Canadian Pain Society Conference May 12 – 15, 2010, Calgary, Alberta

Pain Res Manag. 2010 Mar-Apr;15(2):73.

1 Breaking Barriers In Breakthrough Cancer Pain

Neil Hagen ^1,^2,³, Dwight Moulin ^1,^2,³, Bruno Gagnon ^1,^2,³

Abstract

Learning Objectives:

Review the pathophysiology and characteristics of breakthrough cancer pain, its prevalence and its distinction from baseline pain.
Discuss the current management of breakthrough cancer pain in Canada, its strengths and its limitations.
List attributes of a new class of drugs - rapid onset opioids - and outline how they are used in clinical practice.

BRIEF DESCRIPTION:

Breakthrough cancer pain is phenomenologically distinct from persistent chronic cancer pain, and requires different management strategies. While baseline cancer pain is typically fairly steady, breakthrough cancer pain is commonly sudden in onset, typically reaching peak intensity after about 3 minutes. Episodes of breakthrough cancer pain can be predictable, but in approximately 80% of patients, breakthrough pain occurs unpredictably. (1) Physicians treating cancer patients need to undertake a proper assessment of pain in order to ensure appropriate pain management. Results from one survey suggested that only 25% of patients with breakthrough pain are satisfied with pain control compared to 78% of patients without breakthrough pain. (1) Difficulties in identifying breakthrough pain, and the availability of new emerging therapy justify the need for attention to gaps in current diagnosis and treatment, and implementation of measures to reduce these gaps.

REFERENCES

1.Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999;81(1–2):129–134. doi: 10.1016/s0304-3959(99)00006-8. [DOI] [PubMed] [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):73.

1A Pathophysiology and Characteristics of Breakthrough Cancer Pain

Dwight Moulin ¹

Pain Res Manag. 2010 Mar-Apr;15(2):73.

1B Managing Breakthrough Cancer Pain – Current Practice, Gaps in Treatment Management

Bruno Gagnon ¹

Learning Objectives:

Be aware of the methodology used to develop the NOUGG guideline
Gain knowledge about the guideline recommendations
Be aware of actions underway to implement the guideline to practice

Pain Res Manag. 2010 Mar-Apr;15(2):75.

4A The Development of the Nougg’s Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Andrea D Furlan ¹

Abstract

BRIEF DESCRIPTION:

In 2000, the College of Physicians and Surgeons of Ontario (CPSO) released the ‘Evidence-based Recommendations for Medical Management of Chronic Non-malignant Pain’. Building on efforts underway to update this CPSO material, in late 2007 the National Opioid Use Guideline Group (NOUGG) took on responsibility to develop and implement a Canadian guideline. NOUGG engaged a research team to update the guideline’s methods, a task that involved two new literature searches and subsequent revision of practice recommendations to reflect new evidence. In addition, NOUGG facilitated the work of a national advisory panel of first responders to the draft guideline, using a facilitated consensus process to add expert opinion to the guideline. Recommendations for practice were developed to be useful - address questions and concerns that mirror real clinical issues, and evidence-based - accompanied by explanation of the evidence that supports the recommendation.

Pain Res Manag. 2010 Mar-Apr;15(2):75.

4B Key Messages from the Nougg Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Angela Mailis-Gagnon ¹

Abstract

BRIEF DESCRIPTION:

Review recommendations that address several themes:

- Deciding to initiate opioid therapy
- Conducting an opioid trial
- Monitoring long-term opioid therapy
- Treating specific populations
- Managing opioid misuse and addiction

Pain Res Manag. 2010 Mar-Apr;15(2):75.

4C Implementing the Nougg Guideline to Practice

Clarence Weppler ¹

Abstract

BRIEF DESCRIPTION:

From its inception, NOUGG saw guideline development as only a first step. NOUGG articulated an additional goal to “Develop and implement a knowledge transfer strategy that ensures the guideline moves into practice as a useful decision-making tool for physicians who treat patients with chronic non-cancer pain”. An effective implementation plan was required to make it feasible and easy for physicians to use the guideline in demanding day-to-day practice environments. NOUGG members started work on implementation while the guideline was still in development, and sought support from national partners with experience in knowledge transfer. Early on, NOUGG completed a scan to identify the ‘potential’ that existed across Canada to implement the guideline to practice. Information derived from this scan was organized into eight categories:

College-driven practice enhancement services and programs
Web-based potential
Prescription monitoring systems
Academic partners
Provincial or regional initiatives (including provincial health ministries)
Multi-stakeholder initiatives (potential ‘allies’)
First Nations initiatives
National initiatives

Working with numerous partners, NOUGG developed national and local approaches to support implementation of the guideline to practice.

Pain Res Manag. 2010 Mar-Apr;15(2):75.

5 Using the Alberta Primary Care Low Back Pain Guideline in Practice

Paul Taenzer ^1,², Ted Findlay ^1,², Christa Harstall ^1,²

Abstract

WORKSHOP OBJECTIVE:

Over their lifetimes nearly everyone will experience at least one episode of low back pain. While low back pain is typically self-limiting and resolves in a few days to several weeks, recurrent and chronic low back pain are common and lead to frequent consultations with primary care health professionals. Undergraduate programs for most health care disciplines provide minimal training in managing back pain and practicing professionals report little confidence in their ability to manage back pain.

Clinical practice guidelines are a strategy to summarize research evidence and expert opinion to assist health care providers with clinical decision making. The Alberta Primary Care Low Back Pain Guideline was developed by a multidisciplinary team of health care providers and researchers using a standardized procedure for adapting existing guidelines to new practice settings.

The workshop will use a multidisciplinary team of facilitators to engage with participants to work through a typical primary care case of low back pain. The intention is to direct the discussion to sharing leading practices and consideration of knowledge gaps and emerging evidence.

Questions to address during the interactive workshop:

Discuss practice domains where high quality evidence is lacking and where it is emerging
Share strategies and challenges for implementing the guideline recommendations

Learning Objectives:

To understand the methodology used to develop the guideline.
To be aware of what constitutes the evidence underlying the guideline recommendations.
To apply the guideline while considering a typical primary care case.

Pain Res Manag. 2010 Mar-Apr;15(2):75–76.

6 Developing a Pain Management Team in Primary Care: The Calgary Foothills Primary Care Network Pain Management Team

Chris Spanswick ^1,², Isabel Martin ^1,², Yolanda Martens-van Hilst ^1,²

Abstract

WORKSHOP OBJECTIVE:

The aim of this workshop is to introduce the Calgary Foothills Primary Care Network (CFPCN) multidisciplinary pain management team, and discuss the challenges and successes associated with developing this team and opening a pain management clinic. The CFPCN multidisciplinary pain management team was created to support CFPCN physicians and other health care providers in the community in caring for their patients with non-complex chronic pain. The team is focused on early intervention for patients with non-complex chronic pain, to prevent deterioration and the need for such patients to utilize the Calgary Chronic Pain Centre. This is done by optimizing multidisciplinary care and use of community resources in a primary care setting.

Learning Objectives:

At the end of the workshop, the participant will be aware of chronic pain management, the barriers to effective treatment of patients with chronic pain, and the limitations in the resources currently available for the treatment of patients with non-complex chronic pain in primary care.
At the end of the workshop, the participant will know how to develop a multi-disciplinary chronic pain team within a primary care network.
At the end of the workshop, the participant will know the roles of each health-care provider in the treatment of chronic pain, and how to effectively utilize each team member to contribute to the success of the patient.

Learning Objectives:

List the differential diagnosis of a patient who presents with chronic buttock and low back pain and describe the symptoms, signs and investigations that differentiate the source of buttock and low back pain.
Demonstrate the surface anatomy and examination of possible sources of pain within the low back and buttock.
Use a pain diagram and examination techniques to determine if there is a neuropathic component to the pain.

Pain Res Manag. 2010 Mar-Apr;15(2):76.

7A What Kind of Pain is it?

Pam Squire ¹

Abstract

BRIEF DESCRIPTION:

Low back and buttock pain is commonly described as non-specific when no apparent cause for the pain can be found. Traditionally non-specific pain has been conceptualised as being inflammatory or mechanical in nature, but this approach has done little to improve outcomes in patients with chronic pain. Advances in understanding the neuropathology of pain offer a new approach to the diagnosis and treatment of low back and buttock pain, with the realisation that neuropathic pain may arise locally or centrally and present in this region, or arise locally and present more distally in the lower limb. Dr Squire will discuss the diagnosis of neuropathic pain in the low back, buttock and lower limb and demonstrate examination techniques that will enable the participants to identify neuropathic components to low back and buttock pain.

Pain Res Manag. 2010 Mar-Apr;15(2):76.

7B Where Does it Come from?

Understand the impact of unresolved acute pain.
Review why moderate to severe chronic pain may be undertreated both pharmacologically and non-pharmacologically.
Understand that patient and physician barriers can lead to the under treatment of pain.
Determine if the pathophysiology of pain supports a multipathway approach.

Pain Res Manag. 2010 Mar-Apr;15(2):77.

11 Measuring Functionality in Fibromyalgia: Why Should We Do It, What Are We Measuring And Who Do We Do It For?

Pam Squire ^1,^2,^3,⁴, Owen Williamson ^1,^2,^3,⁴, Janice Sumpton ^1,^2,^3,⁴, Dwight Moulin ^1,^2,^3,⁴

Abstract

Learning Objectives:

At the end of this program, participants will be able to:

Describe why assessing a patient’s function is important and how it could be done.
Recognize the differences between a physician and patient’s perspective on the impact of Fibromyalgia on functionality and formulate explanations for when functionality reports differ between physicians and patients.
Implement functional assessments into the routine care of FM patients.

BRIEF DESCRIPTION:

It is accepted that improved functioning is a key component of any patient with a chronic pain condition like Fibromyalgia. The challenge becomes making functional assessments a routine part of care that will optimize a patient’s outcome. This symposium will address questions such as: What is functioning? Why is it important to assess functioning? What are simple, valid tools to use? How are functionality tools interpreted and how might they impact a treatment plan? A patient will also highlight the significant impact of FM on her life.

Pain Res Manag. 2010 Mar-Apr;15(2):77.

12 Pain – Current Debates

Michael McGillion ¹

Pain Res Manag. 2010 Mar-Apr;15(2):77–78.

12A Learning, Memory and Brain Plasticity in Chronic Pain

Herta Flor ¹

Abstract

Learning Objectives:

Participants will learn that:

Memory and learning processes are essential for the understanding of chronic pain.
These memory processes lead to maladaptive plastic changes in the nervous system.
Treatments for chronic pain must focus on these memory and plasticity processes.

BRIEF DESCRIPTION:

Recently, many similarities have been identified between chronic pain and memory processes and it has been shown that plastic alterations in the central nervous system are a frequent sequel of extended states of pain. We suggest that learning processes, specifically implicit learning such as sensitization, pavlovian and instrumental conditioning but also explicit memory processes, play a major role in the development and maintenance of chronic pain. A characteristic of some of these learning processes is that they occur outside the patient’s awareness and are therefore difficult to detect and modify but greatly influence subsequent behavior and perception. There is convincing evidence that enhanced perceptual sensitisation as evidenced by exaggerated pain ratings is present after repetitive or longstanding painful stimulation in chronic pain patients whereas healthy controls tend to habituate. This sensitisation creates pain memory traces in the brain that upregulate the subsequent processing of both painful and non-painful stimuli. Functional magnetic resonance imaging, magnetoencephalographic recordings and multi-channel EEG recordings revealed enhanced activity in multiple brain areas that are correlated with pain ratings as well as psychological variables such as catastrophizing or affective distress. Furthermore, in neuropathic pain states such as phantom limb pain or complex regional pain syndrome alterations in the cortical map representing the pain-affected body site are closely related to pain intensity ratings. Chronic pain before nerve injury or deaf-ferentation rather than acute pain at the time of the injury or amputation is the best predictor of later neuropathic pain confirming the notion of long-lasting pain memories. Studies involving aversive pavlovian and operant conditioning paradigms revealed that central pain memories can be enhanced by these learning variables and that chronic pain patients show faster acquisition and delayed extinction of both peripheral and central pain-related responses with concurrent changes in brain areas involved in both the sensory and affective processing of pain. In this context it has been shown that the responses of and modelling by significant others have also a powerful influence on pain intensity, pain behaviours and brain-related responses to pain and that social variables must be taken into account in models of pain chronicity. These data confirm the view that learning processes may be more important for the acquisition and maintenance of chronic pain than peripheral nociceptive input. Therapeutic implications of these findings suggest that pain treatments must start early and that acute pain should be adequately controlled in order to prevent the onset of chronicity. Treatments of chronic pain should focus on the extinction of these aversive pain memories and can involve both pharmacological interventions designed to prevent or reverse maladaptive plasticity and behavioral intervention such as mirror training, imagery or sensory discrimination that behaviourally alter pain-related memory traces. The combination of substances that aid in the extinction of pain memories with extinction training might offer especially interesting new therapeutic possibilities.

Pain Res Manag. 2010 Mar-Apr;15(2):78.

12B What’s Wrong with Animal Models of Pain?

Jeffrey S Mogil ¹

Abstract

Learning Objectives:

Appreciate the epidemiological disconnect between common human chronic pain disorders (and their symptoms) and commonly used animal models of them.
Learn how facial expressions of pain may be used as a new dependent measure of pain in animals.
Learn about recently developed animal models of migraine and vestibulodynia.

BRIEF DESCRIPTION:

Recent decades have seen an explosion in our understanding of the molecular and cellular underpinnings of pain, but virtually none of this knowledge has resulted in new clinical therapies. Many pain researchers believe that the problem may lie in the existing animal models of pain, which are reliable but much more complex and subtle than is commonly realized, and of questionable clinical relevance. Most basic science studies of pain continue to rely on the measurement of reflexive, evoked hypersensitivity responses after artificial neuropathic or inflammatory injuries, whereas clinical pain in humans features much spontaneous pain and an important cognitive and emotional overlay. In addition to the disconnect between clinical symptoms and animal measures, there is a disconnect between the clinical epidemiology of pain and the types of pain being modeled in animals. We have recently attempted to develop an “ethological” approach to animal models of common pain pathologies, involving systematic and rigorous analysis of videotaped spontaneous mouse behaviors. I will talk about some recent successes in our laboratory, involving migraine, vestibulodynia, and the development of a facial expression-based pain scale for the mouse.

Pain Res Manag. 2010 Mar-Apr;15(2):78.

13 Unraveling Human Complex Persistent Pain Conditions

Yoram Shir ¹, William Maixner ¹

Abstract

Learning Objectives:

To become knowledgeable in current concepts associated with etiological pathways associated with complex persistent pain conditions
To become knowledgeable in how to assess the biopsychosocial and molecular pathways that underlie heterogeneous complex persistent pain conditions.
To become knowledgeable of the emerging concepts and technologies that may improve the diagnosis and treatment of patients with complex persistent pain conditions.

BRIEF DESCRIPTION:

Pain perception is one of the most complicated measurable traits because it is an aggregate of several phenotypes associated with peripheral and central nervous system dynamics, stress responsiveness and inflammatory state. As a complex trait, it is expected to have a poly-genic nature shaped by environmental pressures. Dr. Maixner will discuss emerging concepts and knowledge of the contribution of genetic variants, including recent discoveries that emphasize a genetic contribution to human pain perception and clinical pain phenotypes (1,2). He will present findings from recently completed (3,4) and ongoing (see www.oppera.org) cross-sectional and prospective studies that examine the biopsychosocial and genetic factors contributing to the onset and maintenance of a common persistent pain condition that is comorbid with many other common persistent pain conditions. Finally, he will discuss emerging technologies that will prove useful in unraveling the pain genetic networks in subpopulation of patients with persistent pain conditions.

REFERENCES

1.Diatchenko L, Nackley AG, Slade GD, Fillingim RB, Maixner W. Idiopathic pain disorders--pathways of vulnerability. Pain. 2006;123:226–230. doi: 10.1016/j.pain.2006.04.015. [DOI] [PubMed] [Google Scholar]
2.Diatchenko L, Nackley AG, Tchivileva IE, Shabalina SA, Maixner W. Genetic architecture of human pain perception. Trends Genet. 2007;23:605–613. doi: 10.1016/j.tig.2007.09.004. [DOI] [PubMed] [Google Scholar]
3.Diatchenko L, et al. Catechol-O-methyltransferase gene polymorphisms are associated with multiple pain-evoking stimuli. Pain. 2006;125:216–224. doi: 10.1016/j.pain.2006.05.024. [DOI] [PubMed] [Google Scholar]
4.Diatchenko L, et al. Genetic basis for individual variations in pain perception and the development of a chronic pain condition. Hum Mol Genet. 2005;14:135–143. doi: 10.1093/hmg/ddi013. [DOI] [PubMed] [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):78–79.

14 Success in Scientific Manuscript Publication: Pearls and Perils of Publishing

Sheila O’Keefe McCarthy ^1,², Ken Craig ^1,², Christine Chambers ^1,²

Abstract

WORKSHOP OBJECTIVE:

There are approximately 3000 doctoral and post doctoral students in Canada. Less than half of those are actively engaged in competitive, peer-reviewed scientific manuscript writing, a recognized benchmark of success, and still fewer who specialize in pain research. Many graduate students find it a challenge to be successful in publishing while doing course work and completing academic and scientific research. The aim of this student trainee workshop is to provide strategies how to navigate and strategize for successful manuscript publication.

Learning Objectives:

Provide publishing tips and strategies from a journal editor’s perspective eager to see researchers’ papers
Discuss what mentoring a new researcher requires in order to be successful in scientific publishing
Provide experiental examples of successful publication from a clinical and/or basic pain scientist’s perspective
Provide trainees a viable strategy to make writing a priority

Pain Res Manag. 2010 Mar-Apr;15(2):79.

14A

Ken Craig ¹

Abstract

BRIEF DESCRIPTION:

At least 50 major journals are dedicated to pain research and close to 1,000 journals publish pain-related research. They need your manuscripts and will work with you to bring scientific understanding to pain relief. But basic expectations must be met. An understanding of editors’ requirements, the review process, and reviewer mandates can greatly improve the likelihood of success.

Pain Res Manag. 2010 Mar-Apr;15(2):79.

14B

Christine Chambers ¹

Abstract

BRIEF DESCRIPTION:

RESULTS:

204 patients were assessed (males 74.5%, median age 40 years (range 18–67 years), major trauma (ISS>15) 27.5%). Median (interquartile range) pain scores at baseline, 3 and 12 months respectively were 3 (2–6), 2 (1–3) and 2 (0–3). Although overall pain scores improved from baseline to 3 months (p<0.001) and did not change from 3 to 12 months (p=0.68), pain scores deteriorated by ≥2 points in 12.3% and improved by ≥2 points in 23.5% of patients from 3 to 12 months. Deterioration was associated with increased catastrophizing (p=0.003) and decreased pain control (p=0.022) but not changes in anxiety or depression.

CONCLUSIONS:

Individual pain trajectories, associated with differing psychological responses to pain, can be identified within a trauma population. Further studies of individual trajectories might lead to improvements in population pain outcomes.

Pain Res Manag. 2010 Mar-Apr;15(2):80–81.

16 Like Nailing Jell-O to a Tree: Acute Pain Management in Difficult Circumstances

Saifee Rashiq ^1,^2,³, Kathryn Dong ^1,^2,³, Yoanna Skrobik ^1,^2,³

Abstract

WORKSHOP OBJECTIVE:

This interactive session is about circumstances in which the act of relieving acute pain is made difficult or impossible by factors other than a lack of technical know-how. What happens when you have to choose between being effective, correct, practical, ethical, expedient and safe? Hear front-line clinicians tell you how they do it, and how they’d like to see it done better. Bring a story and an opinion!

Learning Objectives:

After participating in this session, participants will better understand the principles of pain control in illegal substance users/those who appear to be “drug-seeking” in the ED.
After participating in this session, participants will be able to assess and manage pain in a sedated ICU patient with confidence.
After participating in this session, participants will be challenged to think of ways in which evidence based techniques can be deployed in their own institutions to make acute pain management better.

Pain Res Manag. 2010 Mar-Apr;15(2):81.

16A Pain, Suspicion and Substance Abuse in the ED

Kathryn Dong ¹

Abstract

BRIEF DESCRIPTION:

“Morphine 2.5 - 5 mg IV prn & Gravol 25–50 mg IV q4h prn” are the most commonly written emergency department orders for pain control. What happens, though, if your patient commonly injects him or herself with 100 mg (or a “grey”) of morphine at a time? Most commonly this leads to conflict between the physician or nurse and the patient who is constantly asking for more analgesia. The ultimate outcome is likely to be poor pain control for the patient, possible withdrawal, and a future reluctance to present for medical care when it is needed.

Pain Res Manag. 2010 Mar-Apr;15(2):81.

16B To Sleep, Perchance To Scream…

Yoanna Skrobik ¹

Abstract

BRIEF DESCRIPTION:

Effective pain management in the ICU is not merely humane. In this session, evidence that adequate analgesia actually improves survivor outcome will be presented. Effective ways to assess pain in the sedated ICU patient will be described, and original Canadian research data will be used to show that simple changes in culture can yield big improvements in pain-related care.

Pain Res Manag. 2010 Mar-Apr;15(2):81.

16C Is There a Better Way?

Saifee Rashiq ¹

Abstract

BRIEF DESCRIPTION:

RESULTS:

Healthcare utilization patterns resembled a roller-coaster ride with increased visits at times of stressful life events, financial insecurity and mood disorders. Healthcare utilization fell when major conflicts (lawsuits, acceptance of disability) were resolved and some financial stability was achieved.

CONCLUSIONS:

Physicians, insurers, lawyers and employers may be contributing to patients’ pain and disability by adopting a disbelieving and confrontational approach that is absent in patients suffering other more “visible” disabilities. Better training of physicians in understanding chronic pain as a valid medical condition, teaching patients how to manage stress using self-education, mind-body or psychological therapies may help. However widespread changes to insurance and legal systems might avoid this destructive ride.

FOOTNOTES/REFERENCES:

1.Dubin RE, King-VanVlack C. The Trajectory of chronic pain: can a community-based exercise/educations program soften the ride. Pain Res Manage. 2009 doi: 10.1155/2010/617129. in press. [DOI] [PMC free article] [PubMed] [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):82.

18 Student Presentations

Dean Tripp, Marta Ceko, Valerie Cotton, Samantha Fuss, Adam Samosh, Sarah Walker

Pain Res Manag. 2010 Mar-Apr;15(2):82.

18A Investigation of Confounds in Human Dnic Studies

Marta Ceko ¹, Marissa Lapedis ¹, M Catherine Bushnell ¹, Petra Schweinhardt ¹

Abstract

AIM:

Diffuse noxious inhibitory control (DNIC), i.e. pain inhibits pain, is a well described phenomenon in animals. DNIC is commonly tested in humans by applying a test stimulus before (TS1) and during or after (TS2) a painful conditioning stimulus (CS). If TS2 is perceived as less painful than TS1, DNIC is thought to have occurred. Testing DNIC during the CS, however, is problematic because TS2 might be perceived as less painful due to distraction caused by the painful CS. Therefore, TS2 is sometimes applied after the CS, but none of these studies employed a control condition with a non-painful CS. We aimed at comparing DNIC in an experimental and a control condition.

METHODS:

Subjects: 13 women (age 21–63, mean+/–SD: 43+/–13.6). Design: Within-subject, counter-balanced crossover. TS1: 9 short stimuli (44, 46, 48°C; 3x each) on the forearm (3 loci, pseudorandomized). CS: Immersion of contralateral arm in 10°C (experimental condition) or 32°C water (control condition). TS2: Applied 1 min after the CS. Pain ratings: 0–200.

RESULTS:

Compared to TS1, TS2 was rated as significantly less painful in the experimental (46°C: p=0.04; 48°C: p=0.04) as well as in the control condition (46°C: p=0.02; 48°C: p=0.02). Importantly, the change in pain ratings did not differ between conditions (46°C: p=0.97; 48°C: p=0.69).

CONCLUSIONS:

While replicating several human DNIC studies, i.e. painful CS reduces subsequent pain, we found a similar pain reduction after a non-painful CS. This raises the question whether the observed reduction is driven by DNIC. Novel, well-controlled paradigms are needed to demonstrate DNIC in humans.

Pain Res Manag. 2010 Mar-Apr;15(2):82.

18B The Impact of Long-Term Yoga Practice on Experimental Pain Perception

Valerie Cotton ¹, Chantal Villemure ², MC Bushnell ²

Abstract

AIM:

Yoga practice integrates physical discipline, mental training and moral principles to encourage a healthy and holistic way of living. The emotional and cognitive tools developed in yoga practice could potentially alter a person’s relationship with pain, particularly their affective reaction to pain. In this study, we test the hypothesis that regular yoga practice alters the affective reaction to pain.

METHODS:

We evaluated the pain perception of nine yoga practitioners, who had been practicing regularly for at least six years, and eight sedentary control subjects. Subjects were matched for Body Mass Index, exercise hours per week, education, age and sex. Cool and warm detection thresholds and cold and heat pain thresholds were evaluated using a TSA Medoc contact thermode and the method of limits (3 trials per measure). Pain tolerance was tested twice by asking subjects to submerge their hand in a cold circulating water bath (∼5°C) for as long as they could, up to a maximum of two minutes. The geometric means of each variable were calculated for each group and submitted to ANOVAs.

RESULTS:

The yoga and control group significantly differed only in terms of their tolerance to pain (for thresholds all p’s>0.16). The yoga group kept their hand in the cold water more than three times as long as the controls (Mean±SE: Yoga=87s±10; Control=25s±11; F(1,15)=17.4; p<0.0009).

CONCLUSIONS:

The equivalent thresholds and increased pain tolerance found in yoga practitioners confirms that regular yoga practice influences affective reaction to pain.

Pain Res Manag. 2010 Mar-Apr;15(2):82.

18C Prevalence and Frequency Characteristics of Pain in a Community Sample of Children and Adolescents

Samantha Fuss ¹, Gabrielle Pagé ¹, Andrea Martin ¹, Sarah Ritvo ¹, Suzy Malakhi ¹, Joel Katz ¹

Abstract

AIM:

Previous epidemiological research conducted in Europe has demonstrated that approximately 25–30% of children and adolescents have experienced persistent pain [1, 2]. Very little is known about the incidence of persistent pain among Canadian youth.

The purpose of this study was to ascertain the prevalence and frequency characteristics of pain in a Canadian community sample of children and adolescents between the ages of 8–18.

METHODS:

English-speaking individuals were recruited to participate in this study which took place at the Ontario Science Centre (Toronto, Canada). Participants completed a pain history questionnaire created for this project that assessed chronicity and frequency of pain experiences.

RESULTS:

Of 1006 participants (54% female) with a mean age of 11.2 years (SD = 2.69), 27.6% reported having pain that lasted for longer than three months. In terms of frequency of reported pain, 18.6% experienced no pain, 29.1% experienced pain less often than once a month, 27.4% experienced pain once or twice a month, 19% experienced pain once or twice a week and 5.8% experienced pain everyday.

CONCLUSIONS:

The prevalence of persistent pain in the present sample is consistent with previous research. A sizeable proportion of children and adolescents report experiencing pain on a weekly basis.

FOOTNOTES/REFERENCES:

1.Perquin CW, et al. Pain in children and adolescents: a common experience. Pain. 2000;87(1):51–58. doi: 10.1016/S0304-3959(00)00269-4. [DOI] [PubMed] [Google Scholar]
2.Roth-Isigkeit A, et al. Pain Among Children and Adolescents: Restrictions in Daily Living and Triggering Factors. Pediatrics. 2005;115(2):e152–162. doi: 10.1542/peds.2004-0682. [DOI] [PubMed] [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):83.

18D Safety of Intravenous Lidocaine Infusions for Treatment of Chronic Neuropathic Pain

Adam Samosh ¹, Patricia K Morley-Forster ², Dwight E Moulin ³, Katherine Ower ⁴, James T Watson ⁵

Abstract

AIM:

The purpose of this study was to determine the frequency of side effects in adult outpatients receiving an intravenous infusion of lidocaine for treatment of chronic neuropathic pain. This is the first prospective examination of hemodynamic and central nervous system (CNS) side effects.

METHODS:

All ambulatory patients scheduled for a lidocaine infusion between June 15 and August 21, 2009 at the St. Joseph’s Outpatient Pain Clinic were included in this prospective study (n=46). The dose used was 5 mg per kg of lean body weight determined from their height and weight using the James formula infused over 45 minutes. The infusion was controlled by Alaris Medical system. Monitoring included oximetry, non-invasive blood pressure, and ECG recorded at baseline and Q 5 minutes until 30 minutes post-infusion. Sedation, nausea and dizziness were solicited and measured by VAS from 0–100 mm Q 15 minutes. All other reported side effects were measured Q 15 minutes. Cardiac, CNS, and hemodynamic adverse events were defined and recorded. Observation was continued for 30 minutes post-infusion including presence of postural hypotension. Patients were asked to record in a diary any side effects up to 7 days following infusion.

RESULTS:

Mean dose of lidocaine administered was 268 ± 59 mg; mean age was 51.5 ± 13.6 yrs. Most common side effects during the infusion were sedation (72%), nausea (22%), mild to moderate dizziness (39%) and dry mouth (28%). Intensity of sedation increased significantly as the infusion progressed. No significant adverse events occurred. Fatigue was experienced during post-infusion week in 22% of subjects.

CONCLUSIONS:

Lidocaine infusions of 5 mg/kg are safe and well tolerated in this outpatient population.

FOOTNOTES/REFERENCES:

1.http://www.halls.md/body-mass-index/leanbody.htm

Pain Res Manag. 2010 Mar-Apr;15(2):83.

18E The Association Between Psychological Characteristics and Pain in Women Waiting for Gynaecological Surgery

Sarah Walker ¹, Wilma M Hopman ², Margaret B Harrison ³, Elizabeth G VanDenkerkhof ⁴

Abstract

AIM:

Pain prior to surgical management is frequently a problem for women with gynaecological conditions. Psychological factors also influence an individual’s experience of pain. Minimal research was found that examined pain and psychological symptoms in this population. The primary objective was to examine levels of pain intensity and pain interference in women awaiting gynaecological surgery, and secondarily to examine psychological factors associated with pain, specifically anxiety, depression, somatization and catastrophizing.

METHODS:

Participants included 429 women in a tertiary care centre in southeastern Ontario. Anxiety was measured using the State Trait Anxiety Inventory (STAI), depression with the Centre for Epidemiologic Studies Depression Scale (CES-D), somatization using the Seven Symptom Screening Test (SSST) and catastrophizing was measured using an abbreviated coping strategies questionnaire (CSQ). Pain was assessed using the Brief Pain Inventory (BPI).

RESULTS:

Eighteen percent of women had a high anxiety score, 37.1% demonstrated a risk of depression needing treatment, 46.6% of women had ≥2 symptoms of somatization and 40.1% of women were high catastrophizers. A moderate to severe pain intensity score occurred in 30.5% of participants and 31.5% had a moderate to severe pain interference score. Of the women that experienced pain in the last week, 81.4% believed their pain was due to their primary condition. In multivariable analysis, depression, somatization and catastrophizing were all associated with elevated levels of pain intensity and interference; younger age was associated with interference but not intensity.

CONCLUSIONS:

This study supports the need for appropriate preoperative assessment of physical and psychological symptoms that present while waiting for surgery. This assessment will benefit the patient through reducing complications and improve patient outcomes.

Pain Res Manag. 2010 Mar-Apr;15(2):83.

19 The Impact of Stereotypes and Stigma on the Assessment and Treatment of Patients with Pain

Diane LaChapelle ^1,², Susan Lavoie ^1,², Bruce Dick ^1,²

Abstract

WORKSHOP OBJECTIVE:

To present data from laboratory and clinical studies relating to how stereotypes and stigma influence perceptions of patients with pain and, in turn, how these perceptions influence the assessment and treatment of patients. The goal is to increase awareness of how unconscious biases may influence clinical practice and to provide strategies for reducing the impact of stereotypes and stigma.

Learning Objectives:

Participants will be able to identify:

The most commonly held stereotypes about patients with pain
How stereotypes influence assessment and treatment decisions
Strategies to reduce the potential impact of stereotypes and stigma in clinical practice

Pain Res Manag. 2010 Mar-Apr;15(2):83.

19A Commonly Held Stereotypes about Adults with Pain: Evidence from the Lab and Clinic

Susan Lavoie ¹

Abstract

BRIEF DESCRIPTION:

The multidimensional and subjective nature of pain can cause even the most highly trained professional, well-intentioned family member, or lay observer to be influenced by a variety of factors that are either unrelated to the patient’s pain condition or are inadequate indicators of the patient’s level of pain and disability. The existing stereotype literature related to the influence of patient (attractiveness and perceived personal responsibility for onset and offset of pain condition), illness (presence or absence of visible cues to disability and the degree to which there is supporting objective medical evidence) and observer (attributional style and experience with pain) characteristics on perceptions of patients with pain will be presented. Data from laboratory- and clinically-based studies will be presented in relation to how these stereotypes influence the judgements made by both the general public and health professionals about men and women with chronic pain. Research findings will be discussed in the context of a unifying theoretical model. Lastly, the practical impact that stereotypes and stigma exert on patients’ lives will be explored.

Pain Res Manag. 2010 Mar-Apr;15(2):83–84.

19B Stigma in Children and Adolescents with Chronic Pain

Bruce Dick ¹

Abstract

BRIEF DESCRIPTION:

Stigma is an important problem faced by many individuals with chronic pain. In the adult chronic pain literature, stigma has been found to be associated with increased depression, decreased self-esteem, strained interpersonal relationships, and lower quality of life. Unfortunately, the presence of stigma is often ignored and sometimes even denied in this population. While there is increasing interest in stigma in the adult literature, there is a true dearth of research on stigma in pediatric and adolescent chronic pain populations. Studies of stigma in pediatric and adolescent medical populations affected by HIV/Aids, epilepsy, obesity, depression and other forms of mental illness, have found that stigma affects a child’s self-concept and increases the risk of depression. Many individuals receiving health care services in our Pediatric Chronic Pain Program at the Stollery Children’s Hospital have reported the presence and negative impact of stigma in their lives. As a result, we have adapted an adult scale assessing stigma in chronic pain for children and teens with chronic pain. The Children’s Chronic Pain Stigma Scale (CCPSS) assesses perceived stigma levels from physicians, teachers, family members, and the general public. Data collected using the CCPSS will be presented with a discussion of differences in perceived stigma between target groups. Associations between stigma and age, diagnosis, pain chronicity, disability, and mental health will be presented along with a statistical model of how these factors interact. Clinical methods aimed at decreasing stigma and its effects on children and adolescents will also be presented.

Pain Res Manag. 2010 Mar-Apr;15(2):84.

20 Proteinase Activated Receptors and Pain

Fiona Russell ^1,², Zsuzsanna Helyes ^1,², Nicolas Cenac ^1,²

Abstract

Learning Objectives:

To review how the different proteinase activated receptors (PARs) are involved in different types of pain.
To show the intricate links between PARs, TRP channels and kinin receptors on sensory nerves.
To explore the different PAR-induced mechanisms involved in visceral pain and joint inflammatory pain.

Pain Res Manag. 2010 Mar-Apr;15(2):84.

20A Involvement of Capsaicin-Sensitive Fibres, TRPV1 Receptors and Tachykinins in Par 2-Induced Joint Inflammation and Nociception

Zsuzsanna Helyes ¹

Pain Res Manag. 2010 Mar-Apr;15(2):84.

20B Regulation of Trpv4 Functions by Proteases: Implication in Visceral Pain

Nicolas Cenac ¹

Pain Res Manag. 2010 Mar-Apr;15(2):84.

21 Ultrasound in Pain Medicine

Philip Peng ^1,², Peter Cheng ^1,²

Abstract

WORKSHOP OBJECTIVE:

To give the audience an overview of the application of ultrasound to guide injections in pain management. The anatomy, sonoanatomy, injection techniques and the literature published relevant to some selected ultrasound guided injections in axial, peripheral and musculoskeletal structures will be reviewed.

Learning Objectives:

To provide an basic understanding of the application of ultrasound in injections in pain medicine.
To review the anatomy, sonoanatomy relevant to some selected ultrasound guided injections.
To summarize the injection techniques and the literature published relevant to some selected ultrasound guided injections.

Describe the unique parameters of moderate pain and the pharmacology of buprenorphine.
Summarize the clinical research supporting the use of transdermal buprenorphine for the treatment of moderate pain.
Give examples of the clinical application of this analgesic including indications, contraindications, risks and benefits.

BRIEF DESCRIPTION:

Managing pain has challenged experts for many years, including Canadian healthcare professionals. As the population ages and patients become more involved in their healthcare, physicians and other health care workers are learning to individualize treatment management strategies with the assistance of multiple different treatment options. Typically the focus revolves around treating severe pain but moderate pain also impacts the lives of many Canadians. The Nanos Research looked at the impact that moderate to severe pain has on patient’s ability to work and found that 47% of Canadian pain sufferers had their job responsibilities reduced due to their pain. This session will review the scope of moderate pain and introduce a new 7-day transdermal buprenorphine patch indicated for patients with moderate pain.

Pain Res Manag. 2010 Mar-Apr;15(2):85.

23 Patient Education for Chronic Pain: Where Have We Been, Where Are We Going?

Jason J McDougall ¹, Sandra LeFort ¹

Abstract

Learning Objectives:

To gain an understanding of past approaches to chronic pain patient education.
To learn about new models of patient education and how these might be incorporated into programs for chronic pain patients.

BRIEF DESCRIPTION:

This presentation will briefly review standard patient education approaches that have been described in the literature and discuss how new emerging education trends and technologies might be used in future to improve accessibility and acceptability by chronic pain patients and their families.

Pain Res Manag. 2010 Mar-Apr;15(2):85.

23A How Brain Imaging Can Help to Understand Clinical Pain

Jason J McDougall ¹, Petra Schweinhardt ¹

Abstract

Learning Objectives:

Gain an understanding of the mismatch between objective sign and pain severity in chronic pain conditions.
Learn about different imaging techniques that can be used to investigate brain structure, function, and biochemistry.
Learn about brain alterations in chronic pain and their potential functional significance.

BRIEF DESCRIPTION:

The prevalence of chronic pain is estimated to be around 20% (1). In only a minority of the patients, an obvious origin of the pain can be determined such as nerve or tissue injury. A large proportion of the patients with chronic pain are assigned to the diagnostic category of functional pain syndromes, for which per definition no underlying organic cause can be determined. But also in patients suffering from neuropathic or nociceptive pain mismatches between quantifiable signs such as extent of tissue injury and amount of pain are frequently observed. Moreover, patients with seemingly very similar types of injury might report hugely varying degrees of pain. Several reasons are likely to contribute to those findings, including genetic variability and aspects of the injury/disease that cannot be easily quantified. In addition, it has become increasingly clear in recent years that the brain plays an important role in modifying pain experiences, either by augmentation or attenuation. Pre-existing differences in endogenous pain modulating systems might contribute to the probability of an individual developing chronic pain as well as to the severity of the pain. But evidence is also accumulating that pain itself can alter the brain. In vivo imaging techniques, such as functional and structural magnetic resonance imaging, spectroscopy and positron emission tomography, have provided substantial evidence in recent years that chronic pain patients have an altered function, biochemistry and even structure of the brain. Such brain alterations are predominantly observed in areas involved in pain processing and pain modulation. In several instances, they have been shown to be related to the amount of time for which the patient has been suffering from pain. It appears therefore likely that at least some of the brain alterations observed represent maladaptive plastic processes that contribute to the generation and maintenance of pain. It will be of paramount importance in the next years to determine the causes of such maladaptive plasticity, which might occur due to prolonged nociceptive input, stress, or maybe even “spontaneously”.

REFERENCES:

1.Gureje O, Von Korff M, Simon GE, Gater R. Jama. 1998 Jul 8;280:147. doi: 10.1001/jama.280.2.147. [DOI] [PubMed] [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):85.

24 Moderated Poster Session

Judy Watt-Watson, Peter MacDougall, Christine Popovich, Erica Weinberg

Pain Res Manag. 2010 Mar-Apr;15(2):85.

24A The Nova Scotia Chronic Pain Collaborative Care Network (NSCPCCN) Mentor and Mentee Workshop Assessment Data

Peter MacDougall ¹, Sara Whynot ¹, Michele Chapell ², Michael Cord ³, Spencer Tighe ⁴

Abstract

AIM:

The NSCPCCN is a mentor - mentee network designed to provide clinical support, continuing professional development (CPD) and knowledge translation (KT) to primary care practitioners (PCP’s) in the community. The network was initially launched as a pilot project in one health care district in Nova Scotia. The goal of this study was to determine the baseline characteristics of mentors and PCP mentees at the inauguration of the NSCPCCN through a two day workshop.

METHODS:

A two day workshop was held to launch the NSCPCCN. The first day of the workshop consisted of training for mentor physicians. A questionnaire was provided to the mentors at the end of the session to determine the mentors understanding of the concept of mentoring in this framework. The second day of the workshop was devoted to matching mentor - mentee groups. Data was collected from the mentee physicians to determine the impact of chronic pain on their practice, initial satisfaction with chronic pain management, opioid prescribing and the rate of aberrant opioid behavior screening.

RESULTS:

Mentorship data was expressed in Likert scales from 0 (strongly disagree) to 5 (strongly agree). Of the 7 mentors responding, 6 had no previous similar mentoring experience. Confidence in mentoring, understanding the values of the NSCPCCN and the expectations of the NSCPCCN averaged 3.9/5, 3.4/5 and 3.1/5 respectively. The ability to describe mentoring models, know when to chose the most approrpiate mentor role and confidence in functioning as a mentor in this setting averaged 3.1/5, 2.3/5 and 3.4/5.

The average number of visits for chronic pain was 43/month with a range of 2 – 125. Visit duration ranged from 15 to 400 minutes. The average time without the 400 minute outlier was 22 minutes. Average non-compensated time was 13 minutes. Satisfaction with chronic pain management and opioid prescribing averaged 3.4/5 and 3.7, respectively. The average number of patients screened for aberrant opioid behavior and suspected of same are 22.6 and 5 respectively.

CONCLUSIONS:

Mentors entering the NSCPCCN were unlikely to have acted as mentors in the past. However, the mentors had a reasonable grasp of the concepts of mentoring. Mentee practices demonstrate a wide variation in visits for chronic pain. Non-compensated time was similar to that reported previously (1). Aberrant opioid screening and suspicion of this behavior was much higher than in previous groups (1).

FOOTNOTES/REFERENCES:

1.Chappell, et al. Canadian Pain Society Annual Meeting2009. Abstract. [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):85–86.

24B Sex Differences in the Effects of Attention on The Neural Response to Non-Painful Sensory Stimuli

Christine Popovich ¹, Colleen Dockstader ², Douglas Cheyne ², Rosemary Tannock ²

Abstract

AIM:

To determine whether males and females differ in attention modulation of sensorimotor mu rhythms in response to non-painful somatosensory information. Sex-related differences have been found in cortical oscillations (specifically, the 8–12 Hz mu frequency band) in response to painful stimuli, but it is unclear whether differences also occur in response to non-painful stimuli and whether there are sex differences in attention to sensory stimuli.

METHODS:

We used magnetoencephalography to capture mu oscillation in the primary somatosensory cortex in response to non-painful transcuta-neous median nerve stimulation (MNS) in 10 female and 10 male healthy adults, aged 21–36 years. Stimuli were presented in trains of four (ISI: 2s) followed by a 4-sec gap for a total of 83 trains over 14 minutes. Participants completed two counterbalanced conditions: attend to a videoclip while ignoring MNS; attend to MNS and ignore the videoclip.

RESULTS:

Females showed strong and prolonged mu suppression when attending to MNS stimuli, whereas males showed brief mu suppression followed by mu enhancement. Since mu suppression reflects stimulus processing and mu enhancement reflects cortical inhibition of that region, our findings indicate that females engage in intensive and extensive processing of the sensory stimuli, when directing attention to the stimuli, whereas males engage in brief sensory processing, then inhibit further processing

CONCLUSIONS:

Sex-related differences in attentional processing of sensory stimuli might account in part for the well-documented greater pain sensitivity in females and their decreased response to pain-therapies involving redirection of attention away from nociceptive information.

Pain Res Manag. 2010 Mar-Apr;15(2):86.

24C Knowledge Translation in Pain Education: Is the Message Being Understood?

Erica Weinberg ¹, Philip A Baer ²

Abstract

AIM:

To assess whether new clinical and scientific information potentially impacting pain management is being translated into daily clinical practice at the primary care level in Canada.

METHODS:

Over 190 health care professionals, mostly primary care physicians, were surveyed at a number of CME events in 2009 for current knowledge in pain management. Multiple choice questions regarding prevalence of chronic pain, screening for opioid misuse risk, acetaminophen dosing, risk factors for NSAID-induced GI events, and codeine metabolism were posed.

RESULTS:

In 2009, the majority of respondents were aware of the prevalence of chronic pain in Canadian adults. However, clinicians are still not fully aware of issues surrounding codeine metabolism, maximum safe acet-aminophen dosing in chronic usage, and the increased GI risk of SSRIs used concomitantly with NSAIDs. Only 18.1% of clinicians used validated tools for screening opioid misuse risk prior to initiating opioids, and 20.3% still do not routinely screen their patients at all.

CONCLUSIONS:

Continuing medical education in proper pain management and risk stratification is still required.

REFERENCES:

1.Food and Drug Administration. Organ-Specific Warnings. Internal Analgesic, Antipyretic, and Antirheumatic Drug Products for Over the-Counter Human Use. Final Monograph Federal Register. 2009 Wednesday, April;74(81) [PubMed] [Google Scholar]
2.Chou R, et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. The Journal of Pain. 2009 Feb;10(2):113–130. doi: 10.1016/j.jpain.2008.10.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Macfarlane GJ, et al. Managing low back pain presenting to primary care: Where do we go from here. Pain. 2006;122:219–222. doi: 10.1016/j.pain.2006.03.013. [DOI] [PubMed] [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):86.

25 Do Blocks have a Role in Chronic Pain Management?

Paul Taenzer ^1,², A John Clark ^1,², Ian Beauprie ^1,²

Abstract

WORKSHOP OBJECTIVE:

This workshop will consist of an opening debate of the evidence for and against the use of blocks (interventions) in the management of chronic pain. This will be followed by small group round tables to discuss controversial issues about the provision of interventions. Each small group will report their conclusions back to all workshop participants to allow for discussion and debate amongst all participants.

Learning Objectives:

To review the evidence for and against the use of blocks (interventions) in the management of chronic pain.
To determine if there is an optimum frequency interventions should be provided and whether there should be a maximum number.
To discuss the role ultrasound and/or fluoroscopy should play when interventions are performed and to debate whether Bier blocks should be de-listed from provincial payment plans.

Learning Objectives:

To be able to diagnose pudendal neuralgia in patients with pelvic pain
To understand the role of diagnostic blocks
To look and surgical and non-surgical management techniques.

Learning Objectives:

To gain an understanding about what endocannabinoids are, where they can be found and how they are involved in pain transmission
To learn, how animal models can be used to investigate the endocannabinoid system as a novel target for the treatment of pain.
To get an update on recent approaches to modulate the endocannabinoid system in clinical pain management. Advantages and potential limitations will be discussed.

Will develop an appreciation of the need for multiple and sustained approaches to chronic pain service delivery through a provincial chronic pain initiative.
Will appreciate the various roles required to develop a sustainable provincial chronic pain network.
Will understand the need to ensure involvement and process development in the coordination and implementation of a provincial chronic pain network.
The importance of developing an ongoing accountability or quality improvement component as part of any provincial program.

Learning Objectives:

Awareness of the multi-pronged strategy developed in Nova Scotia to bring evidence based approaches to provincial community based chronic pain clinics.
Broader understanding of the advantages of partnerships between the Provincial Department of Health, academic pain specialists, District Health Authorities, and the community practitioners initiating and sustaining a province wide strategy for improved management of inter-professional chronic pain management.
Broader understanding of the advantages of partnerships between the Provincial Department of Health, academic pain specialists, District Health Authorities, and the community practitioners initiating and sustaining a province wide strategy for improved management of inter-professional chronic pain management.

Pain Res Manag. 2010 Mar-Apr;15(2):89.

29A From Vision to Reality - Leadership & Integration of Acute and Inter-Professional Care Models to Provide Fair Equitable Access to Provincial Chronic Pain Services In Nova Scotia

Mary E Lynch ¹

Abstract

Abstract

Learning Objectives:

Sleep physiology: the basic principles of sleep physiology and neurobiology will be discussed as well as new emerging polysomnographic measures used to evaluate sleep quality.
Interrelationship between pain and sleep: this part of the symposium will focus on the prevalence of sleep disturbances in painful conditions and present study data highlighting the impact of sleep deprivation/disturbances on pain reporting as well as subjective and objective measures of sleep quality in patients suffering from chronic pain conditions.
Impact of pain medication on sleep difficulties: This section is intended to present data on sleep quality in pain patients for medications used to manage chronic neuropathic pain.

BRIEF DESCRIPTION:

This symposium will address the basic principle of sleep physiology, address interrelationships between pain and sleep and what is the impact of pain medication on sleep difficulties.

Pain Res Manag. 2010 Mar-Apr;15(2):90.

31 Interdisciplinary Pediatric Chronic Pain Management: A Team Approach Using Innovative Methods to Reach Out to Children and Teens

Bruce D Dick ^1,^2,³, Mark K Simmonds ^1,^2,³, Kathy L Reid ^1,^2,³

Abstract

WORKSHOP OBJECTIVES:

To help participants understand how straightforward explanations to communicate with a child about their chronic pain validates their pain experience including research results upon which this method is based.
Participants will learn about the professional and ethical standards related to using telehealth to replace the face-to-face visit and outcome data from our pediatric chronic pain program using this technology.
To understand and discuss the rationale, benefits and shortcomings of distance treatment programs for children and adolescents with chronic pain along with qualitative and quantitative findings from our local pediatric cancer pain distance treatment program.

Learning Objectives:

To help participants understand how straightforward explanations to communicate with and validate a child’s chronic pain including data generated from research in this area in our pediatric chronic pain clinic.
Participants will learn about the professional and ethical standards related to using telehealth to replace the face-to-face visit and will understand research results from our pediatric pain management program that incorporates this treatment technology.
To understand and discuss the rationale, benefits and shortcomings of distance treatment programs for children and adolescents with chronic pain and findings from our local pediatric oncology distance treatment program.

Pain Res Manag. 2010 Mar-Apr;15(2):90.

31A Reaching Out to Children with Chronic Pain - Telling Them It’s Real

Mark K Simmonds ¹

Abstract

BRIEF DESCRIPTION:

While it is accepted that multidisciplinary programs are the optimum way of managing pediatric chronic pain, there are only a handful of dedicated pediatric multidisciplinary chronic pain treatment facilities across Canada (1, 2). This woeful shortfall is likely to take many years to address. In the interim there will be a generation of children with untreated chronic pain who will continue to feel isolated, be disbelieved and under-treated (3). A cognitive-behavioural approach to treating chronic pain in children has been found to be empirically supported (4). Discussing the nature and origin of chronic pain is a key part of this treatment.

In our pediatric chronic pain clinic, a needs study was conducted to examine key factors identified by families as important when first attending our clinic. Parents (n=29) were surveyed prior to their initial visit regarding their needs for information concerning chronic pain and its treatment. Information about the causes of their child’s pain was important or very important to 97%. Irrespective of the diagnosis, validation of a child’s pain as a “real” sensory experience is a vital first step in the management of chronic pain (5,6). At our pediatric pain centre this is the primary goal of the initial interdisciplinary consultation.

Our clinic research also found that parents (n=27) reported seeing an average of 4 (range 1 – 9) health care professionals regarding their child’s pain prior to their pain clinic appointment. In the context of our needs assessment research results, we propose that improved health service provision can be achieved through validation and interdisciplinary care of a child’s chronic pain experience. This can be accomplished using straightforward explanations in the primary care setting by interested healthcare professionals, long before the child comes to the attention of an interdisciplinary pain centre.

REFERENCES

1.Berde CB, Solodiuk J. Multidisciplinary programs for management of acute and chronic pain in children. In: Schechter NL, Berde CB, Yaster M, editors. Pain in Infants, Children and Adolescents. Philadelphia: Lippincott Williams & Wilkins; 2003. pp. 471–86. [Google Scholar]
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4.Eccleston C, Yorke L, Morley S, Williams AC, Mastroyannopoulou K.Psychological therapies for the management of chronic and recurrent pain in children and adolescents Cochrane Database Syst Rev 20031CD003968 Review. [DOI] [PubMed] [Google Scholar]
5.Carter B. Chronic pain in childhood and the medical encounter: professional ventriloquism and hidden voices. Qual Health Res. 2002 Jan;12(1):28–41. doi: 10.1177/104973230201200103. [DOI] [PubMed] [Google Scholar]
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Pain Res Manag. 2010 Mar-Apr;15(2):90–91.

31B Using Technology to Replace a Face-to-Face Visit: Using Telehealth in a Pediatric Chronic Pain Clinic

Kathy L Reid ¹

Abstract

BRIEF DESCRIPTION:

The use of technologies such as telehealth allows pediatric institutions to assess and manage the health care needs of children and their families who are geographically disadvantaged when seeking health services (1). Telehealth equipment is available in many health units, hospitals and schools across Canada. The Canadian Nurses Association and the Canadian Medical Association both recognize the importance of using telehealth (2,3). Advantages of using telehealth include increased access to care, decreased travel costs for families, and the ability for children and adolescents to participate from their home town and even from their school. Barriers to the use of telehealth include concerns regarding privacy, security breaches, and the resistance of users, including both health care professionals and clients (4,5). Research has shown that the use of telehealth is an effective method of teaching pediatric diabetes (6), as well as an effective delivery method of a mindfulness program for adults with chronic pain (7). Parents and adolescents report satisfaction with telehealth for child psychiatry assessments (8).

This workshop will address how telehealth has been used to implement our Pain 101 pain management course for children over the age of 10 years. This 10-week course teaches cognitive-behavioural strategies to manage pain, including relaxation, pacing, sleep hygiene, changing thoughts and setback planning. We also offer a 2-hour pain management session for parents of children attending Pain 101. Offering these sessions via telehealth improves access to care, dramatically decreases costs to families, allows patients to remain in school and reduces repeat visits to the city for treatment. To date, a large and growing number of children have attended Pain 101. Approximately 30% have attended via telehealth. Pain 101 outcome data will be presented with comparisons between children enrolled in Pain 101 via telehealth vs. those who attend in person. These outcomes target functional disability, school attendance, sleep, and mood.

REFERENCES

1.Spooner S, Gotlieb E, the Steering Committee on Clinical Information Technology and Committee on Medical Liability Pediatrics. 2004;113:e639–e643. doi: 10.1542/peds.113.6.e639. [DOI] [PubMed] [Google Scholar]
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7.Gardner-Nix J, Backman S, Barbati J, Grummitt J. Evaluating distance education of a mindfulness-based meditation program for chronic pain management. Journal of Telemedicine and Telecare. 2008;14:88–92. doi: 10.1258/jtt.2007.070811. [DOI] [PubMed] [Google Scholar]
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Pain Res Manag. 2010 Mar-Apr;15(2):91.

31C Reaching out to Children with Chronic Pain - Distance Treatment Programs

Bruce D Dick ¹

Abstract

BRIEF DESCRIPTION:

Multidisciplinary treatment programs have been found to be effective in treating children and adolescents with chronic pain (1). Unfortunately, such programs are relatively rare in Canada. Even when families of these children live within program catchment areas, many families requiring services live at a considerable distance from the hospital (2). Consequently, innovative treatment modalities are increasingly being developed and investigated in order to provide families with needed services in a timely and cost-effective way.

Information technology, including web-based delivery, has the potential to provide a medium whereby children with chronic pain and their families can obtain valuable educational materials and interact with skilled service providers from a distance (3,4). There is mounting evidence that these services are effective at providing needed information and treatment strategies, thereby helping children and families take an active role in treatment (5,6). Distance treatment programs have the potential to meet unmet needs, improve mental health and quality of life, reduce travel and operating costs and provide flexibility in services to geographically isolated families while maintaining therapeutic alliance (6, 7, 8).

REFERENCES

1.Eccleston C, Yorke L, Morley S, Williams AC, Mastroyannopoulou K.Psychological therapies for the management of chronic and recurrent pain in children and adolescents Cochrane Database Syst Rev 20031CD003968 Review. [DOI] [PubMed] [Google Scholar]
2.Dedicated multidisciplinary pain management centres for children in Canada: the current status. Can J Anaesth. 2007 Dec;54(12):985–91. doi: 10.1007/BF03016632. [DOI] [PubMed] [Google Scholar]
3.Hicks C, von Baeyer C, McGrath PJ. Online psychological treatment for pediatric recurrent pain: A randomized evaluation. Journal of Pediatric Psychology. 2005:1–13. doi: 10.1093/jpepsy/jsj065. [DOI] [PubMed] [Google Scholar]
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7.Lingley-Pottie P, McGrath PJ. A paediatric therapeutic alliance occurs with distance intervention. Journal of Telemedicine and Telecare. 2008;14:236–240. doi: 10.1258/jtt.2008.080101. [DOI] [PubMed] [Google Scholar]
8.Lingley-Pottie P, McGrath PJ. Telehealth: A child and family-friendly approach to mental health-care reform. Journal of Telemedicine and Telecare. 2008;14:225–226. doi: 10.1258/jtt.2008.008001. [DOI] [PubMed] [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):91.

32 Unravelling Chronic Pain Rehabilitation, an Examination of the Effectiveness of Individual Interventions

Katherine Harman ^1,^2,³, Maureen Simmonds ^1,^2,³, Douglas Cane ^1,^2,³

Abstract

WORKSHOP OBJECTIVE:

Rehabilitation for chronic pain is generally offered in multidisciplinary environments with several interventions offered together. Although there are many strategies used, two related rehabilitation strategies – activity pacing and exercise/activity are among the most frequently employed. A review of evidence will be presented covering the combined interventions and these two approaches.

Learning Objectives:

To understand the specific and non-specific effects of commonly used and novel interventions in chronic pain rehabilitation.
To become familiar with research findings that evaluate the psychosocial outcomes associated with pacing and examine the relationship of pacing to other activity patterns observed in the chronic pain population.
To understand the approach to prescribing therapeutic exercise for specific purposes in chronic pain rehabilitation.

Become familiar with empirical research related to spirituality and chronic pain
Be introduced to a proposed framework for understanding the potential direct and indirect pathways between spirituality, coping, and chronic pain
Become familiar with the ethical issues and guidelines relevant for those who are interested in integrating spirituality and treatment for chronic pain

Learning Objectives:

Become familiar with the empirical research related to spirituality and chronic pain - Spirituality has been linked to many positive mental and physical health outcomes, but relatively little empirical research has been conducted on the importance of spirituality among those with chronic pain, particularly as it pertains to coping and self-management. During the workshop, the pertinent empirical studies will be reviewed, including the efficacy of spiritually-based interventions for chronic pain.
Be introduced to a proposed framework for understanding the potential direct and indirect pathways between spirituality, coping, and chronic pain. A framework describing the potential relationship between spirituality, coping, and chronic pain has recently been proposed by Wachholtz et al, 2007. This framework will be presented, with a description of how it relates to previous empirical research.
Become familiar with the ethical issues and guidelines relevant for those who are interested in integrating spirituality and treatment for chronic pain. Ethical issues related to applying spiritual interventions with patients will be discussed, along with guidelines for those who wish to address the spiritual domain with patients.

Pain Res Manag. 2010 Mar-Apr;15(2):92.

34 Understanding Sleep and its Relationship to Pain: An Introduction for Allied Health Professions

Cary Brown ¹

Abstract

WORKSHOP OBJECTIVE:

Provide an introductory background for allied health professionals to the relationship between disordered sleep and chronic pain.

Learning Objectives:

Develop an understanding of basic sleep architecture and its relationship to chronic pain.
Explore the Model of Human Occupational (MOHO) as a theoretical construct to better understand the complexity of pain, sleep and function from an allied health professional perspective.
Provide participants an opportunity to practice evaluating a patient in an illustrative case-study within the MOHO systems components of habituation, volition and performance.

Pain Res Manag. 2010 Mar-Apr;15(2):92.

34A Understanding Sleep and its Relationship to Pain: An Introduction for Allied Health Professions

Cary Brown ¹

Abstract

BRIEF DESCRIPTION:

We know that there is a relationship between disordered sleep and chronic pain that spans all age groups between children to those elderly persons living in residential care facilities [1–5]. Traditionally healthcare providers have seen disordered sleep (for example insomnia) as a consequence of chronic pain and have assumed that, as pain becomes better managed, restorative sleep patterns will return. However, current research is beginning to support a bi-directional relationship between pain and sleep where the sleep problem may actually have preceded the development of chronic pain [6]. This is an exciting proposal because it highlights the importance of addressing sleep problems early in the intervention process.

There are a range of non-pharmacological interventions for disordered sleep that allied healthcare professionals (AHPs) can implement with their clients who have chronic pain. However, to make the best match between intervention, patient and the socio-cultural context of the treatment environment, AHPs need to understand basic sleep architecture. This workshop will introduce AHP to the basics of sleep, outline how the Model of Human Occupation (MOHO) [7] used by rehabilitation therapists can be applied to better guide evidence –based practice, and offer an illustrative case study. Participants in the workshop will have the opportunity to practice evaluating a patient in an illustrative case-study within the MOHO systems components of habituation, volition and performance. We will provide a resource list of non-pharmacological interventions for AHPs, and there will be an opportunity for participants to share other resources and stories of successful intervention.

REFERENCES:

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CONCLUSIONS:

Suggestions for improving research in psychological treatment for recurrent headaches are discussed, as are directions for improving the efficacy of treatments in the clinical setting.

REFERENCES:

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Pain Res Manag. 2010 Mar-Apr;15(2):95.

P11 The Prevalence of Psychiatric Features Within a Chronic Pain Population

Christina Iorio ¹, Constantina Tsirgielis ², Elizabeth Pawluk ², Monica Vermani ², Martin A Katzman ²

Abstract

AIM:

The reported prevalence rate of chronic pain within Canada ranges from 20% to 44% (Birse, & Lander, 1998; Smith, Hopton, & Chambers, 1999). Along with the high prevalence rate of chronic pain comes a high cost to society, including loss of productivity, increased utilization of health care, and a substantial amount of health care expenditures (Turk, Loeser, & Monarch, 2002). In response to the high cost to the individual as well as to society, examination of this population is imperative to advance treatment options. As coexisting psychiatric disorders are associated with poorer treatment outcomes and greater levels of disability in chronic pain patients (Burns, Johnson, Mahoney, Devine, & Pawl, 1998; Holzberg, Robinson, & Geisser, 1996), investigation of these factors is essential.

METHODS:

The present study gathered data from 200 chronic pain patients receiving treatment from various pain clinics within the Greater Toronto Area (GTA).

RESULTS:

Results revealed the following prevalence rates for current psychiatric presentations within the sample: major depressive episode (38%), major depressive episode with melancholic features (28.5%), dysthymia (22.5%), risk of suicidality (42.5%), generalized anxiety disorder (37%), bipolar mood disorder (2.5%), panic disorder (10.5%), agoraphobia (33.5%), social phobia (19.5%), specific phobia (18%), obsessive compulsive disorder (11%), post-traumatic stress disorder (14%), alcohol dependence (6%), alcohol abuse (12%), substance dependence (9.5%), substance abuse (2%), bulimia (2.5%), and hypochondriasis (7.5%).

CONCLUSIONS:

These prevalence rates suggest greater attention be given to psychiatric features within this population.

REFERENCES:

1.Birse TM, Lander J. Prevalence of chronic pain. Canadian Journal of Public Health. 1998;89:129–131. doi: 10.1007/BF03404405. [DOI] [PMC free article] [PubMed] [Google Scholar]
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FOOTNOTES/REFERENCES:

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Pain Res Manag. 2010 Mar-Apr;15(2):97.

P16 Experience of an Interdisciplinary Clinic with Spinal Stimulation

Terry McCarvill ¹, Ian Beauprie ², Rob Brownstone ³, Paula Chiasson ⁴

Abstract

AIM:

To review the practice of our team approach to neurostimulation with respect to need for trials, indications, and infection rates.

METHODS:

Our centre assesses neurostimulation candidates in a joint clinic with pain medicine, neurosurgery, and an OT/coordinator. Candidates are reviewed in interdisciplinary conferences attended by physical medicine, and psychology as needed. Qualified candidates are then put forward for trial neurostimulation. We reviewed all candidates, examining the diagnosis, success of trial, and complications.

RESULTS:

RESULTS:

Patients analyzed were between 21 years and 49 years old. They were diagnosed with: CRPS II following L5S1 discectomy, CRPS II following left arm brachial plexus injury, CRPS I in all extremities following MVA, CRPS II in all extremities following MVA, CRPS I post soft tissue injury of the right knee, CRPS I post right tibia, fibula fracture secondary to MVA, CRPS I affecting both legs and arms etc. All patients were unable to function and the pain level was 10/10. Patients had burning pain, mottling coldness, and nail and hair changes, and allodynia. Pain was increased by walking, standing or prolonged sitting. The swelling in the extremities was severe. Patients were unable to weight bear on injured extremity.

Patients were treated with different analgesics, opioids, antidepressants, anticonvulsants, sedatives, sympathetic blocks and stellate ganglion blocks with no improvement in pain level or functionality.

Addition of cannabinoid medication resulted in pain level decrease and improved activities of daily living improved. Two patients went to working full time, one is back to part time work and two are in full rehabilitation program.

CONCLUSIONS:

Cannabinoid seems efficacious in the management of severe CRPS patients, resulted in significant reduction of pain intensity (40%–60%), near complete opiate elimination and functional improvement.

FOOTNOTES/REFERENCES:

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FOOTNOTES/REFERENCES:

1.Dubin RE, King-VanVlack C. The Trajectory of chronic pain: can a community-based exercise/educations program soften the ride. Pain Res Manage. 2009 doi: 10.1155/2010/617129. in press. [DOI] [PMC free article] [PubMed] [Google Scholar]

FOOTNOTES/REFERENCES:

1.Liddle SD, Baxter GD, Gracey JH. Chronic low back pain: patients’ experiences, opinions and expectations for clinical management. Disability and Rehabilitation. 2007;29(24):1899–1909. doi: 10.1080/09638280701189895. [DOI] [PubMed] [Google Scholar]
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Pain Res Manag. 2010 Mar-Apr;15(2):103.

P39 Minocycline Attenuates Central Sensitization in Medullary Dorsal Horn in Rats

Chen Yu Chiang ¹, Kazunori Itoh ¹, Jonathan O Dostrovsky ², Barry J Sessle ²

Abstract

AIM:

Abstract

AIM:

Abstract

AIM:

Purpose: This research identified issues home care nurses and other health professionals confronted when managing acute and chronic pain in the home setting and identified ways to address these issues.

METHODS:

Participants: A total of 29 participants were interviewed from the following disciplines: home care nursing, nurse practitioners, physiotherapy, occupational therapy, social work and medicine. The majority of the participants were nurses. Method: Using an open-ended interview guide, data were collected through in-depth focus groups and individual interviews. Data were analyzed using unitizing and categorizing methods.

RESULTS:

The two major issues identified were: i) differing values, beliefs and knowledge levels between nurses, patients and their families and, ii) role and communication practices between acute care and community health care organizations. Unless there is a co-morbid condition or treatment requirements, patients with chronic pain are not usually seen in the home and must manage on their own. Selected populations such as older patients, patients with substance abuse and mental health problems provided unique challenges. Participants identified that good pain assessment in the home requires knowing how, and if, pain medications, opioids in particular, are being taken.

CONCLUSIONS:

Improved communication between organizations, and health professionals can assist patients and their families to achieve more effective pain management. Opioids were the pharmacological treatment that impacted on all aspects of care and, although often helpful to patients, misconceptions about these medications underscores the need for education at all levels.

FOOTNOTES/REFERENCES:

1.Thorne S, Reimer Kirkhan C, MacDonald-Emes J. Interpretive description: A non-categorical qualitative alternative for developing nursing knowledge. Research in Nursing and Health. 1997;2:169–177. doi: 10.1002/(sici)1098-240x(199704)20:2<169::aid-nur9>3.0.co;2-i. [DOI] [PubMed] [Google Scholar]
2.Lincoln Y, Guba E. Naturalistic Inquiry. Sage; Newbury Park CA: 1985. [Google Scholar]

CONCLUSIONS:

Many activities are planned in Ontario and in Canada to disseminate and implement the guideline to clinicians, pharmacists, policy makers, insurers and the public. The recommendations contained in this guideline will have management and policy implications.

Pain Res Manag. 2010 Mar-Apr;15(2):106.

P51 Relationships Between Activity Pacing and Adjustment Among Individuals with Persisting Pain

Heather Getty ¹, Allan Shapiro ¹, Patricia Morley-Forster ¹, Robert Teasell ¹

Abstract

AIM:

Despite an emphasis on activity pacing in treatment programs for chronic pain, there has been limited research on relationships between activity pacing and adjustment to chronic pain. The present study examined relationships between various forms of activity pacing and different aspects of adjustment among pain patients. Relationships between activity pacing and widely-researched psychosocial variables known to be important in adjustment to pain (e.g., experiential avoidance, catastrophizing, fear of pain) were also explored to further understand links between activity pacing and patient outcomes.

METHODS:

350 patients from tertiary chronic pain programs and rheumatology clinics completed self-report measures of activity pacing, a hard-driven workstyle, and Type A behaviour. They also completed measures of pain intensity, functional disability, work status, and distress. Measures of activity pacing were also correlated with psychosocial variables prominent in models of chronic pain, including experiential avoidance, pain catastrophizing, and fear of pain.

RESULTS:

Measures of pacing, a hard-driven workstyle, and Type A behaviour correlated meaningfully with various aspects of adjustment including pain intensity, disability, and distress. Activity pacing was more strongly related to emotional distress than pain intensity or disability. Activity pacing was also related to lower levels of experiential avoidance, pain catastrophizing, and fear of pain.

CONCLUSIONS:

The ability to pace physical activity is a multifaceted construct that is related to better outcomes among individuals with persisting pain. Activity pacing is also meaningfully related to a number of psychosocial variables known to influence adjustment to pain. Further research is needed to test more sophisticated, causal models linking pacing and outcomes among pain patients.

Pain Res Manag. 2010 Mar-Apr;15(2):106.

P52 Persistent Sexual Arousal Syndrome (PSAS) and Genital Pain

Allan S Gordon ¹

Abstract

AIM:

Persistent sexual arousal syndrome can refer to the experience of genital arousal that is not associated with sexual stimulation of any kind. These feelings do not go away on their own and cause the individual pain or distress. Pain is not considered to be the prime feature. The author discusses the syndrome in 5 women in whom it was elicited only after detailed questioning.

METHODS:

Five women have recently been referred to the pelvic pain unit with genital pain. During the detailed evaluation they were found to have PSAS as well.

RESULTS:

One young woman was referred with urinary symptoms of interstitial cystitis and was found to have clitoral pain, vulvar pain and dyspareunia as well as PSAS. A second was referred because of a complex history resulting in symptoms of pudendal neuralgia. She had clitoral, vulvar and deeper pain. On direct questioning the pain condition was preceded by PSAS. A third presented with right sided genital pain including clitoral pain. Investigations suggested right pudendal neurlagia. Post-decompression she developed active symptoms of PSAS. The fourth woman presented with general and genital pain and dyspareunia. She had clitoral pain and tumescence vulvar pain and PSAS. The fifth woman had interstial cystitis with urgency and bladder neck pain as well as PSAS verging on hypersexuality with clitoral sensitivity.

CONCLUSIONS:

CONCLUSIONS:

Measuring BOTH pain AND unpleasantness DURING a prolonged 60s TG stimulus may provide useful information about individual differences in the TGI.

Footnotes

Supported by grants from Toronto Rehab (MP). JH was funded by a fellowship from the Canadian Paraplegic Association Ontario and a NSERC/CIHR Collaborative Health Research Projects (CHRP) grant: NSERC # CHRPJ 350980-2008; CIHR # CPG 87507.

FOOTNOTES/REFERENCES:

Craig AD, Bushnell MC. The thermal grill illusion: unmasking the burn of cold pain. Science. 1994;265:252–255. doi: 10.1126/science.8023144. [DOI] [PubMed] [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):107.

P57 Families and Chronic Pain: A Pilot Meta-Study of Qualitative Research

Sandra LeFort ¹, Shirley Solberg ¹, Joanne Smith-Young ¹, Nicole Snow ²

Abstract

AIM:

Most research on families and chronic pain has been from a quantitative perspective and measures such outcomes as marital satisfaction, affective changes in other members, beliefs about chronic pain, and quality of life. The aim of this project was to conduct a pilot meta-study of published qualitative research in order to identify some of the effects on families when a family member has chronic pain so as to better conceptualize this problem.

METHODS:

We conducted a search of databases MEDLINE, CINAHL, EMBASE, and PsycINFO for qualitative studies using key terms chronic pain and effects on family or family members to locate the studies. We used Paterson et als. guide.

RESULTS:

Eighteen studies were located that met our inclusion criteria. Many of the studies focused on how the person with chronic pain perceived the family to be affected, but others were from the perspective of the partner/spouse or in the case of children with chronic pain from the parents’ perspective. A variety of methodologies were employed and different theoretical orientations informed these studies. Findings suggest that, within families, having a member with chronic pain has an effect on changing relationships and roles within families, social functioning, and placing restrictions on certain family members. Positive effects were noted such as developing greater empathy or deepening relationships.

CONCLUSIONS:

In conclusion, findings from qualitative studies expand the understanding gained from quantitative research of the effects of chronic pain on families.

FOOTNOTES/REFERENCES:

1.Paterson B, et al. Meta-study of qualitative health research: a practical guide to meta-analysis and meta-synthesis. thousand oaks. CA: Sage; 2001. [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):107–108.

P58 Is Perception Reality? Perceived Limb Representation and Clinical Presentation in Complex Regional Pain Syndrome (CRPS)

Jennifer Lewis ¹, Petra Schweinhardt ¹

Abstract

AIM:

Pain in a limb is the primary feature of CRPS. (1) Those with CRPS have a distorted perception of that limb in terms of size and shape and many express strong feelings of hate and have a desire to amputate it. (2,3,4,5) Prevalence of these disturbances is high. (2,6) Clinically, patients with altered perceptions have difficulty engaging with their affected limb, which can be detrimental to rehabilitation. The aim of this part of a wider study is to establish whether there is a relationship between body perception disturbances expressed by CRPS patients and clinical presentation.

METHODS:

To measure the extent of disturbances in body perception, those with CRPS rated various aspects about their affected limb via the body perception disturbance scale (BPDS). Clinically objective signs of swelling using a volumeter and touch via 2pt discrimination of the affected (A) and unaffected (UA) hands were measured.

RESULTS:

Results table.

ID	Age/gender/arm affected	Disease duration months	Pain rating 0–100 VAS	A /UA % volumeter Difference	A/UA Subjective perceived size	A / UA discrimination threshold difference (mm)	BPDS rating (Max score 48)
CRPS01	59/f/L	4.5	60	10% increase	Not assessed (n/a)	n/a	n/a
CRPS02	36/m/L	19	80	16% increase	hand perceived as smaller	10mm	26
CRPS03	30/f/L	66	80	13% decrease	Hand twice as large	2mm	23

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CONCLUSIONS:

Perceived size is different from that of objective assessment. We acknowledge that these preliminary data are too small to make statistical comparisons.

FOOTNOTES/REFERENCES:

1.Scadding J. Textbook of Pain. 1999:835–849. [Google Scholar]
2.Forderreuther S, Sailer U, Straube A. Pain. 2004;110(3):756–761. doi: 10.1016/j.pain.2004.05.019. [DOI] [PubMed] [Google Scholar]
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Pain Res Manag. 2010 Mar-Apr;15(2):108.

P59 Pharmaco-Epidemiology of Chronic Non Cancer Pain (CNCP) Patients Assessed at the Point of Entry to a Tertiary Care Pain Clinic

Angela Mailis-Gagnon ¹, Balaji Yegneswaran ², S Fatima Lakha ³, Ada Louffat ⁴, Amol Deshpande ⁵

Abstract

AIM:

To describe the opioid prescribing patterns of community physicians for CNCP patients entering a tertiary pain clinic.

METHODS:

Cross-sectional study of 455 consecutive CNCP patients over one year period. High Opioid Users (HOU) received > 200mg Morphine Equivalents (ME) daily. Patients were classified in Group I (pure biomedical pathology), Group II (mixed biomedical causes and psychological factors) and Group III (no detectable physical pathology but psychological factors were considered important) (DSM IV TR2000 classification).

RESULTS:

Female to male ratio was 1.2/1. Opioids were prescribed in 55.6%; 1/5 opioid users was HOU; 52.7% of Group I patients were opioid users but consumed the lowest level of opioids (F= 58.1 ±75.7 ME; M = 93.9 ± 124.4 ME), while 62.7% of Group III patients with no detectable pathology used opioids and 1/3 were HOU. Men received substantially higher doses of opioids and were 3 times more likely to be opioid users and 2.5 times more likely to be HOU as compared to females. Canadian born males and females were 5 and 3.75 times respectively more likely to be HOU as compared to foreign born. Oxycodone containing preparations were by far the most commonly prescribed opioids. Patients were much more likely to be prescribed opioids than NSAIDS for MSK pathology and anti-epileptics for neuropathic problems.

CONCLUSIONS:

The data shows that the typical HOU patient is a Canadian born male, 40–55 years of age, unemployed, with significant psychiatric co-morbidity and little biomedical pathology, who receives primarily oxycodone preparations ± other opioids.

Pain Res Manag. 2010 Mar-Apr;15(2):108.

P60 Pain Management in Primary Care

Yolanda Martens van Hilst ¹, Isabel Martin ¹, Chris Spanswick ², Lorraine Bucholtz ³, Rick Ward ⁴

Abstract

AIM:

A. Description of the initiative

Primary Care Networks (PCN) are a tri-partite relationship between the Alberta Health Services (AHS), Alberta Health and Wellness (AHW) and the Alberta Medical Association (AMA). Of the Calgary population, 20% have chronic pain and 3% have severe chronic pain. It is estimated approximately 48,000 patients within the Calgary Foothills PCN catchment area may have chronic pain. Calgary Foothills PCN physicians identify a need for further resources for patients. The Chronic Pain Centre, Calgary Pain Program, Alberta Health Services (CPC) showed interest in increasing access for the patient with chronic pain through developing partnerships with primary care and education. The Calgary Foothills PCN and CPC launch a pain management program on September 1, 2009.

METHODS:

B. Objectives

To develop a strong integrated service for patients with non-complex chronic pain
To improve access for patients with chronic pain while offering direct support for physicians and other health care providers
To optimize multi-disciplinary care for chronic pain patients
To decrease the number of non complex patients waiting for assessment at the CPC
To develop physician and multidiscipline team chronic pain leaders throughout the CFPCN

RESULTS:

C. Project description

Multi-professional primary care teams skilled in managing patients with chronic pain
Tele-chronic pain consultation service
CFPCN non-complex chronic pain management primary care clinic
Increase chronic pain primary care education opportunities
Podcast education on chronic pain topics
Lunch and learn sessions
MainPro-C course
Identify and assertively treat acute care injuries (<6 weeks) and potentially decrease the incidence of the development of chronic pain
Utilize chronic disease management and living well or other community programs
Work closely with the CPC to estimate the long-term impact of the program on health care resource

CONCLUSIONS:

The Calgary Foothills Primary Care Network and AHS Chronic Pain Centre launched a Primary Care pain management program on September 1, 2009.

Pain Res Manag. 2010 Mar-Apr;15(2):108.

P61 The Experience of Learners in the University of Toronto Interfaculty Pain Curriculum Simulation Trial

Michael McGillion ¹, Sara Promislow ¹, Judy Watt-Watson ¹, Judith Hunter ¹, Jennifer Stinson ¹, Fiona Campbell ², Helen Grad ³, Andrea Cameron ³, Lalitha Raman-Wilms ³, Thuan Dao ³, Leila Lax ³, Sheila O’Keefe-McCarthy ³, Lynn Cockburn ³, Robyn Davies ³, Cindy Shobbrook ³, Louise Rose ³

Abstract

AIM:

Health care professionals have misbeliefs about pain that contribute to ineffective pain assessment. As part of the 2009 University of Toronto Interfaculty Pain Curriculum (UT-IPC) trial, this study explored the experiences of pre-licensure health sciences students in two different simulation-based interventions designed to improve learners’ knowledge of pain-related misbeliefs and pain assessment. These included standardized patients (SP) and deteriorating patient-based simulation (DPS).

METHODS:

One hundred and fifty inter-professional students were randomized to a three-hour SP or DPS intervention. Participants completed a post-intervention questionnaire with open-ended questions regarding their intervention experiences, perceived knowledge acquisition, and anticipated changes in practice.

RESULTS:

Qualitative questionnaires (n=122) were coded for major themes by two independent raters with a high level of inter-rater agreement. Salient themes among participants’ responses from both arms of the study (SP and DPS) point to a perceived increase in knowledge about pain misbeliefs and management. Participants in both groups reported an increase in their understanding of different professional approaches and roles, and anticipated the use of an interdisciplinary approach in patient care. Direct comments on the simulation-based methods were limited (n=18); however, some preference for the SP method was apparent (n=10).

CONCLUSIONS:

The findings suggest that both DPS and SP are viable, effective and satisfactory methods for pre-licensure inter-professional education on pain-related misbeliefs, with comparable impact on learning.

Pain Res Manag. 2010 Mar-Apr;15(2):108–109.

P62 Methadone Pain Program - Lessons Learned

Don McIntosh ¹, Chris Spanswick ²

Abstract

AIM:

Review outome of rotating patients to methadone from other opioids for the treatment of refractory chronic pain.
Examine obstacles and solutions in an attempt to optimize analgesia and minimize side effects from methadone therapy.
Confirm analgesic potency conversion ratio vs. that in published literature.
To develop a clinical pathway to ensure safe practice.

METHODS:

Combined retrospective and prospective study to gain qualitative and quantitative data with respect to outcomes including pain measures, morphine equivalent daily dose, final methadone dose, side effects and global impression of change.

Method of rotation was achieved with a modified 3-stage rotation as originally specified by M. Lynch, Pain Res Manage, Vol 10 No. 3 Autumn 2005.

RESULTS:

A majority of patients described a positive experience with 63% of patients reporting better pain control, 21% returned to their previous opioid and 16% described little difference between methadone and their previous opioid. Two patients described their pain as worse.

Average conversion ratio appeared to be approximately 10 : 1. The majority of patients converted over a 3 week period to methadone with few requiring a more extended conversion period. A small percentage of patients seemed to find beneficial effect from a combination of a second opioid with methadone. In addition, there was an impression of improvement in aberrent behaviour once stabilized on methadone.

CONCLUSIONS:

For a select group of patients, a rotation to methadone was beneficial in terms of analgesia, reduced side effects, maintenance of stable dosing and reduction of aberrent drug behaviour. Published data on dose equivalence (Lynch) appear to represent a safe methodology in conversion to methadone. It is possible to establish a clinical pathway to rotation in this patient group.

FOOTNOTES/REFERENCES:

1.Lynch ME. A review of the use of methadone for the treatment of chronic non-cancer pain. Pain Research & Management. 2005;10(3):133–144. doi: 10.1155/2005/286713. [DOI] [PubMed] [Google Scholar]

FOOTNOTES/REFERENCES:

1.Guite JW, logan DE, McCue R, Sherry DD, Rose JB. parental beliefs adn worries regarding adolescent chronic pain. Clinical Journal of Pain. 2008;25(3):223–32. doi: 10.1097/AJP.0b013e31818a7467. [DOI] [PubMed] [Google Scholar]
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6.Lynch AM, Kashikar-Zuck S, Goldschneider KR, Jones B. Psychosocial risks for disability in children with chronic back pain. The Journal of Pain. 2006;7:244–251. doi: 10.1016/j.jpain.2005.11.001. [DOI] [PubMed] [Google Scholar]
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Pain Res Manag. 2010 Mar-Apr;15(2):110.

P67 Methodology of a Web-Based Observational Study to Evaluate The Impact of Opioid Tolerability Issues on Chronic Pain Management

Kevin Rod ¹, Joseph Kozak ², Krista Payne ³, Rosanna S Prinzo ⁴

Abstract

AIM:

An observational study enrolling approximately 200 chronic pain patients from 15 centres, is being conducted across Canada to assess the clinical and economic impact of opioid tolerability related outcomes on chronic pain treatment patterns, including adherence.

METHODS:

To capture a thorough representation of opioid exposure, eligibility criteria are: opioid naive or opioid experienced patients diagnosed with non-malignant chronic pain requiring opioids for >=4 days per week. Eligible patients are invited to participate by their physician during routine care appointments at family or pain medicine practices. Interested and eligible patients are directed to a website where they provide consent and then complete a weekly on-line questionnaire documenting their chronic pain experience over a 3 month period. The anonymized, password protected, web-based survey can be completed at home; data entry reminders are issued via email and telephone. At the end of the study, physicians collect opioid prescription regimen data retrospectively from the charts of each consenting patient and enter these data into the study website.

RESULTS:

Assessments include pain severity via the Numerical Rating Scale, opioid treatment adherence, concomitant medication surveillance, impact of opioid tolerability on activities of daily living, medical resource use, quality of life and productivity.

CONCLUSIONS:

Data will inform unmet care needs and health economic analyses.

Pain Res Manag. 2010 Mar-Apr;15(2):110.

P68 The Development and Implementation of an Inter-Professional Orientation Program for the Delivery of Outpatient Chronic Pain Services: Improving Resource Utilization

Gail Sloane ¹, Doug Cane ¹, June Trenholm ¹, Shelley LeDrew ¹

Abstract

AIM:

The aim of this poster is to examine the role of a new orientation program in the delivery of outpatient chronic pain services. It is also to examine the impact of no-shows on the overall delivery of scarce chronic pain care. Further to report the patient evaluation of the program.

METHODS:

Some evidence is available in the chronic pain literature identifying the impact of patient and/or family orientation programs in outpatient healthcare service delivery. The impetus to develop this new program at the chronic pain clinic was the significant number of patient no-shows and extensive chronic pain waitlist. Using existing resources an inter-professional orientation program for new patients to the chronic pain clinic was offered once a month. The patients were asked to complete program evaluations and no-show rates were collected on a monthly basis.

RESULTS:

We report the no-show data from the year prior to the orientation program and then data from the year after the program was initiated. Further we report the patient evaluation data including quantitative and qualitative data. Additionally, we report the operational issues that impact the consistent delivery of the orientation program.

CONCLUSIONS:

Patient no-show rates have significant impact on appropriate healthcare resource use in the delivery of outpatient chronic pain services.
The development and implementation of an inter-professional orientation program has provided an active process to address resource use concerns in the delivery of outpatient chronic pain services.
The data supports the assertion that the implementation of the chronic pain clinic orientation program has both practical and ethical implications in the delivery of a high demand service.
Upfront communication prior to entry into the chronic pain clinic provides opportunity for questions and concerns to be discussed prior to the medical assessment.
Identification of this resource use issue has implications for other CP Centres across Canada as the demand for chronic pain services increases.

FOOTNOTES/REFERENCES:

1).The Global challenge of Health Care Rationing : State of Health Coulter A, Ham, editors. 2000.
2).An Ethical Analysis of Crisis in Chronic Pain Care: Facts, Issues and Problems in Pain Medicine; Part I (Giordano J, Schatman ME.2008 [PubMed]

Pain Res Manag. 2010 Mar-Apr;15(2):112.

P73 The Nova Scotia Chronic Pain Collaborative Care Network (NSCPCCN) Mentor and Mentee Workshop Assessment Data

Peter MacDougall ¹, Sara Whynot ¹, Michele Chapell ², Michael Cord ³, Spencer Tighe ⁴

Abstract

AIM:

The NSCPCCN is a mentor - mentee network designed to provide clinical support, continuing professional development (CPD) and knowledge translation (KT) to primary care practitioners (PCP’s) in in the community. The network was initially launched as a pilot project in one health care district in Nova Scotia. The goal of this study was to determine the baseline characteristics of mentors and PCP mentees at the inauguration of the NSCPCCN through a two day workshop.

METHODS:

A two day workshop was held to launch the NSCPCCN. The first day of the workshop consisted of training for mentor physicians. A questionnaire was provided to the mentors at the end of the session to determine the mentors understanding of the concept of mentoring in this framework. The second day of the workshop was devoted to matching mentor - mentee groups. Data was collected from the mentee physicians to determine the impact of chronic pain on their practice, initial satisfaction with chronic pain management, opioid prescribing and the rate of aberrant opioid behavior screening.

RESULTS:

Mentorship data was expressed in Likert scales from 0 (strongly disagree) to 5 (strongly agree). Of the 7 mentors responding, 6 had no previous similar mentoring experience. Confidence in mentoring, understanding the values of the NSCPCCN and the expectations of the NSCPCCN averaged 3.9/5, 3.4/5 and 3.1/5 respectively. The ability to describe mentoring models, know when to chose the most approrpiate mentor role and confidence in functioning as a mentor in this setting averaged 3.1/5, 2.3/5 and 3.4/5.

The average number of visits for chronic pain was 43/month with a range of 2 – 125. Visit duration ranged from 15 to 400 minutes. The average time without the 400 minute outlier was 22 minutes. Average non-compensated time was 13 minutes. Satisfaction with chronic pain management and opioid prescribing averaged 3.4/5 and 3.7, respectively. The average number of patients screened for aberrant opioid behavior and suspected of same are 22.6 and 5 respectively.

CONCLUSIONS:

Mentors entering the NSCPCCN were unlikely to have acted as mentors in the past. However, the mentors had a reasonable grasp of the concepts of mentoring. Mentee practices demonstrate a wide variation in visits for chronic pain. Non-compensated time was similar to that reported previously (1). Aberrant opioid screening and suspicion of this behavior was much higher than in previous groups (1).

FOOTNOTES/REFERENCES:

1.Chappell, et al. Canadian Pain Society Annual Meeting2009. Abstract. [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):112.

P74 Sex Differences in the Effects of Attention on The Neural Response to Non-Painful Sensory Stimuli

Christine Popovich ¹, Colleen Dockstader ², Douglas Cheyne ², Rosemary Tannock ²

Abstract

AIM:

To determine whether males and females differ in attention modulation of sensorimotor mu rhythms in response to non-painful somatosensory information. Sex-related differences have been found in cortical oscillations (specifically, the 8–12 Hz mu frequency band) in response to painful stimuli, but it is unclear whether differences also occur in response to non-painful stimuli and whether there are sex differences in attention to sensory stimuli.

METHODS:

We used magnetoencephalography to capture mu oscillation in the primary somatosensory cortex in response to non-painful transcutaneous median nerve stimulation (MNS) in 10 female and 10 male healthy adults, aged 21–36 years. Stimuli were presented in trains of four (ISI: 2s) followed by a 4-sec gap for a total of 83 trains over 14 minutes. Participants completed two counterbalanced conditions: attend to a videoclip while ignoring MNS; attend to MNS and ignore the videoclip.

RESULTS:

Females showed strong and prolonged mu suppression when attending to MNS stimuli, whereas males showed brief mu suppression followed by mu enhancement. Since mu suppression reflects stimulus processing and mu enhancement reflects cortical inhibition of that region, our findings indicate that females engage in intensive and extensive processing of the sensory stimuli, when directing attention to the stimuli, whereas males engage in brief sensory processing, then inhibit further processing.

CONCLUSIONS:

Sex-related differences in attentional processing of sensory stimuli might account in part for the well-documented greater pain sensitivity in females and their decreased response to pain-therapies involving redirection of attention away from nociceptive information.

Pain Res Manag. 2010 Mar-Apr;15(2):112.

P75 Knowledge Translation in Pain Education: Is the Message Being Understood?

Erica Weinberg ¹, Philip A Baer ²

Abstract

AIM:

To assess whether new clinical and scientific information potentially impacting pain management is being translated into daily clinical practice at the primary care level in Canada.

METHODS:

Over 190 health care professionals, mostly primary care physicians, were surveyed at a number of CME events in 2009 for current knowledge in pain management. Multiple choice questions regarding prevalence of chronic pain, screening for opioid misuse risk, acetaminophen dosing, risk factors for NSAID-induced GI events, and codeine metabolism were posed.

RESULTS:

In 2009, the majority of respondents were aware of the prevalence of chronic pain in Canadian adults. However, clinicians are still not fully aware of issues surrounding codeine metabolism, maximum safe acet-aminophen dosing in chronic usage, and the increased GI risk of SSRIs used concomitantly with NSAIDs. Only 18.1% of clinicians used validated tools for screening opioid misuse risk prior to initiating opioids, and 20.3% still do not routinely screen their patients at all.

CONCLUSIONS:

Continuing medical education in proper pain management and risk stratification is still required.

FOOTNOTES/REFERENCES:

1.Food and Drug Administration. Organ-Specific Warnings. Internal Analgesic, Antipyretic, and Antirheumatic Drug Products for Over the-Counter Human Use. Final Monograph Federal Register. 2009 Wednesday, April;74(81) [PubMed] [Google Scholar]
2.Chou R, et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. The Journal of Pain. 2009 Feb;10(2):113–130. doi: 10.1016/j.jpain.2008.10.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Macfarlane GJ, et al. Managing low back pain presenting to primary care: Where do we go from here. Pain. 2006;122:219–222. doi: 10.1016/j.pain.2006.03.013. [DOI] [PubMed] [Google Scholar]

Pain Res Manag. 2010 Mar-Apr;15(2):112–113.

P76 The Illness Perception Questionnaire-Cancer Pain Chinese Version (IPQ-CAPC): The Pilot Testing in Taiwanese Patients with Cancer-Related Pain

Shu-Liu Guo ¹, Doris Howell ¹, Judy Watt-Watson ¹

Abstract

AIM:

Studies suggested that pain intensity may be related to patients’ beliefs about cancer pain and pain medication. Most measures examined cancer patients’ beliefs have focused on barriers to pain management. Moss-Morris et al. developed the Illness Perception Questionnaire-revised (IPQ-R) based on Leventhal’s Self-Regulatory Model. The multiple components of IPQ-R, which were labeled as Identity, Cause, timeline, Consequences, and Cure/Control, was used to assess patients’ representation about illness and also was determined the association with their health behaviour on various illnesses. IPQ-R has not been used to explore Taiwanese patients’ beliefs about cancer pain that may influence pain perception. Therefore, the purpose of study is to examine the validity and feasibility of the Illness Perception Questionnaire-Cancer Pain Chinese version (IPQ-CaPC).

METHODS:

The English version IPQ-CaP will be translated into Chinese and evaluated for relevance to Taiwanese cancer patients by 5 oncology pain experts. Content validity will be measured using a 4-point scale. The item-rating scale appears to be: 1=not relevant, 2=somewhat relevant, 3=quite relevant, 4=highly relevant. The translated IPQ-CaP will also be examined for its face feasibility by 10 cancer patients in Taiwan. Those same patients will be asked to repeat completing IPQ-CaPC after three days for test-retest reliability. One question for the face feasibility is how long you take to answer completely the questionnaire. The test-retest reliability with the Pearson’s correlation will be determined.

RESULTS:

This study will provide data about the relevance and feasibility of the Illness Perception Questionnaire-Cancer pain Chinese version (IPQ-CaPC) for this population as the first phase of a larger study on the influence of beliefs about cancer pain and management on the pain experience and analgesic use of Taiwanese patients with lung or colorectal cancer.

CONCLUSIONS:

A feasible and relevant measure is needed to explore beliefs about cancer pain and management of Taiwanese cancer patients with pain.

Pain Res Manag. 2010 Mar-Apr;15(2):113.

P77 A Dissertation Proposal: An Experimental Investigation of the Role of Anxiety in Children’s Memories for Pain and Pain Processing

Melanie Noel ¹, Christine T Chambers ², Patrick J McGrath ³, Raymond M Klein ⁴, Sherry H Stewart ⁵

Abstract

AIM:

The study will systematically examine the impact of state anxiety on the development of children’s memories for a painful experience. It will also examine the role that these memories play in children’s distress and coping during subsequent exposure to the same painful experience. Finally, more stable anxiety-related variables that have been shown to increase pain perception (e.g., trait anxiety and anxiety sensitivity) will be measured to determine the roles that these variables play in the development of children’s memories for pain.

METHODS:

One hundred healthy children aged 8 through 12 years will undergo an experimental pain task (the cold pressor task; CPT). Half of the children will be randomly assigned to complete a stressful task (Trier Social Stress Test for Children) prior to the CPT. Children will complete measures of pain intensity (Faces Pain Scale-Revised), pain affect (Facial Anxiety Scale; Facial Affective Scale), state and trait anxiety (State Trait Anxiety Index for Children; STAIC), anxiety sensitivity (Child Anxiety Sensitivity Index) and a memory interview immediately following the pain task and 2 weeks later. Children will repeat the pain task 1 month later to determine how their memories affect distress and coping during subsequent exposure to the same painful stimulus. Child distress and coping during completion of the pain task will be coded using the Child-Adult Medical Procedure Interaction Scale-Revised.

RESULTS:

(pending)

CONCLUSIONS:

The results will address current gaps in the literature and may be used to develop interventions that target anxiety and pain experienced by children during painful medical procedures thereby improving their health into adulthood.

Pain Res Manag. 2010 Mar-Apr;15(2):113.

P78 Examination of Modulatory Interactions Between Sensory Neurons and Chondrocytes

Maral Tajerian ¹, Magali Millecamps ², Laura Stone ³

Abstract

AIM:

Determine if chondrocytes release modulators that alter neurite outgrowth.
Determine if chondrocytes release modulators that activate sensory neurons.
Determine if sensory neurons release modulators that activate chondrocytes.

METHODS:

Cell culture: Chondrocytes: The chondrocyte culture system and protocols for their phenotypic validation will be performed as described previously (1). Sensory neurons: Mouse DRG cultures will be derived as described by Malin et al (2). Co-culture: Chondrocytes will be seeded on the permeable membranes of Transwell cell culture inserts. A single culture media that can maintain both cell types will be used.

Chondrocyte modulation of neurite outgrowth: DRG cell bodies will be labeled with a preparation of the membrane dye DiI developed specifically for cell culture. The DiI will be incorporated into growing axons and can therefore be used for neurite detection. DRG cultures will be grown in the presence of inserts containing chondrocytes (or empty insert controls). Neurite outgrowth will be quantified 1, 3 and 6 days later as previously described (3).

Chondrocyte modulation of sensory neuron excitation: Neuronal activation will be assessed by Ca2+-imaging following application of chondrocyte-conditioned media. We will use microspectrofluorimetry to monitor changes in [Ca2+]i neurons loaded with Ca2+-sensitive dye fura-2. Cells loaded with fura-2 will be placed in a chamber mounted on an inverted microscope and conditioned media will be applied using. Changes in fluorescent emission at 510 nm, following alternate excitation at 340 and 380 will be recorded using a cooled CCD camera. Images will be collected and analyzed using image analysis software.

Neuronal modulation of chondrocytes: Same as previous paragraph, except the cells will be reversed.

RESULTS:

Pending

CONCLUSIONS:

Significance of the proposed studies: There is an emerging literature suggesting complex bi-directional modulation between chon-drocytes and the sensory nervous system. It has been shown, for example, that increased innervation of intervertebral discs is associated with chronic low back pain (4). In addition, abnormal nerve ingrowth is reported at the osteochondral junction of degenerating arthritic joints (5). These and other studies suggest that joints release modulators that stimulate neurons.

FOOTNOTES/REFERENCES:

1.Lefebvre V, Garofalo S, Zhou G, et al. Matrix Biol. 1994;14(4):329. doi: 10.1016/0945-053x(94)90199-6. [DOI] [PubMed] [Google Scholar]
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[b1-prm15073] 1.Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999;81(1–2):129–134. doi: 10.1016/s0304-3959(99)00006-8. [DOI] [PubMed] [Google Scholar]

PERMALINK

Canadian Pain Society Conference May 12 – 15, 2010, Calgary, Alberta

1 Breaking Barriers In Breakthrough Cancer Pain

Neil Hagen, MD

Dr Dwight Moulin, MD

Dr Bruno Gagnon, MD

Roles

Abstract

Learning Objectives:

BRIEF DESCRIPTION:

REFERENCES

1A Pathophysiology and Characteristics of Breakthrough Cancer Pain

Dwight Moulin, MD

1B Managing Breakthrough Cancer Pain – Current Practice, Gaps in Treatment Management

Bruno Gagnon, MD

1C Breakthrough in Treating Breakthrough Cancer Pain – A New Therapeutic Option

Neil Hagen, MD

2 Phenomics of Pain in Humans and Rodent Models

Michael McGillion

Ze’ev Seltzer

Roles

Abstract

Learning Objectives:

BRIEF DESCRIPTION:

3 Contributions of the CNS to Functional Pain Syndromes

Petra Schweinhardt, MD, PhD

Karen D Davis, PhD

Herta Flor, PhD

Roles

Abstract

WORKSHOP OBJECTIVE:

Learning Objectives:

3A CNS Abnormalities in Patients with Irritable Bowel Syndrome

Karen D Davis, PhD

Abstract

BRIEF DESCRIPTION:

3B Psychobiological Aspects of Chronic Pain in Children

Herta Flor, PhD

Abstract

BRIEF DESCRIPTION:

3C Brain Alterations in Fibromyalgia

Petra Schweinhardt, MD, PhD

Abstract

BRIEF DESCRIPTION:

4 National Guideline Development - Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Andrea D Furlan, MD PhD

Angela Mailis-Gagnon, MD MSc

Clarence Weppler, B.Sc Pharm

Roles

Abstract

WORKSHOP OBJECTIVE:

Learning Objectives:

4A The Development of the Nougg’s Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Andrea D Furlan, MD PhD

Abstract

BRIEF DESCRIPTION:

4B Key Messages from the Nougg Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Angela Mailis-Gagnon, MD MSc

Abstract

BRIEF DESCRIPTION:

4C Implementing the Nougg Guideline to Practice

Clarence Weppler, B.Sc Pharm

Abstract

BRIEF DESCRIPTION:

5 Using the Alberta Primary Care Low Back Pain Guideline in Practice

Paul Taenzer

Ted Findlay, DO, CCFP

Christa Harstall, MHSA

Roles

Abstract

WORKSHOP OBJECTIVE:

Learning Objectives:

6 Developing a Pain Management Team in Primary Care: The Calgary Foothills Primary Care Network Pain Management Team

Chris Spanswick, MB ChB

Isabel Martin, MD

Yolanda Martens-van Hilst, RN

Roles

Abstract

WORKSHOP OBJECTIVE:

Learning Objectives: