chronic Pain Management Unit
Written by: Eldon Tunks MD FRCP(C), Professor Emeritus of Psychiatry, McMaster University Pain Management, Chedoke Rehabilitation Center
The Pain Management Program at Chedoke and McMaster began with three separate initiatives that gradually coalesced.
Dr. Sikhar Banerjee, physiatrist, and Dr. Avrum Green, psychologist, inspired by the 1969 report of W. Fordyce on using operant conditioning for rehabilitation of chronic pain disability, began in 1972 to treat patients on Ward 25 of the Chedoke Rehabilitation Center, up to two patients at a time, using this method. The results were encouraging.
I was in my third year psychiatry residency 1972-1973 and took that year to be the neurology and neurosurgery resident at McMaster, and while there became interested in patients who had persistent pain because I also had read the report by Fordyce et al (1969), demonstrating that patients with disability associated with chronic pain could be helped using operant behavioral methods. I began to employ these methods at McMaster to treat some chronic pain patients using operant techniques, with success."
Dr. Jay Forrest, anesthesiology department at McMaster, was doing nerve blocks for some patients with pain disorders in 1973.
I teamed up with an anesthesiology resident, Dr. Frieda Reddekop, in early 1973 to look at the potential for a pain clinic at McMaster, and made a couple of trips to Toronto to meet with Dr. Ray Evans (Hamilton General and Wellesley Cancer Center) who is running a surgically-oriented pain clinic, for the most part using medication, and opioid for cancer. There was no psychological or psychiatric or multidisciplinary input available. However we also learned that Dr. Ronald Needs at Sunnybrook was doing nerve blocks, and Dr. Ron Melzack had gathered a group of anesthetists and a nurse at Montréal General to form a pain relief clinic there. Given that we had good information that there was a need, that others were recognizing it, we called a meeting in the summer of 1973 with representatives of department of anesthesiology from the Henderson Hospital, Dr. J. Forrest from McMaster, Dr. Sikhar Banerjee from Chedoke, and we proposed a pain management program which initially was set up at McMaster out-patients. At that point the two clinicians were Dr. J. Forrest and I and one nurse from the Department of neurology. We began to see patients in December 1973, and by June 1974 there was already a three month waiting list.
In July 1974, I moved the outpatient pain clinic to the outpatient rehabilitation service at McMaster 2F clinic, where I was joined by Dr. S. Banerjee, physiatrist, Dr. Sid Dinsdale, physiatrist, Dr. Bill Viviani, orthopedic surgeon, and Dr. Stan Schatz, neurosurgeon, and continued to collaborate with Dr. J. Forrest from anesthesiology.
At that time there was no multidisciplinary support apart from physicians. However there was significant interest from the head of a Physiotherapy Liz Morrison, the head of Occupational cap therapy Sue Baptiste, and two academic faculty nurses Professor Robin Weir and Professor Joan Crook, they formed part of the team. About a year later Ranjan Roy, social worker, also joined the program. There are others also who joined along the way and I can't name them all, but would say that they were all people who had caught the vision that there was something that could be done to alleviate the pain and disability of chronic pain. About that time in the mid-1970s scientific reports began to emerge that group methods and cognitive-behavioral therapy could be used for pain management. In 1979 we published the first article in pain dealing with cognitive-behavioral therapy in groups used for patients with chronic pain, and from then on we continued to employ these methods.
In 1979, I transferred to Chedoke hospital full-time in the rehabilitation unit to manage the pain management program inpatients while I also maintained the interdisciplinary program at McMaster outpatient rehabilitation clinic.
Beginning in 1984, as a group we began to do the first epidemiological studies of chronic pain and its outcome. Since then it has become a major field of study internationally. Our particular interest has been in core morbidity or the cumulative effects of chronic pain along with other conditions as risk factors for future health and outcome. Our specialty has been treating people whose cases are complex and who therefore need a concerted multidisciplinary approach. Our belief is that one should relieve pain where possible while at the same time dealing with other concurrent conditions and promoting the rehabilitation, self-help and patient education.
In 1989, the McMaster pain rehabilitation clinic was transferred to Chedoke to amalgamate it with the existing inpatient pain management program.
In the 1990s, Dr. Norman Buckley took over the leadership of the anesthesiology services at McMaster from Dr. Forrest, and combined the efforts of the anesthetists to a pain diagnosis, relief and management service centered at the Hamilton General. There continues to be a collaborative relationship in the city between our program at Chedoke and other clinics dealing with pain; palliative care under family practice and pain relief at Hamilton General. Students and postgraduates come here for training, and recently postgraduate physicians who are completing subspecialty fellowships in pain management. In 1996 until present, I was part of a group with the College of Physicians and Surgeons of Ontario in drafting the first set of guidelines for chronic pain management These are important in being the first set of evidence-based guidelines by a regulatory body anywhere (based on scientific principles). These guidelines are currently being revised with an inter-provincial consortium.
In the mid-'90s, Dr. Jeff Ennis spent several years managing the pain program at Chedoke, Dr. Brian Kirsh was the medical director from 1999 to 2010. Dr. Dinesh Kumbhare and Dr. Sean Curran were each in the role during a short interim period, until Dr. Ramesh Zacharias took over the director role in January 2012.
I continue as the consultant in the rehabilitation center, have a significant practice in neuropathic and spinal cord injury pain, am president of the Canadian Academy of Pain Management, and vice president of the Chronic Pain Section of the Ontario Medical Association.
In all of this, the Chronic Pain Management Program at Chedoke Hospital is one of the first such programs in the world and has an illustrious history.