Poster Abstracts

Pain Res Manag. 2007 Summer;12(2):121.

P1: Pain, Fear of Pain, and Disability: A Repeated Measures Analysis with a Tertiary Treatment Sample

Murray P Abrams, R Nicholas Carleton, Shane S Kachur*, Gordon J G Asmundson

Abstract

Fear-avoidance models of musculoskeletal pain posit individual differences in fear of pain responding along a continuum of confrontation and avoidance (Asmundson et al., 2004). Individuals who confront their pain are believed more likely to adaptively resume physical and social activities, experiencing only minimal psychological or physiological complications. Conversely, those who engage in fear-related pain avoidance behaviors are expected to exhibit psychological and physical consequences, increased pain perception, and disability. It is reasonable to expect that multidisciplinary treatment resulting in reduced fear of pain will produce corresponding reductions in pain and disability (de Jong et al., 2005). There are few prospective studies that evaluate this hypothesis (Sieben et al., 2005). The purpose of the present study was to longitudinally assess patients with chronic musculoskeletal pain over the course of a six week tertiary treatment program. Thirty individuals (23% women; M age = 44.5, SD= 10.7) enrolled in a government sponsored multidisciplinary rehabilitation program were assessed at intake, three weeks, and six weeks. Participants completed the McGill Pain Questionnaire, the Pain Anxiety Symptoms Scale-20, and were assessed with an objective measure of functional ability. Repeated measures analysis of variance revealed several significant linear effects: increases in reported pain intensity, F(1,27)=4.81, p<.05, eta²=.18; reductions in fear of pain, F(1,24)=8.27, p<.01, eta²=.35; and reductions in functional deficit, F(1,28)=20.57, p<.01, eta²=.74. These findings suggest that over the course of multidisciplinary treatment, although reported pain intensity increased, both reported fear of pain and functional deficit decreased. Implications and future research directions are discussed.

AIM:

To evaluate the long-term efficacy and safety of CR tramadol in chronic osteoarthritis pain.

METHODS:

Patients who completed a double-blind, placebo-controlled crossover study were offered open label CR tramadol for up to 6 months. The primary outcome was pain intensity (VAS and ordinal). Other questionnaires included: WOMAC, Pain and Disability (0–10 ordinal), Pain and Sleep (VAS) and SF-36. All assessments were completed every 2 months.

RESULTS:

Of 75 eligible patients, 53 (70.7%) chose to continue CR tramadol; 29 (54.7%) completed 6 months of open label treatment. Mean treatment duration was 133.0±63.2 days. The mean final CR tramadol dose was 313.2±100.1 mg/day, compared with 330.2±93.7 mg/day at the end of double-blind treatment. Pain intensity significantly decreased to 36.3±17.9 mm in the double-blind phase. This was maintained during open label (35.4±22.7 mm, p=0.7809). WOMAC subscale scores for pain and physical function were significantly decreased at the end of the double-blind phase (177.2±81.6 mm and 582.7±287.5 mm, respectively). Both were maintained throughout open label (185.6±101.8 mm, p=0.5735; 609.1±364.3 mm, p=0.5664, respectively). Significant double-blind reductions in overall pain and disability (21.6±10.1) and overall pain and sleep scores (89.2±78.8) were sustained throughout open label (21.5±13.4, p=0.9660; 96.7±85.1, p=0.4555, respectively). Significant deterioration in the Physical Functioning and Physical Component scales of the SF-36 may be attributable to osteoarthritis progression. Most patients reported moderate (44.2%) or a great deal of benefit (42.3%) from CR tramadol.

CONCLUSION:

Long-term CR tramadol treatment provided sustained pain control for up to 6 months without evidence of analgesic tolerance.

Acknowledgments

This research was supported by Purdue Pharma, Canada.

Pain Res Manag. 2007 Summer;12(2):122.

P5: Development and Evaluation of a Hospital Chronic Pain Consultation Service

J Boyd ¹, AJ Clark ¹, PA Taenzer ¹, CC Spanswick ¹, S Chary ¹, V Wiebe ¹

Abstract

AIM:

To provide a consultation service to physicians caring for hospitalized patients with chronic pain.

METHODS:

The CHR Regional Pain Program identified poorly managed chronic pain as a significant hospital service gap. A consultation service –nurse practitioner (NP), 3 physicians, psychologist – is being rolled out sequentially to 3 acute care hospitals. Consultations from attending physicians are assessed by the NP who will provide suggestions to the attending physician after discussing the patient with a physician. Rounds are held twice weekly by the NP and a physician. A consultation report is provided with suggestions about care during hospitalization and at discharge (for the family physician). The service does not take over care of the patient's pain. Evaluation consists of tracking service events, pre- and post-consultation pain levels, patient satisfaction with pain care, physician impression of impact of service and audit of discharge notes.

RESULTS:

134 consults were received between Jan–Sep 2006. Pre-post data are available on 37 patients and indicates a 46% reduction of average pain. Patients commented that the NP listened, took their problem seriously and educated them about pain management. Attending physicians found the service easy to access, recommendations were easy to implement and led to reduced pain intensity, increased function and decreased length of hospital stay. An audit showed 80% of attending physicians included the consult service's recommendations in the discharge note to the family doctor.

CONCLUSIONS:

This data indicates that the service provides effective pain management for hospitalized patients by providing recommendations to attending physicians.

Pain Res Manag. 2007 Summer;12(2):122.

P6: Improving the Management of Low Back Pain in the Community Using Collaborative Action Learning Groups.

E Carr ¹, A Breen ², C Campion-Smith ¹, H Austin ¹, E Mann ¹

Abstract

AIMS:

To evaluate the educational interventions with specific reference to

Patient outcomes (eg impact on function, return to work)
Professional behaviour (eg utilisation of national guidelines)
Organisational changes (eg referral services)

BACKGROUND AND SIGNIFICANCE:

The management of acute low back pain in primary care can be a difficult and frustrating experience for General Practitioners (GP). Our research team1 has focused on collaborative research to explore the feasibility of a nurse-led back pain service (Breen et al 2004) and more recently how GP's manage the psychosocial aspects of patients' experiencing acute low back pain2.

METHOD:

18 practices in the South West region of the UK were invited to participate. Four practices responded before the closing date and a further two afterwards. Each practice was presented by a GP, practice nurse and either a receptionist, a further nurse or physiotherapist. Twelve participants attended a series of four local half-day workshops. The Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) was completed by all participants before and after the series of workshops and a Visual Analogue Scale of how confident they felt managing low back pain. Workshops used a participatory action learning framework and included content identified by participants and group work. Practice based activity occurred between meetings. Rapid feedback questionnaires were completed at the end of each workshop.

RESULTS:

All participants evaluated the workshops positively. One item showed a significant difference PAB-PT (p<0.05 Wilcoxin Ranked signed test). There was a significant improvement in ‘confidence to manage back pain’; (before workshop mean confidence 3.9 (SD1.96) compared with afterwards 7.0 (SD1.36) p<0.001). Four quality improvement projects on low back pain are ongoing.

CONCLUSIONS:

Using collaborative action learning groups with practitioners can help practitioners improve the management of low back pain in the community3.

References

1.Breen A, Carr E, et al. “Acute back pain management in primary care: a qualitative pilot study of the feasibility of a nurseled service in general practice.”. Journal of Nursing Management. 2004;12:201–209. doi: 10.1111/j.1365-2834.2004.00469.x. [DOI] [PubMed] [Google Scholar]
2.Breen A, Austin H, Campion-Smith C, Carr ECJ, Mann E. “You feel so hopeless”: A qualitative study of GP management of acute back pain. European. Journal of Pain. 2007;11:21–29. doi: 10.1016/j.ejpain.2005.12.006. [DOI] [PubMed] [Google Scholar]
3.This work has subsequently been successful in acquiring a grant from the Health Foundation (UK) for a three year project to extend and develop it further. A short summary will be included.

Pain Res Manag. 2007 Summer;12(2):122–123.

P7: Reconceptualizing ‘Professionalism’: Why Chronic Pain Service Providers Need to Rethink the Affective Domain

Cary A Brown ¹

Abstract

INTRODUCTION:

Service providers working with people who have complex health problems like chronic pain are considered at particular risk from the heavy emotional content (frustration, guilt, hostility) of these interactions[Bellon 2002]. It is important for service providers (SPs) to employ reflective practice acknowledging these issues [Freemantle 1996, Novack 1999, Adler 2002]. However, despite the growing awareness that wellbeing can no longer be envisioned as a linear (cause and effect) process divorced from socio-cultural influences and attendant values and beliefs [Sweeney 2002, WHO 2002], service providers are still inculcated to negate the affective domain of their practice [Meier 2001, Smith 1988, Zinn 1988].

AIM:

To examine to what degree SPs believe their decision-making is influenced by self-image and emotion and the reasons they offered for these beliefs.

METHOD:

As part of a larger study involving members of the British Pain Society, the National Occupational Therapy Pain Association and service-user lead support groups, participants were asked to identify their level of agreement with statements about how the themes (coherence, purposiveness, self-image and affect) [Chapman 1999] influenced their decision-making. A second stage questionnaire asked participants to comment on why the affect and self-image were rated as of little influence.

RESULTS:

Only 20.5% of service providers rated the influence of self-image as 3 (mostly) or 4 (completely). The influence of affect was similarly low with only 19.4% of respondents selecting a rating of 3 or 4. In marked contrast, service users rated the influence of self-image and affect as strong. Themes emerged in the SPs' statements about these findings.

CONCLUSION:

Although SPs felt that affect and self-image had little influence on their decision-making, there is growing evidence to suggest that it is not possible, nor preferable, to divorce emotion from the clinical encounter.

REFERENCES

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Pain Res Manag. 2007 Summer;12(2):122.

P8: Chronic Pain and Complexity: The Beliefs of People with Pain and Service Providers

Cary A Brown ¹

Abstract

INTRODUCTION:

The director of the British National Health Service (NHS) Modernisation Agency, David Fillingham, stated that ‘the NHS is the epitome of a complex adaptive system. Such systems do not always respond well to mechanistic formulae’ (Fillingham 2002). A growing number of theorists and researchers echo this sentiment in relation to many aspects of healthcare in the 21^st century. It is increasingly emphasized that people are complex biological systems that do not behave in a linear fashion and that effective healthcare for the growing number of chronic disease and lifestyle issues (like chronic pain) must be grounded in a non-reductionist paradigm focused on understanding relationships and applying flexible problem-solving. Chapman et al. have predicted that for pain research, ‘…the principle challenge will not be technological advancement but rather the generation of a theoretical framework that can guide complex scientific inquiry’ (Chapman and Nakamura 1999, p.138).

AIM:

The aim of this study was to examine, from the perspective of people with chronic pain and service providers, the congruence between characteristics of a complex adaptive system (CAS) and features of the chronic pain experience.

METHODS:

This data was extracted from a much larger study regarding congruence between service users and providers in beliefs about treatment for chronic pain. The data were gathered by postal questionnaire during the final round of a 4-part Delphi study. Participants rated their agreement on a 4-point scale with 23 statements based on the 8 principles of CAS outlined by Plsek (2003). Additionally, they identified on separate visual analogue scales how much disagreement and uncertainty they believed people have about which treatments for chronic pain are important.

RESULTS:

Findings lend support to applying a CAS framework to the chronic pain experience. Respondents indicated that in regards to treatments for chronic pain relationships and context are important, structures and process are varied, and actions can be linked to persisting practices and personal beliefs. Additionally, the chronic pain experience is seen as changing and requiring high amounts of giving and receiving information. Participants believe that there is little certainly and agreement regarding treatments for chronic pain. A graphic representation of their responses clearly illustrates a system in the ‘zone of complexity’ (Stacey 1996).

Paradox seemed to exist within responses of participants to questions about certain beliefs and behaviors. For example, responses indicate that search for cure and the medical system as the source of assistance are still part of the personal belief system most people hold for dealing with chronic pain. Many participants said that chronic pain has a wide range of biological, psychological and social influences. However, the responses indicated that they were also attempting to find solutions within a simple, cause-and-effect biomedical model at times.

CONCLUSIONS:

The findings supported that CAS theory is an appropriate framework for seeking to understand chronic pain.

REFERENCES

Chapman R, Nakamura Y, Flores L. Chronic pain and consciousness: a constructivist perspective. In: Gatchel, Turk, editors. Psychosocial factors in pain: critical perspectives. Guilford Press; New York: 1999. pp. 35–55. [Google Scholar]
Fillingham Open space. Take five. Health Services Journal. 2002;112(5791):27. [PubMed] [Google Scholar]
Plsek P. Complexity and the Adoption of Innovation in Health Care. Accelerating Quality Improvement in Health Care; Washington, D.C.: 2003. [Google Scholar]
Stacey RD. Complexity and creativity in organizations. London: Pitman Publishing; 1996. [Google Scholar]

Pain Res Manag. 2007 Summer;12(2):123.

P9: Relationship Between Concentration of Intramuscular Glutamate and Sensitization of Rat Masseter Muscle Nociceptors

Brian E Cairns ¹, Xudong Dong ¹, Mandeep K Mann ¹, Peter Svensson ², Barry J Sessle ³, Lars Arendt-Nielsen ⁴

Abstract

AIMS:

Evidence suggests that elevated tissue levels of glutamate may contribute to pain and sensitivity in certain musculoskeletal pain conditions. The present experimental study investigated whether systemic administration of monosodium glutamate (MSG) could elevate tissue levels of glutamate and sensitize muscle nociceptors to mechanical stimuli.

METHODS:

MSG 50 mg/kg was administered intravenously to rats (n = 5 male, 5 female) and the interstitial concentration of glutamate in the masseter muscle measured with a glutamate selective biosensor. Putative muscle nociceptors were recorded in the rat trigeminal ganglion and identified by their response to mechanical stimulation of the masseter muscle and projection to the caudal brainstem. An electronic von Frey Hair was used to measure nociceptor mechanical threshold after intravenous administration of 50 mg/kg MSG (n = 5 male, 5 female) or saline (control, n = 5 male, 5 female).

RESULTS:

The mean (±SE) pre-injection interstitial concentration of glutamate in the rat masseter muscle was 24±11 μM, and was unchanged after saline injection, but increased to a peak of 63±19 μM after MSG injection. The average afferent mechanical threshold was decreased by ~25% during the first 5 min after injection of 50 mg/kg MSG but was not changed after saline injection. No sex-related differences in interstitial glutamate concentrations or in MSG-induced mechanical sensitization were detected.

CONCLUSIONS:

The present results indicate that a 2–3 fold elevation in muscle interstitial glutamate concentration is sufficient to induce mechanical sensitization and suggest that even modest elevations of interstitial glutamate concentration could alter musculoskeletal pain sensitivity.

Pain Res Manag. 2007 Summer;12(2):124.

P10: Development and Preliminary Evaluation of a Measure of Three Pain-Related Patterns of Activity

Douglas Cane ¹, Warren R Nielson ², Mary McCarthy ³, Dwight Mazmanian ⁴

Abstract

AIM:

Chronic pain affects numerous aspects of an individual's life including activity. Three distinct patterns of activity may develop among individuals with chronic pain. Avoidance/under-doing is characterized by escape/avoidance of activities associated with pain and a consistently low level of activity. Over-doing/under-doing is characterized by persevering with activities until completed and results in alternating periods of high and low activity. Pacing is characterized by a moderate approach incorporating periods of activity and rest. Pacing is assumed to result in a moderate, consistent level of activity.

Despite their assumed significance for chronic pain, existing measures do not adequately assess these patterns of activity. The present study describes the development of a questionnaire assessing these three pain-related patterns of activity.

METHOD:

Descriptions of these three patterns of activity were developed and 51 items representing these patterns were written. An initial version of the questionnaire was administered to a large sample of adults experiencing mixed chronic pain conditions. Items demonstrating acceptable response distributions, significance correlations with their own scale, and low correlations with other scales were retained.

RESULTS:

Analyses indicated that the three scales demonstrated excellent internal consistency and good test-retest reliability. The three scales were independent of social desirability and generally independent of each other. The scales correlated as expected with existing measures of related constructs.

CONCLUSIONS:

The resulting questionnaire demonstrates good psychometric properties and evidence of construct validity. Further development of this questionnaire and potential applications, such as assessing the prevalence and psychosocial consequences of these patterns of activity, will be discussed.

Pain Res Manag. 2007 Summer;12(2):124.

P11: A Survey of Nutrient Intakes of Patients with Chronic Non-Cancerous Pain.

Stéphanie Chevalier ¹, Cyrille Naïm ², Yoram Shir ²

Abstract

INTRODUCTION:

Diet has been shown to possess analgesic properties in animals and in humans. In a previous pilot study we observed low intakes of dietary nutrients in chronic pain patients.

HYPOTHESIS:

Patients with chronic non-cancerous pain are at risk of nutrient deficiencies.

AIMS:

To quantify, for the first time, nutrient intakes of patients with chronic pain and examine possible correlations with pain levels.

METHODS:

Dietary intake was assessed with three 24-h food recalls within 3–5 days. One recall was face-to-face and two were done by telephone, all using two-dimensional visual aids for estimating portion sizes. Socio-demographic and anthropometric data were also obtained.

RESULTS:

Ninety-seven patients, 68 women and 29 men with chronic non-cancer pain were recruited. Mean age was 49 ± 15 years (±std dev), pain duration was 8.5 ± 8.6 years and the body mass index (BMI) was 26.2 ± 5.2 kg/m². From 68 full food records, total energy intake was above that of the Quebec population due to higher fat and carbohydrate intakes, whereas protein intake was similar. Although 59% of patients consumed dietary supplements, high proportions of them had low intakes (below 2/3 of recommended dietary intakes) of essential fatty acids, vitamin D, vitamin E, vitamin K, folates, calcium and magnesium (30%, 55%, 74%, 66%, 37%, 28% and 24% of patients, respectively).

CONCLUSIONS:

Although macronutrient intakes were more than sufficient, low essential fatty acids and micronutrient intake indicates a poor dietary quality in patients with chronic non-cancer pain. Possible correlation between dietary deficiency and pain levels is currently been assessed.

Pain Res Manag. 2007 Summer;12(2):124.

P12: Suffering Relief: A Basic Human Right

Beverley M Clarke ¹, Adrian R Upton ¹, Claudia M Castellanos ¹

Abstract

AIM:

To provide evidence to show that suffering and pain are separate and only sometimes related phenomena in chronic illness.

METHODS:

381 subjects (166 arthritis, 113 epilepsy, 79 migraine, 23 spinal cord) were given a validated questionnaire (MASQ) to assess suffering. Mean age ranged from 30 – 74 years old. Items were scored using a 5 point Likert-type scale (5 = most negative response). Of the total sample, severe pain was reported in: arthritis n=166, epilepsy n=38, spinal cord n=18 and migraine n=30 cases.

Data analyses consisted of Pearson correlation coefficients and z-scores.

RESULTS:

The relationship between Total Suffering and Pain Intensity is weak: arthritis r=0.343 (p=0.000), epilepsy r=0.500 (p=0.000), migraine r=0.210 (p=0.06), spinal cord r=0.576 (p=0.004). The relationship is weak also for the pain specific sub groups: epilepsy (n=38) r=0.363 (p=0.02), spinal cord (n=18) r=0.538 (p=0.02), migraine (n=30) r= −0.03 (p=0.86). Z-scores indicated that some subjects with low suffering scores had high pain scores and others with little pain had severe suffering.

CONCLUSIONS:

Because suffering and pain are separate and only sometimes related phenomena, suffering relief per se is clinically important.

Pain Res Manag. 2007 Summer;12(2):124.

P13: Involvement of Neuronal Nitric Oxide Synthase in a Rat Model of Neuropathic Pain

LJ Dableh ^1,³, K Yashpal ^1,³, JL Henry ^2,³

Abstract

Neuropathic pain is a chronic condition that is debilitating for the sufferer, and often resistant to pharmacological intervention. The Mosconi and Kruger model (1996) of sciatic nerve cuff implantation was used, and mechanical hypersensitivity was measured using von Frey filaments. This model was modified by removing the cuff at different time points. Removal of the cuff 24 hours after implantation led to hypersensitivity that reversed within 2 weeks. Removal of the cuff at 4 days led to long-lasting hypersensitivity that was less severe compared to rats with an intact cuff. This suggests that there may be an early, reversible phase and a subsequent irreversible phase of neuropathic pain. Since nitric oxide (NO) may be involved in nociceptive transmission, the role of neuronal nitric oxide synthase (nNOS) was examined in this model. Administration 10, 20 or 30 mg/kg of 7-nitroindazole, a selective nNOS inhibitor, increased withdrawal thresholds in cuff-implanted rats. However, at the 30 mg/kg dose, rats showed somnolence and motor deficits. Western blot analysis of nNOS in the lumbar spinal cord showed an increase at day 1 and day 4 after cuff-implantation, but not at day 4 when the cuff was removed one day after implantation. Future studies will target levels of nNOS at later time points following cuff removal, as this will indicate whether nNOS is involved in the early phase of neuropathic pain. The results to date suggest that nNOS activity may contribute to the persistence of hypersensitivity in this model of neuropathic pain.

Footnotes

Supported by CIHR.

BACKGROUND:

Currently, there are no culturally relevant, evidence-based pain assessment and education resources in Inuktitut. The key to effective pain management is a pain assessment scale that is culturally sensitive, age appropriate, easy for the children to use and easy for health professionals to score. The Northern Pain Scale (NPS) is a revised version of the Wong-Baker FACES scale and is used in Alaska with adults. The scale has not been validated or used in other Inuit communities. This study is phase one of a three phase study to develop pain education materials for use in the circumpolar north.

OBJECTIVES:

1) Describe the concurrent validity of the Northern Pain Scale (NPS), the FACES scale and a numerical rating scale (NRS) for use with Inuit children and adults; 2) Describe the test-retest reliability of the three scales with Inuit children and adults; 3) Describe factors that influence the preference of Inuit children and adults for using the NPS, the FACES scale or a NRS.

METHODS:

In a test-retest design participants were shown a sequence of 17 pain scenarios in two interviews. Pain intensity was rated with the FACES scale, the NRS and the NPS. Participants were then asked which pain scale they preferred and why. Interviews were conducted in Pangnirtung, Nunavut.

RESULTS:

Seventy-two adults, 72 children aged 8–18 years and 22 children aged 5–7 years were included in the study. Data collection is complete and data analysis is underway to be completed by January.

CONCLUSIONS:

The second phase of this multi-phase study is to develop pain education materials in Inuktitut and the results of this study will guide us with respect to a culturally appropriate pain scale to feature in the materials.

Pain Res Manag. 2007 Summer;12(2):126.

P20: How Painful is it? Portuguese Doctors and Nurses Attitudes about Neonatal Pain and Pain Management

FERNANDES Ananda ¹, MOREIRA Ana Carolina ², MACHADO Eduarda ³, MOREIRA Vera ³

Abstract

BACKGROUND:

Abstract

AIM:

The aim of this study was to validate the English version of the Critical-Care Pain Observation Tool (CPOT), a behavioural tool originally developed in French, in critically ill adults.

METHODS:

Both conscious (n = 30) and unconscious (n = 25) intubated patients participated in the study. Patients were assessed by research team and ICU nurses (n = 51), previously trained to use the CPOT, during two procedures: 1) nociceptive procedure : turning, 2) non-nociceptive procedure : taking blood pressure. Assessments were completed at rest pre-procedure, during the procedure and 20 minutes post-procedure. Conscious patients were asked to provide their self-report of pain (yes/no and pain intensity from 0 to 10).

RESULTS:

Interrater reliability was supported with intraclass correlation coefficients (ICC) from 0.80 to 0.93 (p ≤ 0.001). For criterion validity, a CPOT cutoff score > 3 yielded a specificity of 83.3% and a sensitivity of 66.7%, and patients' self-reports of pain intensity were strongly related to CPOT scores (r = 0.71; p ≤ 0.05). Discriminant validity during the nociceptive procedure and the non-nociceptive procedure was also examined. The turning procedure (mean = 3.02) had higher CPOT scores compared to the blood pressure procedure (mean = 0.55) (F = 59.35; p ≤ 0.001).

CONCLUSIONS:

The use of valid behavioral pain assessment tools in non-verbal patients is highly recommended in clinical guidelines. As the CPOT is a reliable and a valid tool, it could be implemented in intensive care practice so that pain could be assessed in a systematic way.

Acknowledgments

The principal investigator was supported by a Post-Doctoral Fellowship of the “Fonds de recherche en santé du Québec” (FRSQ) and the “Fondation de recherche en sciences infirmières du Québec” (FRESIQ), and a subvention from the “Groupe de recherche interuniversitaire en sciences infirmières de Montréal” (GRISIM) and the Canadian Foundation of Nurses (CNF) for the conduction of this study.

Pain Res Manag. 2007 Summer;12(2):127–128.

P24: Comparison of Pain Responses in Infants of Varying Gestational Ages

Sharyn Gibbins* ^a,^b, Bonnie Stevens ^b,^c, Patrick McGrath ^d, Janet Yamada ^b, Joseph Beyene ^e, Lynn Breau ^f,^g,^h, Carol Camfield ⁱ, Allen Finley ^h, Linda Franck ^j, Alexandra Howlett ^k, Celeste Johnston ^l, Patricia McKeever ^m, Karel O'Brien ⁿ, Arne Ohlsson ⁿ

Abstract

BACKGROUND:

There is a plethora of infant pain measures; however, none of them have been validated for extremely low birth weight ([ELBW]) infants. To date, clinicians, researchers and parents use information gleaned from more mature infants to make inferences about pain in ELBW infants. Using physiological or behavioural pain indicators from more mature infants may lead to inaccurate assessments and management.

OBJECTIVES:

To compare physiological (heart rate, oxygen saturation) and behavioural (9 facial activities, cry) pain indicators of ELBW infants with infants of varying more mature gestational ages.

METHODS:

The aim of this study was to determine the effects of gestational age (GA) on pain response. GA was categorized into four mutually exclusive age strata: <27 6/7 weeks, 28–31 6/7 weeks, 32–35 6/7 weeks and > 36 weeks. Physiological data during four phases of a routine heel lance were collected by placing disposable ECG electrodes and pulse oximetry probes on the infant's chest. Behavioural data were collected by videotaping facial activities, and cry data were collected by audio recording.

RESULTS:

Four facial activities (brow bulge, eye squeeze, nasolabial furrow, vertical mouth stretch) in response to acute pain were present in ELBW infants. Facial activities increased following painful procedures and the magnitude of responses was proportional to GA with the youngest infants (<27 6/7 weeks) showing the least amount of change (F_3,145 =6.5, p<0.001). Decreased oxygen saturation and increased heart rate were associated with the most invasive lance phase, but the differences were not clinically or statistically significant across any age group. Cry was not a sensitive pain indicator in extremely premature infants, due to the presence of endotracheal tubes in this high-risk population.

DISCUSSION:

ELBW infants' have similar pain responses to older infants, but the responses are less developed. Other factors such as severity of illness, frequency of painful procedures or medication use should be examined, as they may influence the pain responses in this infant population.

Pain Res Manag. 2007 Summer;12(2):128.

P25: Electro Neuromuscular Facilitator: A New Approach in the Treatment for Low Back Pain.

F Gonçalves ¹, T Moore ¹, B Oucharek ¹, T Borys ¹

Abstract

AIMS:

Our objective was to identify the efficacy of the Moore Muscle Therapy and Rehabilitation/Electro Neuromuscular Facilitator (MMTR/ENF) protocol for patients suffering from low back pain (LBP).

METHODS:

Fifteen volunteers participated in this study. Eight females (mean age 47.5±12.4) and seven males (mean age 41.8±13.0), followed the MMTR/ENF protocol for a minimum of four and maximum of ten sessions within two months. Volunteers were excluded from this study if they presented with neurologic deficits in the legs due to a medical condition other than the back, severe obesity (BMI > 34.9), severe spinal stenosis, fibromyalgia and/or pregnancy. All subjects followed the same protocol: electromyotherapy using the ENF followed by a ten-minute trigger point release and a protocol of stretches and strengthening for the low back muscles. The Borg pain scale was used to acquire pain levels.

RESULTS:

Pain levels were gathered prior (pre) and after (post) the first treatment (Tx1), fourth session (Tx4) and last visit (Txlas). All data was analyzed using One-way ANOVA. Results were statistically significant (p<0.05) when comparing pre and post for Tx1 (p=0.03) and Txlas (p=0.02). A significant difference was also found when comparing Tx1 to Tx4 (p=0.00), Tx4 to Txlas (p=0.00) and Tx1 to Txlas (p=0.00).

CONCLUSION:

Perceived pain levels were lower after subjects received their first treatment with the ENF and significantly decreased after completion of the treatment plan. This improvement leads us to believe that the MMTR/ENF protocol is an efficient tool in the treatment for LBP.

Pain Res Manag. 2007 Summer;12(2):128.

P26: A Randomized, Double-Blind, Crossover Comparison of Buprenorphine Transdermal System (BTDS) and Placebo in Patients with Chronic Low Back Pain

Allan Gordon ¹, Denis Callaghan ², Donald Spink ³, Christian Cloutier ⁴, Peter Dzongowski ⁵, William O'Mahony ⁶, Duncan Sinclair ⁷, Saifee Rashiq ⁸, Norm Buckley ⁹, John Sibley ¹⁰, Geoffrey Cohen ¹¹, James Kim ¹², Aline Boulanger ¹³, Paula S Piraino ¹⁴, John Eisenhoffer ¹⁴, Zoltan Harsanyi ¹⁴, Andrew C Darke ¹⁴

Abstract

OBJECTIVE:

To compare the efficacy and safety of a 7-day BTDS and placebo in chronic low back pain patients.

METHODS:

Patients requiring at least 1 tab/day of an opioid preparation underwent a 2–7d washout from all opioids before randomization to 10mg BTDS or placebo and titrated weekly according to efficacy and tolerability to 20mg and 40mg. After 4 weeks, patients crossed over to the alternate treatment for another 4 weeks. Acetaminophen 650mg q4–6h prn was provided for rescue.

RESULTS:

Of 78 randomized patients, 52 (67%) were included in the per-protocol population. BTDS resulted in significantly lower VAS (45.3±21.3 vs. 53.1±24.3mm, p=0.0219) and 5-point ordinal (1.9±0.7 vs. 2.2±0.8, p=0.0439) pain intensity scores during the last week of treatment than placebo. The overall Pain and Sleep score was significantly better with BTDS than placebo (177.6±125.5 vs. 232.9±131.9, p=0.0268). There were no differences between treatments on the Pain Disability Index, Quebec Back Pain questionnaire or SF-36. 66% of patients (p=0.0009) and 60% of investigators (p=0.0079) preferred BTDS, compared to placebo (patients: 24%; investigators: 28%), while 10% of patients and 12% of investigators had no preference. 65% of patients (p=0.0139) and 63% of investigators (p=0.0139) assessed BTDS as moderately or highly effective. These results were confirmed by ITT analysis. Patients receiving BTDS reported significantly more adverse events (mainly opioid-related: nausea, dizziness, somnolence, vomiting, constipation, sweating) than those receiving placebo (p=0.0005). 77% of patients chose to continue receiving BTDS in a long-term open-label evaluation.

CONCLUSION:

BTDS is effective for management of chronic low back pain.

Acknowledgments

This research was supported by Purdue Pharma, Canada.

Pain Res Manag. 2007 Summer;12(2):128.

P27: Infant Gender and Its Impact on Maternal Regulatory Behaviours Following Immunization

Jessica Hillgrove ¹, Aruvita Aggarwal ¹, Glynnis Dubois ¹, Rebecca Pillai Riddell ^1,³, Bonnie Stevens ^2,³, Saul Greenberg ^2,³

Abstract

AIM:

The purpose of this study was to describe maternal behaviours post-immunization and explore the relationship between infant gender and maternal soothing behaviours.

METHODS:

Seventy-five mothers (M= 33.04 years old, SD= 3.90 years), and their healthy infants (M=11.21 months old, SD= 4.83 months, 37 males) were recruited from a paediatrician's office during a routine immunization procedure. Using the Parent Regulatory Behaviour Categories ([PRBC], Jahromi, Putnam & Stifter, 2004), nine soothing behaviours (affection, touching, holding, rocking, vocalizing, caretaking, distraction, feeding, and pacifying) were coded. In addition, soothing behaviours were further categorized as proximal (affection, touching, holding and rocking) vs. distal (vocalizations, distraction, pacifying, feeding and caretaking).

RESULTS:

During the first minute post-needle stick, vocalization, rocking, holding and affection behaviours were most frequently seen. For the later time periods, soothing vocalizations in combination with caregiving were the most commonly utilized strategies.

Four one-way MANOVA's, one for each of the minutes observed, were used to analyze the relationship between infant gender and soothing behaviours. Maternal soothing behaviours did not significantly differ by infant gender for any of the four minutes observed.

CONCLUSION:

A combination of maternal proximal and distal behaviours are seen directly after immunization, while engaging in soothing talk and caretaking occur in the latter time periods post-immunization. Distraction was not frequently used as a soothing behaviour following the painful procedure. Regardless of infant gender, mothers provided similar frequencies and types of soothing behaviours after immunization. These findings suggest that infant gender does not appear to have an impact on maternal soothing behaviours within the immediate immunization context.

Pain Res Manag. 2007 Summer;12(2):129.

P28: Caregiver Beliefs Underlying Infant Pain Judgments: Comparing Parents, Nurses and Paediatricians

Rachel E Horton ¹, Rebecca R Pillai Riddell ^1,², Kenneth D Craig ³

Abstract

AIM:

Research suggests that caregivers' beliefs significantly influence paediatric pain assessment and management. Recent work found that parents rated infants as having greater pain intensity than paediatricians, while nurses' ratings did not differ significantly from either group. Using both quantitative and qualitative data, the purpose of the current study was to clarify these findings and evaluate how differences in pain judgments relate to pain beliefs and pain management practices by: 1) analyzing the pain beliefs underlying caregivers' pain judgments and 2) examining how the wording of belief questions may have impacted caregivers' responses.

METHODS:

The larger analysis was a cross-sectional, quasi-experimental video judgment study requiring caregivers to judge infant pain and complete a questionnaire package containing four questions targeting beliefs concerning infants' pain capacity and suitable pain management practices. The final sample (N = 123) consisted of 41 parents, 41 nurses and 41 paediatricians.

RESULTS:

Chi-square analyses suggested that a greater number of parents (as opposed to health professionals) endorsed beliefs that would be considered suboptimal for infant pain management. Moreover, only parents' responses regarding beliefs about infants' pain experience differed depending on variants of question wording.

CONCLUSIONS:

The current study suggests that researchers cannot assume higher pain judgments will result in better pain management as parents may take a more cautious and less well-informed perspective than health professionals. Caution must be taken when interpreting past research pertaining to parental beliefs about infant pain as question wording may confound interpretation of caregivers' pain beliefs.

AIMS:

Postoperative pain has been identified as a key issue about which patients wish to learn. However, little attention has been devoted to finding out what patients themselves identify as important. This study, grounded in Patient-Centered Care, investigated what informational content patients themselves identified as being most important.

METHODS:

150 primarily English speaking, general day surgery patients participated in a telephone survey within 72 hours after discharge from a large, quaternary care hospital in Toronto. Using a 10-point Likert scale, 19 statements were rated to determine which issues were of most importance. The responses were grouped to determine if variables such as sex or pain history effected expressed information needs.

RESULTS:

The top 3 information items identified were: 1) “What to do if I still have pain or side effects? ” ; 2) “Who to call if my pain is not well controlled? ” ; and 3) “The plan for which drugs to take and when”. The lowest average score for all information items, “If I can get help to pay for pain medicines”, was 5.9/10. Women rated 8 of the 19 items as significantly more important than men (p<0.05).

CONCLUSIONS:

This study validates previous findings that information about pain and pain management is important to patients. The findings may also be used to improve current approaches to patient education about acute postoperative pain and in doing so improve the patients' experience of pain and satisfaction with its management. Currently are conducting phase II of this study with a multilingual population.

Pain Res Manag. 2007 Summer;12(2):130.

P32: A Community-Based Education and Exercise Program (Y-PEP) for Individuals With Chronic Pain

Meaghan Kinlin ¹, Gina DiRienzo ¹, Dean Tripp ², Ruth Dubin ³, Cheryl King-VanVlack ¹

Abstract

AIM:

This pilot study examined the effects of a community-based education and exercise program (Y-PEP) on physical activity, pain perception, pain catastrophizing, level of depression and locus of control in individuals with chronic pain.

METHODS:

The Y-PEP program ran for 12 weeks program (3 hours/week). The education component was developed using the Chronic Pain Self-Management Program (© S.M. LeFort) and the low-intensity multi-exercise component was developed by a consortium of YMCA personnel and health care professionals. Participants completed the Human Activity Profile (HAP), Patient Health Questionnaire (PHQ), Pain Catastrophizing Scale (PCS), Brief Pain Index (BPI), Health Locus of Control Form C (LOC) and a demographics information sheet prior to and upon completion of the Y-PEP program.

RESULTS:

Full data sets were obtained for 10 (7 women, 3 men) of the 17 individuals originally enrolled in the program. Maximal activity levels increased 40% and the number of activities that had stopped doing was reduced by 35% (p<0.05). Participants reported a 21% reduction (p<0.05) in the rating of their “worst” pain and a 17% decrease in the interference that pain imposed on their activities (NS). No significant changes were noted in results from the PCS, BPI, LOC and PHQ.

CONCLUSION:

The Y-PEP program resulted in significant gains in physical activity among participants and less imposition of pain on their daily activities. Low statistical power in the current investigation may have prevented the detection of any substantive effects of the Y-PEP program on psychosocial parameters.

Pain Res Manag. 2007 Summer;12(2):130.

P33: A Novel Nurse-Lead Follow-Up and Education Program for Patients Treated With Methadone for Chronic Pain

Louise Lamb ¹, John Pereira ¹, Yoram Shir ¹

Abstract

Introduction:

Abstract

INTRODUCTION:

Pain is a frequent, debilitating and under-treated problem in older persons. Even though older patients can benefit from interdisciplinary pain clinics, their multiple comorbidities and frailty often make them more difficult to treat. The interdisciplinary Geriatric Pain Clinic of the McGill University Health Center, developed in 2004, is among the first clinics WITH AN INTERDISCIPLINARY TEAM COMBINING EXPERTISE IN PAIN AND GERIATRIC MEDICINE.

AIM:

Describe the population and interventions of the Geriatric Pain Clinic, to determine whether it serves a different role than general pain and geriatric clinics

METHODS:

Retrospective review of the initial evaluation of the first 88 patients assessed at the Geriatric Pain Clinic

RESULTS:

The average age of the patients was 80 years old. 14 patients had an MMSE Score lower than 24, suggestive of cognitive impairment. Most presented impairments in activities of daily living (average Barthel Score 88). The average number of medications taken was 11,3. In addition to management of pain, 9 patients were diagnosed and treated for dementia, 3 for depression and 9 for other diseases. Referral to CLSC for assistance at home was done for 10 patients.

CONCLUSION:

Patients referred to the Geriatric Pain Clinic represent a very old population with a high prevalence of cognitive and functional impairment. They often require a specialized expertise in assessment and management of other diseases and disabilities. An interdisciplinary Geriatric Pain Clinic seems to address specific needs of this population.

Pain Res Manag. 2007 Summer;12(2):131.

P37: The Injury-Stroop-Image Test: A Measure of Attentional Disengagement Deficits Associated With Pain

Marc Olivier Martel ¹, Michael JL Sullivan ¹

Abstract

AIM:

It seems that hypervigilance to pain may be particularly explained by an impaired attentional disengagement from pain signals. Given the potential utility of measures of disengagement in the assessment of patients with persistent pain conditions, we wanted to develop a new instrument providing a robust index of attentional disengagement deficits associated with pain.

METHOD:

30 pain-free volunteers (8 men and 22 women) completed the Pain Catastrophizing Scale (Sullivan et al., 1995), the Anxiety Sensitivity Index (Reiss et al., 1985) and performed a computerized modification of the Stroop Task. In our new task, a pain-related (or control) image was presented in the centre of the monitor for 500 ms, followed by the presentation of a word (e.g. green written in yellow) at the top or the bottom of the computer screen. Participants were instructed to read out loud the ink color of the word as fast and as accurately as possible.

RESULTS:

Preliminary analysis revealed that in overall, participants were significantly slower in naming the colour of words following pain-related pictures than control pictures, indicating a general attentional disengagement deficit from pain. However, disengagement deficits were not associated with pain-related psychological variables. Pain catastrophizing, but not anxiety sensitivity, was significantly associated with participants' evaluation of pain-related pictures level of unpleasantness.

CONCLUSION:

These results suggest that disengagement deficits might be a distinct dimension of psychological factors associated with pain outcomes. Pain catastrophizing might be more related to the affective (unpleasantness) rather than to the cognitive (attentional) component of the pain experience.

Pain Res Manag. 2007 Summer;12(2):131.

P38: Role of Inflammation and Injured vs. Uninjured Sensory Fields in α, β-Methyleneatp/Noradrenaline (NA) Interactions on Nociceptive Signaling

Jason Meisner ¹, Allison Reid ¹, Daniel Marsh ², Jana Sawynok ¹

Abstract

INTRODUCTION:

The partial sciatic nerve ligation (PSL) model of nerve injury has become a common experimental tool to investigate neuropathic pain. In examining the effects of ATP and NA (which are co-released from sympathetic nerves) on sensory function following PSL, injury was found, paradoxically, to decrease sensitivity to α, β-MethyleneATP (α, β-MeATP) alone and α, β-MeATP/NA combination. This observation prompted the current investigation wherein: (a) the inflammatory component of PSL was investigated using the L5 neuritis model, and (b) the role of injured vs uninjured fibres was examined using the spared nerve injury (SNI) model to inject drugs into injured or uninjured sensory fields. When distinct changes were observed between sensory fields, dorsal root ganglia in SNI rats were assessed for differences in P2X₃ and α₁-adrenergic receptors using ATF-3 to distinguish injured from uninjured neurons.

RESULTS:

Effects of injury on flinching responses to drug treatment are shown below.

Model (injection site)	NA	a,b-MeATP	a,b-MeATP/NA
PSL (central)	^↔	^↓	^↓
L5 Neuritis (central)	^↔	^↑	^↔
SNI (medial)	^↔	^↓	^↓
SNI (lateral)	^↑	^↑	^↑

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(↔ = no difference vs sham,

↑ = increased flinching vs sham,

OBJECTIVES:

Although the role of expectancies has been discussed as an important determinant of pain-related outcomes, little research attention has been paid to the development of reliable and valid measures of recovery expectancies. To date, most research in this area has relied on single-item measures of unknown reliability and validity.

METHODS:

75 pain patients (27 men and 48 women) with a mean age of 40 years were asked to complete the Multidimensional Expectancies Questionnaire (MEQ; Thibault et al), the McGill Pain Questionnaire (MPQ, Melzack., 1975), the Pain Catastrophizing Scale (PCS, Sullivan et al., 1995), the Tampa Scale of Kinesophobia (TSK, Kori et al., 1990) and the Beck Depression Inventory (BDI-II, Beck., 1996). The MEQ is a 15-item self-report questionnaire where respondents are asked to report the probability of different outcomes associated with their pain condition. The MEI addresses expectancies for 6 domains of pain outcomes addressing the probability that 1) pain will increase, 2) pain will worsen, 3) social and recreational activities will be resumed, 4) work activities will be resumed, 5) medication will be reduced, and 6) sleep will improve.

RESULTS:

The MEQ showed good psychometric qualities in term of reliability (Cronbach's alpha = .91) and validity. Initial analyses reveal that scores on the MEI are significantly correlated with other psychological correlates of pain including pain intensity (r = −.53), pain catastrophizing (r = −.64), depression (r = −.64) and fear of pain (r = −.64).

CONCLUSION:

A reliable and valid measures of expectancies for pain-related outcomes will promote both theoretical and clinical advance in this area.

Pain Res Manag. 2007 Summer;12(2):133.

P45: Pain Assessment and Flowsheet Specific to a Complex Rehabilitation and Continuing Care Centre: Evaluation of Reliability and Validity, Outcome Measurement Post Best Practice Implementation.

Susan Oates ¹, P Derkach ¹, Tim Pauley ¹, Abel Cheng ²

Abstract

Guided by the 2005, Canadian Council of Health Services Accreditation (CCHSA) standards and the ‘best practice’ evidence provided by the Registered Nurses Association of Ontario (RNAO), Best Practice Guideline (BPG), Assessment and Management of Pain (2004), this rehabilitation and complex continuing care centre began to examine improvements in pain assessment and management.

Pain assessment is the first step in pain management and is a critical component of high quality patient care. A literature search supported the health care professionals' observations that pain effects rehabilitation and complicates recovery.

The Centre identified the need for a quantitative assessment tool that would quickly and reliably measure the plethora of pain the patients presented with, nociceptive, neuropathic, phantom limb pain, and chronic pain syndromes, reflex sympathetic dystrophy (complex regional pain syndrome, type 1) and causalgia (complex regional pain syndrome, type 2). The tool needed to capture the patient's self-report, behaviour and physiological reactions.

The Pain Assessment and Flowsheet developed provides staff with a screening tool, based on systematic, validated pain assessment tools, the Short-Form Brief Pain Inventory (BPI-SF) and the short-form McGill Pain Questionnaire (MPQ-SF). The tool uses the Numeric Rating Scale (NRS) and the Faces Scale which allows for screening all persons at risk for pain.

The aim of this poster is to present the development of a Pain Assessment and Flowsheet, which is specific to the needs of a rehabilitation and complex continuing care patient population. The outcome of the research project, which tested for validity and reliability, will be presented as well as the outcome of the implementation of the RNAO, BPG, Assessment and Management of Pain (2004).

The Cronbach alpha was used to determine internal consistency for the tool, while an intraclass correlation coefficient (ICC) was calculated to examine test-retest reliability for total score. Kendall's tau-b statistic was used to assess test-retest agreement retest reliability for total score. Kendall's tau-b statistic was used to assess test-retest agreement for individual items.

Outcome evaluation, based on admission and discharge statistics from National Rehabilitation Reporting System (NPS) has indicated major success for staff and patients. Stats indicate a 31% reduction in the prevalence of severe pain intensity at discharge for patients in Rehabilitation after the implementation of the RNAO, BPG, Assessment and Management of Pain (2004), using the Centre's Pain Assessment and Flowsheet.

Five interrelated themes emerged from the qualitative data: modifying or finding new activities; making trade offs to maximize participation and minimize pain; rationalizing threat to identity; dealing with disruptions in lifestyle; and hoping coupled with the use of active coping strategies. Quantitative analysis of participants' CSQ-R responses indicated praying was the most widely used coping strategy. This however, was not identified during the interviews.

CONCLUSION:

The CSQ-R did not support the qualitative findings or capture the complex, multi-dimensional coping strategies and decision-making processes required to maintain engagement in activities. This pilot study suggests qualitative methodology can reveal information about coping that is quite different from that engendered by the CSQ-R.

REFERENCE

Riley JL, Robinson ME. CSQ: Five factors or fiction? The Clinical Journal of Pain. 1997;13:156–162. doi: 10.1097/00002508-199706000-00010. [DOI] [PubMed] [Google Scholar]

Pain Res Manag. 2007 Summer;12(2):135.

P54: A Systematic Review of the Prevalence of Neuropathic Pain

Fatima Lakha ¹, Andrea Furlan ^1,^2,³, Balaji Yegneswaran ¹, Angela Mailis-Gagnon ^1,^2,⁴

Abstract

AIM:

To identify the prevalence of different types of neuropathic pain (NeP) according to world regions, settings and population.

METHODS:

We searched MEDLINE and EMBASE from 1990 onwards for epidemiological studies reporting on prevalence data published in English. Methodological quality was assessed for risk of biases. The influence of potential effect modifiers will be assessed using meta-regression.

RESULTS:

The searches yielded 2490 titles/abstracts and 33 studies met inclusion criteria. Seventeen studies were conducted in Europe, 9 in the USA, 4 in Asia and 3 in Australia (including 149,980 males and females). Sample sizes varied from 31 to 121,523. Two studies only were conducted in the general population, one in the USA (reporting prevalence of CRPS I 0.021% and CRPS II 0.009%) and one in the UK (detecting NeP in general in 8.2% of the population). Four studies were conducted in primary care settings and 27 in specialized or rehabilitation clinics, in patients with spinal cord injury, multiple sclerosis, herpes zoster, diabetes, AIDS, stroke, low-back pain and general chronic pain. The prevalence rates ranged from 1 to 80.5%.

CONCLUSION:

The variable prevalence rates for specific disorders vary widely due to differences in population and settings. The prevalence of NeP in the general population seems to be higher than previously thought. If this holds true for Canada, based on current population statistics, the number of Canadians with NeP could exceed 2.5 million. High quality epidemiological studies in Canada are needed to confirm the above rates.

Pain Res Manag. 2007 Summer;12(2):135.

P55: Parsing the Highly Variable Response of Human Subjects to Capsaicin Receptor Activation for Gene Mapping and QST

William R Lariviere ¹, Krystle J Englehart ¹, Lauren M Taylor ¹, Kristie McVay ¹, Donald H McBurney ², Carey D Balaban ³

Abstract

Accurate assessment of fundamental pain traits/phenotypes is essential to detect significant genotype-phenotype associations. Despite widespread use of capsaicin application as an experimental pain model, no method has been developed to address the inherent marked variability in reported pain responses.

The current study applies common psychophysical methods and a novel dynamic mathematical model with phasic, tonic, and integrator components that has successfully parsed variability in the response to oral capsaicin stimuli to detect three common dynamic response patterns in human subjects. We determined the temporal response patterns to intraoral and topical capsaicin application in and out of the trigeminal region in the same subjects to test the effect of stimulation site and the trigeminal nerve. Sex differences in mean responses to both cheek and ankle stimulation can be accounted for by a greater gain in the tonic mechanism. Mean responses to ankle stimulation showed a greater integrator component than responses to cheek stimulation, a negligible phasic component, and required a time delay. In addition, ratings of capsaicin stimulation using a 10 cm visual analogue scale (VAS) vary independently from capsaicin responder type (tonic, phasic, or integrator types), indicating that our model provides a unique method of quantitatively phenotyping the response to capsaicin receptor activation. Within subjects, a significant degree of similarity of temporal response occurred across stimulation site. Application of this model is expected to facilitate our current efforts to detect underlying genetic mechanisms, and be useful for the interpretation of quantitative sensory testing (QST) results in the clinic and laboratory.

Pain Res Manag. 2007 Summer;12(2):135.

P56: The Interaction Between the Experience of Pain And The Perception of Pain in Others

To Nhu Ly ¹, Philip Jackson ², Jean Decety ³, Emma Jakmajian ¹, Pierre Rainville ¹

Abstract

INTRODUCTION & OBJECTIVE:

Recent brain imaging studies have demonstrated a partial overlap between the brain activity related to the experience of pain and that of the perception of pain in others, also referred to as pain empathy. However, it is still unclear whether this “shared representation” for pain, influences our perception of pain. The objective of this study is to assess whether our own experience of pain modulates our perception of pain in others. We hypothesized that experiencing pain while observing facial expression of pain would increases subjects' rating of the latter.

METHODS:

Thirty-four healthy right-handed subjects viewed and rated series of 1-sec movie clips of actors depicting three levels of pain expressions (low, medium, high). During each clip, subjects received either non-painful thermal stimuli (WARM) or moderately painful stimuli (PAIN) on the leg. Subjects completed 3 sessions: Session 1 = all WARM; Sessions 2 and 3 = 50% WARM and 50% PAIN stimuli, counterbalanced.

RESULTS:

A 2 (WARM, PAIN) X 3 (Pain Expression Level) repeated measures ANOVA performed on the ratings of the facial expressions showed a significant main effect of Pain Level as well as a significant interaction. Compared to WARM stimuli, PAIN increased pain expression ratings attributed to the low and medium facial displays but decreased ratings of the high pain expressions.

CONCLUSIONS:

These findings suggest that the perception of pain in others is affected not only by the level of pain expressed but also by the congruency between self and other's pain.

Pain Res Manag. 2007 Summer;12(2):135–136.

P57: Mothers' Practices and Attitudes Regarding Analgesia During Routine Immunizations

Jennifer Manley ^1,², Leah Potash ¹, Vibhuti Shah ³, Moshe Ipp ⁴, Michael Sgro ⁵, Anna Taddio ^1,²

Abstract

BACKGROUND:

Routine immunizations are the most common source of iatrogenic pain in healthy children. Although previous studies demonstrated that the pain from immunization can be managed with topical local anesthetics,1,2,3,4,5 analgesic utilization in clinical practice has not been investigated.

OBJECTIVE:

To assess mothers' analgesic practices during routine immunizations in their children.

DESIGN:

Prospective interview.

SETTING:

Postnatal ward at Mount Sinai Hospital, Toronto, Ontario.

SUBJECTS:

Mothers of newborn infants, with at least one older child.

PROCEDURES:

Participants were asked questions about their analgesic practices during routine immunization in their children.

RESULTS:

200 women participated; mean age was 34 (±4.5) years, median number of children was 2 (range 2 to 7). 25.5% of mothers reported using analgesia prior to immunization in their children; acetaminophen was chosen most frequently (86.3%), followed by ibuprofen (7.8%) and topical local anesthesia [i.e., EMLA® (5.9%)]. The most commonly reported reasons for not using analgesia were that the physician did not recommend it (47.7%) and not knowing about the option (45.0%). Interestingly, however, 51% of mothers reported that analgesics should be used prior to immunizations.

CONCLUSIONS:

Mothers reported that analgesia should be used prior to immunizations for the treatment of pain; however, the majority did not utilize this option. Strategies to increase mothers' use of analgesics should be implemented.

REFERENCES

1.Taddio A, Nulman I, Goldbach M, Ipp M, Koren G. Use of lidocaine-prilocaine cream for vaccination pain in infants. J Pediatr. 1994;124:643–648. doi: 10.1016/s0022-3476(05)83150-6. [DOI] [PubMed] [Google Scholar]
2.Uhari M. A eutectic mixture of lidocaine and prilocaine for alleviation of vaccination pain in infants. Pediatrics. 1993;92(5):719–721. [PubMed] [Google Scholar]
3.O'Brien L, Taddio A, Ipp M, Goldbach M, Koren G. Topical 4% amethocaine gel reduces the pain of subcutaneous measles-mumps-rubella vaccination. Pediatrics. 2004;114(6):e720–e724. doi: 10.1542/peds.2004-0722. [DOI] [PubMed] [Google Scholar]
4.Halperin SA, McGrath P, Smith B, Houston T. Lidocaine-prilocaine patch decreases the pain associated with the subcutaneous administration of measles-mumps-rubella vaccine but does not adversely affect the antibody response. J Pediatr. 2000;136(6):789–794. [PubMed] [Google Scholar]
5.Halperin BA, Halperin SA, McGrath P, Smith B, Houston T. Use of lidocaine-prilocaine patch to decrease intramuscular injection pain does not adversely affect the antibody response to diphtheria-tetanus-acellular pertussis-inactivated poliovirus-Haemophilus influenzae type b conjugate and hepatitis B vaccines in infants from birth to six months of age. Pediatr Infect Dis J. 2000;21(5):399–405. doi: 10.1097/00006454-200205000-00010. [DOI] [PubMed] [Google Scholar]

Pain Res Manag. 2007 Summer;12(2):136.

P58: Characterisation of Pain-Related Behaviour in a Rat Model of Osteoarthritis: Implications for TRPV1 Involvement

G Martino, C Puma, Y Théberge, MN Perkins, JM Laird

Abstract

Osteoarthritis (OA), is a degenerative joint disease, characterised by destruction of articular cartilage and associated with chronic pain and impaired function.

There are few animal models of OA relating specifically to pain. Vanilloid receptor1 (TRPV1) may be involved in disease progression and pain-related behaviour associated with intra-articular (i.a.) injection of monosodium iodoacetate (MIA) and FCA. TRPV1 expression in joint afferents is increased following MIA (Fernihough J et al 2005), and a VR1 antagonist, reverses MIA-induced deficit in weight bearing (Honore P et al 2005). In TRPV1 knockout mice, Freund's complete adjuvant (FCA)-induced deficit in weight bearing and joint swelling was reduced (Barton NJ et al 2006), and both referred heat and mechanical hyperalgesia in the paw were absent (Keeble J et al 2005).

This study has developed and characterised pain endpoints in rats with MIA-induced OA, and investigated the role of TRPV1 in the development and maintenance of joint pain.

Intra-articular injection of MIA in rats produced a robust, dose-dependent, and persistent deficit in weight bearing in the injured limb and a redistribution of weight to uninjured limbs including the tail (Tekscan™ system). Moreover, MIA-treated rats showed a weak and, interestingly, a delayed referred mechanical (von Frey threshold) and heat (plantar test) hyperalgesia. Naproxen and a TRPV1 antagonist were effective in the early, inflammatory, stage of the disease but were ineffective in the late stage. This data suggests that this rat model of MIA-joint inflammation can provide insight into the mechanisms of pain in degenerative joint disease, and the development of novel therapeutic intervention.

Pain Res Manag. 2007 Summer;12(2):136.

P59: Cost of Illness for Chronic Stable Angina Patients

Michael McGillion ¹, Ruth Croxford ², Peter Coyte ¹, Judy Watt-Watson ¹, Sandra LeFort ³, Bonnie Stevens ¹

Abstract

AIM:

Chronic stable angina (CSA) is a ubiquitous, cardinal symptom of coronary artery disease (CAD) with a major negative impact on health-related quality of life (HRQOL) including pain, poor general health status and inability to self-manage. CSA accounts for 16% of all CAD-related physician visits in Canada and is among the top 3 most common cardiovascular reasons for hospital admission. To date, lack of minimum cardiovascular data sets has precluded estimation of the economic impact of CSA. As part of a larger randomized controlled trial, this study evaluated the cost of illness for CSA patients.

METHODS:

Cost data were collected on 117 participants using the Ambulatory Home Care Record. Median annualized direct, indirect and system-related CSA costs (2003 – 2005) were estimated. The total cost of care from a societal perspective for each participant was calculated as the sum of these costs.

RESULTS:

The mean age of participants was 68, 80% were male. Direct out-of-pocket CSA costs, including money paid for healthcare, travel to appointments, medications, equipment and home support were $1,495. Indirect costs, reflecting the estimated value of all unpaid time spent by angina participants and unpaid caregivers engaged in angina-related care were $7,542. System costs, including costs paid by public and private insurers were $2,035. Total estimated annual societal CSA costs were $12,615 per participant.

CONCLUSION:

These data indicate that CSA imposes a major economic burden to society. Advancements in secondary prevention are required to address CSA as a major societal cost burden.

Pain Res Manag. 2007 Summer;12(2):136.

P60: A Regional Pain Strategy: Provider Engagement Project

Janice Muir ¹, Gerry O'Hanley ², Michael Negraeff ³, Brian Warriner ⁴

Abstract

The aim of this Regional Pain Strategy provider engagement project was for Vancouver Coastal Health, in collaboration with Providence Health Care, B.C. Cancer Agency, B.C. Children's Hospital and B.C. Women's Hospital to embark on a major initiative to improve services and quality of life for people living with pain across the continuum of care. This was done by identifying current service coverage against health needs and desired health outcomes of people living with pain.

The methods used were focus group interviews and questionnaires to learn more from the care providers about the services they provide, the current status of pain management and what improvements should be made to meet the needs of people living with pain. The results from the focus group interviews and questionnaires were collated and common themes outlined.

The conclusions then were used to recommend an optimal service model of care that meets the needs of people living with pain encompassing acute, cancer, palliative and non-cancer chronic pain in all care settings for patients/individuals across the lifespan.

Pain Res Manag. 2007 Summer;12(2):136–137.

P61: Amputation for Complex Regional Pain Syndrome at the Worksafebc.

K Noertjojo ⁽¹⁾, C Martin ⁽¹⁾, C Dunn ⁽¹⁾

Abstract

BACKGROUND:

Complex regional pain syndrome (CRPS) type I and CRPS type II are debilitating pain syndromes that have been recognized, perhaps, since the 5^th century BC as described in the story of Philocetes written by Sophocles. Despite the lengthy history of these disorders, the natural history and pathophysiology of CRPS type I and type II are still unclear. As a result, the treatment of patients with these disorders remains controversial and frequently ineffective. One of the most drastic and dramatic surgical treatments occasionally considered for these patients is that of amputation of the affected body part.

AIM:

to conduct a systematic literature review on amputation of the affected extremity as a treatment for selected patients with CRPS.
to describe a case series of eight injured workers covered by WorkSafeBC that underwent limb amputation for treatment of their CRPS condition.

METHODS:

narrative systematic literature review
case series

RESULTS:

A systematic literature search, conducted in various commercial medical databases in October 6, 2006, identified 90 published papers. Of these, 9 papers were relevant to the purpose of the systematic review. The results of these papers will be described and compared with the results of amputation among WorkSafeBC claimants diagnosed with CRPS. The characteristics of the patients, treatments prior to amputation, indication for amputation and outcomes of the surgical procedure will be described.

CONCLUSIONS:

Amputation is a rare and drastic surgical procedure that is unlikely to be of benefit to patients with CRPS.

Pain Res Manag. 2007 Summer;12(2):137.

P62: Moved To Friday (45)

Pain Res Manag. 2007 Summer;12(2):137.

P63: Examining the Impact of Catastrophizing Subscales on Interdisciplinary Chronic Pain Program Outcomes

Lorraine Overduin ^1,², Joyce L D'Eon ^1,^2,³

Abstract

AIM:

The present study aimed to examine the impact of the three components of catastrophizing (helplessness, magnification and rumination) and behavioural coping strategies on treatment outcomes in an interdisciplinary treatment program for chronic pain patients.

METHOD:

Participants eligible for inclusion completed a six-week treatment program (N = 70). Pre-post evaluations included measures of catastrophizing (Pain Catastrophizing Scale; PCS), depression (BDI-II), disability (Rolland Scale), behavioural coping (Chronic Pain Coping Inventory; CPCI), client ratings of change, and pain ratings.

RESULTS:

Significant reductions in pre-post PCS total scores and for each of the three components were found. Only reductions in helplessness and PCS total scores were correlated with reductions in disability. Helplessness and magnification were significantly correlated with patient ratings of the positive changes they experienced in the program

Significant improvements in behavioural coping strategies were noted (Coping, Social Support, Guarding, Relaxation, Exercise/stretch and Pacing; CPCI). Reduction in guarding was significantly and inversely correlated with changes in helplessness and the PCS total score. No other CPCI or PCS change scores were significantly correlated.

CONCLUSIONS:

Results suggest that the helplessness component of catastrophizing is a primary contributor to the positive changes noted in catastrophizing in interdisciplinary treatment programs. Changes in helplessness are also highly correlated with changes in guarding which previous research has indicated is related to good outcomes. These data suggest that helplessness, as a component of catastrophizing, warrants further investigation in influencing chronic pain outcomes.

Pain Res Manag. 2007 Summer;12(2):137.

P64: Can Sodium Channel Blockers Modulate Spontaneous Activity Originating from the Rat Saphenous Nerve Neuromas?

M Paré ¹, MN Perkins ¹, CQ Cao ¹

Abstract

A neuroma is formed following peripheral nerve damage where the regeneration process is impeded. The sprouts form a tangle mass accumulating sodium channels that are believed to underlie neuronal hyperexcitability and ectopia (Devor et al. 1993). A neuroma could sustain neuropathic pain in 2 ways, contributing to direct afferent signal, which is felt as ongoing pain, as well as triggering and maintaining central sensitization. We investigated the ability of sodium channel blockers to modulate the generation of ectopic action potential at the lesion site of a neuroma. Neuromas were induced by lesioning the saphenous nerve of Sprague-Dawley rats (male, from 175g to 225g). After 10 to 75 days, the saphenous nerve was excised, perfused with synthetic interstitial fluid and electrophysiological recordings performed using the fiber teasing method. Surprisingly, high doses of lidocaine, mexiletine and tetrodotoxin were necessary to inhibit, partially, ongoing discharge. Up to 2mM lidocaine were required to block completely spontaneous activity whereas doses up to 5 μM tetrodotoxin did not inhibit spontaneous activity in some afferents. The data suggest that TTX-insensitive sodium channel provide a major contribution to the generation of ectopic action potentials in the neuroma.

Pain Res Manag. 2007 Summer;12(2):137.

P65: Evaluating Nursing Student's Knowledge of Pain Management in a Collaborative Bscn Program

Maurine Parzen ⁽¹⁾

Abstract

AIM:

Despite the advances in treatments for pain, pain is still largely under treated. The literature suggests that the reason for inadequate treatment is the result of insufficient knowledge about pain management, which originated from the lack of focus on pain in nursing curriculum ^(1–3). There are limited studies conducted evaluating Canadian nursing programs for gaps in pain content subsequently this research was conducted to gain further insight into nursing students knowledge of pain management in a BScN Program in Ontario.

METHOD:

Students in year 2, 3, and 4 were invited to participate by email to complete Ferrell's and McCaffery's⁽⁴⁾ “Nurses knowledge and Attitude Survey Regarding Pain” online. The survey was accessible from March 2006-May 2006. A repeat invitation was sent midway through the study.

RESULTS:

185 students accessed the survey with a response rate of 23%. Data analysis reflects knowledge gaps about pain in all 3 levels of the program with a mean average score of 24.91(SD= 3.82) out of 39. No significant differences were found as students advanced through the program nor did clinical experiences improve scores except for those students who had a palliative care placement. Topics showing greatest knowledge gaps were surrounding common effects of analgesics, attitudes and perception of pain.

CONCLUSION:

These results strongly reflect insufficient focus on pain in this nursing program. Ensuring students have an opportunity to work in palliative care can provide a meaningful learning experience about pain. It is strongly recommended that nursing curriculum be reviewed and update to ensure that effective pain management content is being incorporated throughout a nursing program.

REFERENCES

1.Zalon M. Pain management instruction in nursing curricula. Journal of Nursing Education. 1995;34:262–267. doi: 10.3928/0148-4834-19950901-06. [DOI] [PubMed] [Google Scholar]
2.CHUK P. DETERMINING THE ACCURACY OF PAIN ASSESSMENT OF SENIOR STUDENT NURSES: A CLINICAL VIGNETTE APPROACH. NURSE EDUCATION TODAY. 2002;22:393–400. doi: 10.1054/nedt.2001.0734. [DOI] [PubMed] [Google Scholar]
3.Twycross A. Education about pain: a neglected area? Nurse Education Today. 2000;20:244–252. doi: 10.1054/nedt.1999.0412. [DOI] [PubMed] [Google Scholar]
4.City of Hope Web site. Available at: http://www.cityofhope.org/prc/res_inst.asp Accessed January 28, 2007.

Pain Res Manag. 2007 Summer;12(2):138.

P66: Characterization of Pediatric Multidisciplinary Pain Treatment Facilities (Mptf) in Canada: Stoppain Project-Study II

Philip Peng ¹, Jennifer Stinson ², Manon Choiniere ³, Dominique Dion ³, Chelsea Maddock ¹, May Ong ⁴, Saifee Rashiq ⁵, Gregg Tkachuk ⁶, Howard Intrater ⁷, Yves Veillette ⁸, Mary Lynch ⁹, Sandra Lefort ¹⁰; STOPPAIN investigators group

Abstract

OBJECTIVE:

To describe the services offered in MPFT exclusively for pediatric populations in Canada.

METHODS:

MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of patients with chronic pain and had a minimum of three different health care disciplines (including at least one medical speciality) whose services were available and integrated within the facility. The search method included approaching all hospital administrators in Canada, the Insurance Bureau of Canada, the Workman and Safety Board or similar body in each province and several large drug companies for their knowledge of pain clinics. Designated investigators were responsible for identifying true MPTF from this preliminary list in their provinces. Eligible MPTF were asked to complete the questionnaire on their infrastructure, clinical, research, teaching and administrative activities.

RESULTS:

There were five pediatric MPTF (NS, QC, ON, AB, BC) in Canada, with one recently established in April 2006. Workload and wait times are shown in Table 1. Headache was the most commonly treated pain syndrome. All of the pediatric MPTF consisted of anesthesiologists, nurses and psychologist. Each of these programs provided teaching for residents or students from various medical specialties and other healthcare professions. Only four provided specialty fellowship training. Government funding was the major source of funding for patient services and overhead except for one MPTF that relied on a compensation agency as a major source of funding for patient services.

CONCLUSION:

Our survey showed a wide geographic disparity in the chronic pain services available to children in Canada.

Table 1.

Median MPTF workload and wait times

WORKLOAD/WAIT TIME	MEDIAN (RANGE)
Days of operation/week	1 (0.5–5)
Number of new consultations in last 12 months	31 (21–90)
Number of follow up visits in last 12 months	450 (53–1308)
Number of patients waiting	10 (0–20)
Wait time (weeks)	4 (1.5–36)

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Pain Res Manag. 2007 Summer;12(2):138.

P67: Role of Non-Physician Healthcare Professionals in Canadian Multi-Disciplinary Pain Treatment Facilities (MPTF): Stoppain Project-Study II

Philip Peng ¹, Jennifer Stinson ², Manon Choiniere ³, Dominique Dion ³, Chelsea Maddock ¹, May Ong ⁴, Saifee Rashiq ⁵, Gregg Tkachuk ⁶, Howard Intrater ⁷, Yves Veillette ⁸, Mary Lynch ⁹, Sandra Lefort ¹⁰; STOPPAIN investigators group

Abstract

OBJECTIVE:

To describe the role of non-physician healthcare professionals in MPTF in Canada.

METHODS:

MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of patients with chronic pain and had a minimum of three different health care disciplines (including at least one medical speciality) available and integrated within the facility. The search method included approaching all hospital administrators in Canada, the Insurance Bureau of Canada, the Workman and Safety Board or similar body in each province and several large drug companies for their knowledge of pain clinics. Designated investigators were responsible for confirming MPTF from this preliminary list in their provinces. Administrative leads at each eligible MPTF were asked to complete a detailed questionnaire on their infrastructure, clinical, research, teaching and administrative activities. Data concerning the activity of non-physician health professionals was extracted.

RESULTS:

101 MPTF completed and returned the questionnaires (response rate 88%). The representation of various healthcare professions that were integrated in MPTF or worked as full-time staff (4–5 days/week) is shown in Figure. The three most common non-physician professionals were physiotherapists, psychologists and nurses with 50% of MPTF staffed with at least one full-time physiotherapist. The three top services provided by physiotherapists were patient assessment, individual physiotherapy or exercise and TENS. The three most common services provided by psychologists were individual counseling, cognitive behavioral therapy and psychodynamic therapy. The major roles of nurses were patient assessment, assisting in interventional procedures and patient education.

CONCLUSION:

Our survey showed that non-physical healthcare professionals play a variety of important roles in MPTF in Canada.

Muscarinic acetylcholine receptors have been suggested as pharmacological targets for the treatment of pain. However, studies have focused on effects in acute pain rather than pathological pain states. Here, we have explored a potential role for muscarinic receptors in inflammatory and neuropathic pain in rats using xanomeline, an M1/M4 preferring muscarinic receptor agonist. Inflammatory pain was examined using Freund's complete adjuvant injected into one hindpaw (FCA model). Heat hyperalgesia 24 hrs after FCA injection was measured as paw withdrawal latency. Effects on peripheral neuropathic pain were explored using chronic constriction injury of the sciatic nerve (CCI) and spinal nerve ligation (SNL) models. Heat hyperalgesia was measured in both these models and punctate hyperalgesia (von Frey threshold) tested in SNL. We also investigated the circuitry underlying any in vivo analgesic responses of xanomeline by recording effects on cortical field potentials from rat brain slices maintained ex vivo.

Xanomeline (0.3 to 90 μmol/kg s.c.) produced a dose dependent reversal of both CCI and SNL heat hyperalgesia and punctate hyperalgesia in SNL rats. In the FCA model, xanomeline also produced a robust dose dependent (0.3 to 10 μmol/kg/sc) anti-hyperalgesia. Finally, xanomeline produced a significant attenuation of cortical neurotransmission when superfused over somatosensory cortex slices. The selective M1 antagonist, pirenzepine, blocked this effect.

There was a significant increase in caregiver heart rate and anxiety but not blood pressure during their child's venipuncture procedure. There was an association between child pain and caregiver maximum heart rate, anxiety, child distress and caregiver distress promoting behaviours but not nurse distress promoting behaviours during children's venipuncture.

Many low back pain conditions can be effectively managed with specific early interventions. However, the optimal management of low back pain in Canada is significantly confounded by inadequate primary care and prolonged wait in access to tertiary care.

AIM:

The objectives of this report are to document: (i.) the demographics and presenting conditions, (ii.) the “care-gap” between adequate primary care and that provided by the clinic, and (iii), the access to tertiary interventional care.

METHODS:

The Ottawa Acute Spinal Pain Centre (OASPC) was established to address many of the above concerns. A multidisciplinary panel developed an evidence-based algorithm for appropriate primary and interventional care to be followed by the OASPC clinicians. A prospective database of consecutive patients has been created evaluating this.

RESULTS:

85% of patients presented with acute, sub-acute or acute on chronic exacerbation of back pain with the lumbar region being the most common. 54% to 98% of patients (based on the intervention) reported not having received the specific primary care intervention as outlined in the developed algorithm, which is significantly improved upon by OASPC clinicians. There are significantly shorter wait times for specialist consultations from the OASPC compared to standard referrals.

DISCUSSION:

The preliminary results of the OASPC suggest that this type of clinic can provide appropriate primary care and triaging to specialty care for patients with acute back pain. Further research is required to demonstrate the prevention of chronic pain.

Pain Res Manag. 2007 Summer;12(2):142.

P80: Smoked Cannabis for Chronic Neuropathic Pain: Results of a Pilot Randomized Controlled Trial

MA Ware ¹, T Wang ², T Ducruet ³, S Shapiro ², A Gamsa ¹, G Bennett ¹, Y Shir ¹, JP Collet ²

Abstract

INTRODUCTION:

An estimated 10–15% of patients suffering from chronic noncancer pain (CNCP) use cannabis for relief of pain, improvement in sleep and mood. Here we report preliminary results of a pilot study of smoked cannabis for CNCP.

METHODS:

A randomized double-blind placebo-controlled crossover trial compared four strengths of cannabis (0%, 5%, 6% and 9% THC). Otherwise healthy subjects with chronic neuropathic pain with allodynia or hyperalgesia following trauma or surgery, who were not currently using cannabis, were enrolled. Consenting subjects were exposed to all four cannabis strengths in four 14-day cycles; they smoked 25mg of the drug using a pipe three times daily for five days, with a nine-day washout in between cycles. The primary outcome was average daily pain intensity over the five-day exposure period. Secondary outcomes were feasibility, adverse events, quality of life and sleep. Adverse events were recorded throughout.

RESULTS:

Twenty-three subjects were randomized (mean age 45.4y (SD 12.3), 11 male (48%)) and two were withdrawn within the first week for protocol violations. Twenty-one subjects completed all four cycles. The effect of cannabis on the primary outcome will be reported at the meeting (final analysis is not complete at the time of submission). There were no serious or severe adverse events.

CONCLUSIONS:

This study has shown that placebo-controlled clinical trials of smoked cannabis are feasible and the drug is well-tolerated at this dose over this short period. A number of lessons from conducting this trial can be learned and will be discussed. Further trials are needed.

Aim:

Distance, cost, and availability of relevant sessions can be barriers to accessing education for health care professionals. Clinicians at an Academic Health Sciences Centre sought to determine whether Telehealth videoconferencing would be a viable option to reduce these barriers for local and remote health care providers. A pilot study was designed to: a) increase access to pain management education; and b) examine the feasibility of videoconferencing pain management education.

Methods:

The 6-month pilot study consisted of four videoconferenced sessions of Inter-professional Pain Management Rounds. The host site was the Academic Health Science Centre, which broadcast to multiple locations across the province using a secure Telehealth network. Participants completed post-session, self-report questionnaires (n=227), modified for this study from an existing tool.

RESULTS:

Findings from the pilot study were as follows:

Quality – 90% of participants reported session quality was “very good/excellent”.
Access – 162 participants used videoconferencing thereby increasing event attendance by 140%. Participating sites increased steadily from 3 to 16 locations.
Acceptability – 97% of host site participants “strongly agreed” with videoconferencing educational sessions to other locations. Sign up for the sessions by remote sites was rapid (< 0.5 days to reach capacity).
Cost – Costs associated with videoconferencing were negligible to the organization, due to support from multiple partners.

CONCLUSION:

Telehealth videoconferencing has been integrated into Pain Management Rounds as a dynamic solution to increase access to inter-professional pain education. These pilot study findings have been used successfully to secure funding for ongoing program sustainability.

References

i.Taddio A, Nulman I, Goldbach M, Ipp M, Koren G. Use of lidocaine-prilocaine cream for vaccination pain in infants. J Pediatr. 1994;124:643–648. doi: 10.1016/s0022-3476(05)83150-6. [DOI] [PubMed] [Google Scholar]
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iii.O'Brien L, Taddio A, Ipp M, Goldbach M, Koren G. Topical 4% amethocaine gel reduces the pain of subcutaneous measles-mumps-rubella vaccination. Pediatrics. 2004;114(6):e720–e724. doi: 10.1542/peds.2004-0722. [DOI] [PubMed] [Google Scholar]
iv.Halperin SA, McGrath P, Smith B, Houston T. Lidocaine-prilocaine patch decreases the pain associated with the subcutaneous administration of measles-mumps-rubella vaccine but does not adversely affect the antibody response. J Pediatr. 2000;136(6):789–794. [PubMed] [Google Scholar]
v.Halperin BA, Halperin SA, McGrath P, Smith B, Houston T. Use of lidocaine-prilocaine patch to decrease intramuscular injection pain does not adversely affect the antibody response to diphtheria-tetanus-acellular pertussis-inactivated poliovirus-Haemophilus influenzae type b conjugate and hepatitis B vaccines in infants from birth to six months of age. Pediatr Infect Dis J. 2000;21(5):399–405. doi: 10.1097/00006454-200205000-00010. [DOI] [PubMed] [Google Scholar]

[b1-prm12121] 1.Breen A, Carr E, et al. “Acute back pain management in primary care: a qualitative pilot study of the feasibility of a nurseled service in general practice.”. Journal of Nursing Management. 2004;12:201–209. doi: 10.1111/j.1365-2834.2004.00469.x. [DOI] [PubMed] [Google Scholar]

[b2-prm12121] 2.Breen A, Austin H, Campion-Smith C, Carr ECJ, Mann E. “You feel so hopeless”: A qualitative study of GP management of acute back pain. European. Journal of Pain. 2007;11:21–29. doi: 10.1016/j.ejpain.2005.12.006. [DOI] [PubMed] [Google Scholar]

[b3-prm12121] 3.This work has subsequently been successful in acquiring a grant from the Health Foundation (UK) for a three year project to extend and develop it further. A short summary will be included.

PERMALINK

Poster Abstracts

P1: Pain, Fear of Pain, and Disability: A Repeated Measures Analysis with a Tertiary Treatment Sample

Murray P Abrams, B.A.Hons

R Nicholas Carleton, M.A.

Shane S Kachur*, BMR(P.T.)

Gordon J G Asmundson, Ph.D.

Abstract

P2: A Suggested Abbreviation of the Pain Coping Questionnaire (PCQ)

S Ahola

R Pillai Riddell

GJ Reid

C Chambers

Abstract

AIM:

METHODS:

RESULTS:

CONCLUSIONS:

P3: Enhanced Delta Opioid Receptor-Mediated Antinociception Following Prolonged Morphine Treatment: The Role of Spinal Glial Activation

SA Armstrong, VT

SV Holdridge, BScH

AMW Taylor, BScH

CM Cahill, PhD

Abstract

P4: Long-Term Open Label Extension of a Double-Blind, Randomized, Placebo-Controlled Trial of Controlled Release (CR) Tramadol (Zytram XL®) in Patients with Chronic Osteoarthritis Pain

Andre Beaulieu, MD

William O'Mahony, MD

Carter Thorne, MD

John Sibley, MD

John Bartlett, MD

Gunnar Kraag, MD

Paula S Piraino, Ph.D.

John Eisenhoffer, MD

Zoltan Harsanyi, MBA

Andrew C Darke, Ph.D.

Abstract

AIM:

METHODS:

RESULTS:

CONCLUSION:

Acknowledgments

P5: Development and Evaluation of a Hospital Chronic Pain Consultation Service

J Boyd, MSN

AJ Clark, MD

PA Taenzer, PhD

CC Spanswick, MB ChB

S Chary, MB BS

V Wiebe, MN

Abstract

AIM:

METHODS:

RESULTS:

CONCLUSIONS:

P6: Improving the Management of Low Back Pain in the Community Using Collaborative Action Learning Groups.

E Carr, BSc (Hons) RGN, PGCEA, RNT, MSc, PhD

A Breen, PhD, DC

C Campion-Smith, MB, ChB, FRCGP

H Austin, RGN, HV

E Mann, BSc, PGCHE, RGN, SCM

Abstract

AIMS:

BACKGROUND AND SIGNIFICANCE:

METHOD:

RESULTS:

CONCLUSIONS:

References

P7: Reconceptualizing ‘Professionalism’: Why Chronic Pain Service Providers Need to Rethink the Affective Domain

Cary A Brown, BMR, MA, PhD

Abstract

INTRODUCTION:

AIM:

METHOD:

RESULTS:

CONCLUSION:

REFERENCES

P8: Chronic Pain and Complexity: The Beliefs of People with Pain and Service Providers

Cary A Brown, BMR, MA, PhD

Abstract

INTRODUCTION:

AIM:

P4: Long-Term Open Label Extension of a Double-Blind, Randomized, Placebo-Controlled Trial of Controlled Release (CR) Tramadol (Zytram XL^®) in Patients with Chronic Osteoarthritis Pain