The Structure and Regulation of pain Training:

The Egyptian Pain Fellowship Board requires one year of supervised

training program that must be conducted in accredited hospitals before sitting
for the final examination. A list of accredited hospitals will be announced
yearly by the board. Entry to the pain training program has the following
requirements for trainees who are affiliated to MOHP:

1-. Trainees, who finished their Egyptian fellowship degree, master /diploma
degree in anesthesiology, , can join the program. .
Also , Trainees, who finished their national fellowship programs for all Arabic
countries can join the program

The Egyptian pain fellowship-training program consists of one year of training.

During the entire training program, the candidate must be dedicated full time
and must be responsible for patient care under supervision or independently
according to his training stage and acquired competencies.

The trainee should spend the first 6 months of training as

follows:
 2 months cancer pain management
 2 months benign chronic pain management
 2 months acute pain service

* The sequencing of rotations is flexible.

The trainee should spend the Second 6 momths of training as
follows:
 Six months fluoroscopy guided interventional pain therapy
 three months ultrasound guided interventional pain therapy
 three months ultrasound guided interventional Regional anesthesia

* The sequencing of rotations is flexible.

 Trainees duties and obligations
1. Trainees must attend at least 75% of lectures in pain subjects.
2. They should be actively involved and fully responsible for patient care
including sharing in making decisions under supervision of the consultants.
3. They must attend 75% of weekly meetings including clinical meetings,
tutorials and journal clubs.
Their performance will be monitored and evaluated by trainers and a report
made of their performance on monthly basis to the Panarab Fellowship Board.
5. All trainees will work as residents in the training specialty and they must
fulfill all residents jobs defined by supervisors and trainers
6. They should be responsible under supervision for routine work until getting
competent.
7. They must take supervised shifts according to the hospitals requirements
and regulation

Specific Requirements and Obligations

By the end of the training program the trainee should be competent
in:
a. Pain assessment.
b. Post-operative pain management of surgical cases
c. Adequate and safe pharmacotherapy for various pain problems
d. Proper understanding of acute pain service and its value in prevention of
chronic pain.
e. Understanding basic principles of equipment, radiofrequency machine,
Fluoroscoy and ultrasound machine.
F. Pain management for ICU and trauma patients.

The trainee should be working independently and he should be able to

diagnose, manage and do safely the appropriate interventional pain
procedure for most of the routine cases without immediate supervision.
 The Logbook
The trainees must keep and update the logbook where they record all
activities and skills performed and learned during the training program.
The activities should be dated and categorized to whether been
performed by the trainee him/herself or as an assistant or participant.
Each activity registered in the logbook should be counter signed by the
trainer and finally the educational

supervisor. The trainer and educational supervisor shall sign the completed
logbook.

II Intended Learning outcomes of Program

(ILOs)

1. Knowledge and understanding: By the end of the program the

candidate should be able to:
a) Understand the anatomical, physiological and pharmacological
background related to various acute and chronic pain disorders.
b) Recognize the radiological background needed for various pain
procedures.
c) Identify the instruments and machines used in acute and chronic pain
practice.
d) Describe different management modalities for common acute and
chronic pain disorders.
2. Intellectual skills: By the end of the program the candidate should be
able to:
a) Analyze symptoms and signs and construct a differential diagnosis of
various pain conditions with focusing on pain source.
b) Design appropriate diagnostic plan for common acute and chronic pain
disorders taking in consideration the cost and benefit to the patient.
c) Interpret the results of different investigations for common acute and
chronic pain disorders.
d) Design treatment plans for common acute and chronic pain disorders
and select the ideal interventional procedure for each case.

3. Professional and practical skills: By the end of the program the

candidate should be able to:
a) Collect clinical data specially the art of history taking.
b) Properly examine and pick up signs of various pain disorders.
 c) Do all interventional procedures for low back pain (e.g. facet joint
denervation and injection, intradiscal procedures, nerve root injections
and radiofrequency, epidurography and epidural injections).
d) Perform simple office clinical procedures (e.g. trigger point injection).
e) Do sympathectomies (e.g. cervical, thoracic, lumbar and pelvic).
Do various cancer pain interventions (e.g. celiac plexus destructions,
superior hypogastric plexus destruction).

4. General and transferable skills: By the end of the program the

candidate should be able to:
a) Communicate with patients and gain their confidence.
b) Communicate with other health care providers.
c) Respond effectively to patient emotional and psychosocial concerns.
d) Appreciate team working.
e) Give talks in various pain conditions.
f) Teach pain procedures to junior staff.
g) Write scientific articles and papers according to the basics of scientific
research.

PAIN MANAGEMENT (acute & chronic)

At the end of training, the trainees should be able to:
Knowledge:
1. Describe the influence of therapy on nociceptive mechanisms, the analgesic ladder, and
methods of measurement and assessment of acute pain.
2. Describe the mechanisms of action of the following drugs: simple analgesics, opioids, non-
steroidal anti-inflammatory agents, local anesthetic agents, and discuss the application of
pharmacological principles to the pain control and side effects; problems of drug dependency
and addiction.
3. Describe other medication used to manage chronic pain: antidepressants, anticonvulsants,
antiarrhythmics and other adjuvant medication .
4. Describe the techniques for control of acute pain: postoperative and post-traumatic -
including children and neonates, the elderly, and patients who are handicapped, unconscious
or receiving critical care .
5. Outline the principles of neural blockade for pain management: peripheral nerve, plexus,
epidural and subarachnoid blocks; sympathetic blocks including stellate, coeliac plexus and
lumbar sympathetic blocks; neurolytic agents and procedures; implanted catheters and pumps
for drug delivery.
6. Outline non-pharmacological methods of pain control, the principles of stimulation
induced analgesia: transcutaneous electrical nerve stimulation and acupuncture, as well as the
role of other treatment modalities; physical therapy, surgery, psychological approaches,
rehabilitation approaches, pain management programmers.
7. Describe methods of assessment of patients with chronic pain and of pain in patients with
cancer and outline the principles of chronic pain management in the pain clinic setting and the
importance of psychology and pain, as well as management of severe pain and associated
symptoms in palliative care, and principles and ethics of pain research.

Skills:
1. Assess and manage postoperative pain and nausea, post-traumatic and non-
surgical acute pain .

2. Monitor acute pain and pain relieving methods, with special extra care to specific clinical
groups: children, elderly, impaired consciousness, intensive care.
3. Appropriately use simple analgesics: paracetamol: NSAIDs, opioids: intramuscular,
intravenous infusion, intravenous PCA, subcutaneous PCA, epidural, intrathecal, and apply
regional local anesthetic techniques: lumbar epidural, caudal epidural, simple peripheral
nerve blocks or inhalational anal-gesia when indicated.
4. Manage acute pain including special clinical groups: infants, patients with opioid
dependence or tolerance, non-surgical acute pain (e.g. sickle cell disease crisis), patients who
are handicapped or with impaired consciousness.
5. Educate patients and colleagues about various analgesic methods: oral; sub-lingual;
subcutaneous, IM; IV; inhalational analgesia, patient controlled analge-sia, epidural; regional
techniques and local blocks; possible side effects and complications.
6. Provide neural blockade: brachial plexus blocks, paravertebral nerve block, intrathecal and
epidural drug administration for acute and cancer pain.
7. Manage side effects of pain relieving medication and procedures.
8. Perform basic assessment of patients with chronic pain, recognize neuropathic pain, assess
and manage pain in patients with cancer.
9. Prescribe medication for chronic pain including antidepressants and anticon-vulsants.
10. Use stimulation induced analgesia: transcutaneous electrical nerve stimulation.

GENERAL ATTITUDE AND BEHAVIOUR, COMMUNICA-TION SKILLS AND ETHICS FOR

Interventional Pain physician TRAINEES

1. Communicate with patients to obtain consent for Interventional Pain procedure

(including a discussion of the risks), as well as for epidural/caudal/spinal/regional/local
blocks (including a discussion of the risks).
2. Explain pain management, side effects and complications of oral/ sublingual/ rectal/
subcutaneous/IM/IV/nasal/transdermal drugs, epidural/regional techniques/local blocks,
inhalational analgesia, and patient controlled analgesia.
3. Discuss postoperative expectations, care, and communicate with other professionals.
4. Transfer information appropriately, demonstrating ethical behavior, politeness and
punctuality, provides reassurance and show a clean neat appearance.
5. Reassure the patient and allay anxiety, and explain (as appropriate)
problems/complications to patients/relatives concerning difficult blocks, partial pain relief
and scope of each black and how to deal with residual pain.
6. Recognize that pain equipment and tools (C-ARM , ultrasound, peripheral nerve
stimulator, Different needle kits) should be working properly to maximize safety.
7. Prioritize safety first, always knowing the whereabouts of senior assistance, clearly
explain to patient and staff, reassure patients during interventional pain procedures.
8. Show vigilance, pay attention to detail and to multiple sources of data continuously, and
recognize the need to communicate with colleagues of different specialities.
9. Respond rapidly to calls for help (break through pain) and follow up sick patients on the
ward before going home.
10. Appreciate the needs and behavior of worried and grieving relatives, willing to accept
failures of therapy, involve others with specialist skills, and recognize team approach.
11. Show calmness under pressure, compassion and kindness when the outcome is poor, and
rapidly respond to unrelieved pain.
12. Pay special efforts to communicate clearly with the elderly (N.B. deafness and blindness),
pay respect for the social norms of older people, manage problems of consent in mental
infirmity.
13. Communicate effectively with surgical colleagues / other members of the theatre team,
summarize a case to critical care staff, maintain accurate clinical records, present the material
to departmental meetings and participate in clinical audit.
14. Show good communication skills in breaking bad news, in requesting post mortem
investigation, in explaining the need for unexpected / early discharge.
15. Manage problems of obtaining consent in patients with impaired consciousness,
16. Communicate a balanced view of the advantages, disadvantages, risks and benefits of
various forms of analgesia appropriate to individual patients, allocate resources and call for
assistance appropriately
17. Obtain consent from the child’s parents, respecting the law, appreciate and deal with
restraints.
20. Gently handle the patient during positioning and performance of interventional pain
procedures or regional anesthesia, relieve patients’ anxieties about regional techniques,
especially the stress of undergoing most interventions while conscious, pay meticulous
attention to safety and sterility during performance of regional blocks.

Syllabus:
The curriculum will be divided into two main parts:

1- The theoretical background

2- The practical part ( interventional blocks); which will include common blocks
that candidate can do them or know their steps in full details

I- The theoretical background

Pain pathway and pain modulation
 Pharmacology of local anesthetics and commonly used
adjuvant drugs

1. HEAD & NECK

1-Trigeminal ganglion block and neurolysis

2- Maxillary nerve block

3- Mandibular nerve block

4- Glossopharyngeal nerve block

5- C1, 2 sleeve root injection

6- Cervical (C3-7) sleeve root injection

7- Sphenopalatine ganglion block and neurolysis

8- Stellate ganglion block

9- Cervical facets/RFTC block

10- Cervical epidural block

11- Brachial plexus block

12- DCS placement

2. Chest/Thorax

Intercostals nerve block

Thoracic sleeve root/dorsal root ganglion blocks

Suprascapular nerve block

T2, 3 sympathetic block, including RFTC

T2, 3 neurolytic lesioning

Thoracic facet/RFTC and injections

Thoracic epidural block

DCS placement

3. LUMBAR/ABDOMEN

Lumbar sleeve root/ dorsal root ganglion blocks

Splanchnic nerve block

Celiac ganglion block

Lumbar sympathetic block

Lumbar sympathetic neurolytic lesioning

Lumbar facet injections

Intraarticular injections

Median branch block and neurolysis

Transforaminal epidural catheter placement

Lumbar discography

Intra discal electro thermocoagulation

Vertebroplasty

17 Psoas and quadratus lumborum muscle injection

DCS placement

Lumbar epidural block

4. PELVIS

Sacral sleeve root injection

Hypogastric plexus block and neurolysis

Ganglion of Impar block

Sacroiliac joint injection

Caudal neuroplasty

5. UPPER EXTREMITIES

Brachial plexus block

5. LOWER EXTREMITIES
Femoral nerve blocks

Sciatic nerve blocks

Piriformis muscle injection

7. AUGMENTATION TECHNIQUES

Occipital stimulation

Cervical stimulation

Thoraco abdominal stimulation

Sacral stimulation

8. IMPLANTABLE DEVICES

Intrathecal Implantation

9. RADIATION SAFETY

10- ultrasound basics and blocks

II interventional blocks to be known how to be done safely or better to be

done by candidates:
• Head and neck
1- Stellate Ganglion Block

2- Cervical ESI

3- Cervical Facet Block

• Thorax
1- T2, 3 Sympathetic Block

2- Splanchnic Nerve Block

3- Thoracic Epidural Catheter Placement

4- Thoracic Facet Block

• Lumbar
1- Lumbar Sympathetic Block

2- Lumbar Selective Nerve Root Block

3- Lumbar Discography Procedure

4- Lumbar Facet Block

• Pelvic
1- Hypogastric Plexus Block

2- Caudal Neuroplasty

3- Sacral Nerve Root Block

4- Piriformis Block

5- Sacroiliac joint injection

Methods of Assessment:
 11-

Students should be assessed at the end of the program by the following Four
examinations:

1- Paper I (2 hours): Multiple choice questions with a single best answer format.
2- Paper II (2 hours): Ten to twelve short answer questions.

Both papers test trainees' knowledge in applied basic sciences mentioned in the
curriculum.

Trainees who passed the written exam will continue the oral and clinical exams

Clinical exam ;the traine will undergo discussion with examiners on the
following items:

Interventional pain procedures

Regional anesthesia procedures
RF machines
Ultrasound machine
C ARM images
different needles and kits

and oral exam : the trainees will undergo discussion with examiners on the
following:

:
a. Apply knowledge in decision-making.
b. Make an accurate diagnosis and differential diagnosis
c. Plan for management according to priorities
d. Attitudes and interpersonal communication skills

candidate spend 5-10 minutes with each examiner.

e uses a structured question' cards in the oral examination.
Program Director
Prof.Inas Kamel ( Cairo University)

Prof. Mohamed Abd El-Raouf Nasr ( Cairo University)

Pro. Dr Magda Fouad ( El Menoufia University)