Abstracts

Acute Pain

001

Do patients suffer more pain when trainees changeover?

Category: Acute Pain

Swinda Esprit, Colm Lanigan

University Hospital Lewisham, London, UK

Background

The first Wednesdays in August and February are the annual changeover days, when UK junior doctors swap their rotational posts. Whilst these doctors may feel anxious starting at a new institution, it has been suggested that patients should also be anxious at this time because patients admitted to English hospitals on the August changeover day have a higher early death rate compared to those admitted on the previous Wednesday [1]. Fatal medication errors have similarly been linked to the July changeover in the United States [2]. We wondered if UK changeover dates affect post-operative pain.

References:

1. Jen M.H, Bottle A, Majeed A, Bell D, Aylin P. Early In-Hospital Mortality following Trainee Doctors’ first day at work. PLoS ONE Sept 2009;4(9): e7103.

2. Phillips D.P., Barker G.E.C. A July spike in fatal medication errors: a possible effect of new medical residents. Journal of General Internal Medicine 2010 Aug; 25(8):774-9

Methods

We retrospectively analysed the Acute Pain database at University Hospital Lewisham between 01/08/2001 & 12/09/2011. The percentage of patients with moderate to severe pain on movement on day one post-operatively was noted for all patients with an epidural infusion or a patient controlled opioid analgesia (PCA) pump in each of the 10 years for four 30-working-day periods before and after the trainee changeover dates in August and February: Group A=Aug/Sept; B=Nov/Dec; C= Feb/Mar & D= May/June. Median values and 10-90% centile ranges were calculated. Chi-squared statistical analysis was used to compare the groups.

Results

1. Epidural patients with moderate/severe pain: Total numbers (n),median, (10-90%)centile range for the 10 years in each group: Group A:407, 25% (17-36%). Group B:357, 14%, (10-34%). Group C:329, 22% (10-34%). Group D:476, 17%, (15-32%). Pain scores were worst after the August changeover- A (Chi-squared analysis, P<0.01 compared to B, and P<0.05 compared to D.)

2. PCA patients with moderate/severe pain: Total numbers (n), median (10-90%)centile range for the 10 years in each group: Group A: 796, 25% (12-34%), Group B: 756, 30% (18-40%), Group C: 689, 29% (12-37%), & Group D: 899, 29% (13-32%): no statistical difference found between groups after Chi-squared analysis.

Conclusion

The proportion of epidural patients with moderate to severe pain seems to be greatest following a changeover period, with the greatest difference seen between A & B and A & D. Such an association was not seen with PCA, which may reflect the decreased complexity of PCA compared to epidural analgesia, which generally involves a simpler protocol common to most hospitals. Our results suggest that patients with epidurals suffer more pain when trainees start new posts. Trainee changeover periods should allow time for adequate induction and competency assessments in local hospital procedures and protocols to maximise good quality pain control.

002

A prospective snapshot audit on pain after sternotomy in children undergoing cardiac surgery in a tertiary level paediatric hospital in 2011

Category: Acute Pain

Senthil Jayaseelan¹, Annette Davis²

¹Mersey Deanery, Liverpool, Merseyside, UK, ²Alder Hey Children’s NHS Foundation Trust, Liverpool, Merseyside, UK

Background

Effective pain management affects morbidity and duration of hospital stay[Dolin SJ et al. BJA 2002]The aim of the audit was to evaluate the incidence of post operative pain in children having sternotomies for various congenital heart diseases.

There are only a few centres in the United Kingdom which perform paediatric cardiac surgical procedures routinely and the Alderhey Childrens’ hospital at Liverpool is one of them. No patient should return to the ward in uncontrolled pain where problems will escalate. This may be defined as a pain score of 4 or more on a VAS[RCoA(Acute Pain Services)-Raising the Standard: a compendium of audit recipes; American Pain Society Quality of Care Committee, JAMA 1995].There is a good correlation of FLACC with VAS scores as a measure of pain in children[Terri Voeper-Lewis et al. Anesthesia and Analgesia 2002]

An understanding of the incidence and degree of pain would help to improve the quality of care in these sick children.

Methods

Audit Standards-[Royal College of Anaesthetists-Raising the Standard: a compendium of audit recipes-Acute Pain Services]1.No patient should return to the ward in uncontrolled pain[pain score of 4 or more] 2. Failure of analgesia should be detected within 2 hours and managed effectively 3.100% patients with acute pain should have a completed record of pain scores.

Data collection-Data collection was done on an Alderhey audit department approved form over 3 months starting from August 2011 as a prospective audit. All patients intubated greater than 24 hours were excluded. Patients were followed up on Paediatric Intensive Care Unit and subsequently on the ward for a total of 72 hours post operatively. Pain scores were recorded using developmentally appropriate pain scales by nursing staff and they were collected along with the pain management interventions throughout this period.

Results

The total number of patients after applying the exclusion criteria - 30.

Gender-16 females and 14 males.

ASA grades- 9[ASA 2], 18[ASA 3], 3[ASA 4]

Surgical prodecures-ASD repair[6],Complete AVSD repair[3], VSD repair[4], Partial AVSD repair[4],Fallots repair[3],Aortic valve repair[3], Mitral valve repair[3], Completion of Fontan’s[2],Rastelli procedure[1], Redo TAPVD[1]

Intraperative analgesia- Opioid infusion in all patients[Fentanyl/Morphine].Ultrasound guided single shot paraveretebral injections were done in 7 out of 30 patients after induction of anaesthesia. 23 patients also received intraoperative paracetamol.

Postoperative analgesia- Morphine/Fentanyl-NCA/PCA as standard in all patients. Other drugs used-IV/Oral paracetamol,codeine, NSAIDs and tramadol alone or in combination.

Pain scores: 1st 24 hours=Less than 4[58%], Score of 4 or more[36%], Not recorded[6%]

2nd 24 hours=Less than 4[68%], Score of 4 or more[22%], Not recorded[10%]

3rd 24 hours=Less than 4[65%], Score of 4 or more[16%], Not recorded[19%]

2 cases of chest infection were reported in the 3 month period because of poor pain control.

Conclusion

1. Lower pain scores were not achieved in 100% of all paediatric cardiac surgical patients post procedure

2. Pain scores were not documented in 100% of the patients

3. Failure of analgesia was not detected within 2 hours and managed effectively in all patients

4. There was a disconnection between the analgesia received on PICU and what happened in the ward-a decision seems to be made to stop the NCA/PCA without proper establishment of oral analgesia and the patients became distressed.

Recommendation

- Team involvement[ Medical and Nursing staff] in managing pain proactively and effectively with good communication

- Education of all medical and nursing staff

003

Epidural survival rates - a re-audit

Category: Acute Pain

Payashi Garry², Sarah Kwok³, Jane Quinlan¹

¹John Radcliffe Hospital, Oxford, UK, ²Milton Keynes General Hospital, Milton Keynes, UK, ³Royal Berkshire Hospital, Reading, UK

Background

In 2008 we performed an audit evaluating the effectiveness of post-operative epidurals following the introduction of patient-controlled epidural analgesia (PCEA) in our trust. Factors influencing successful analgesia included use of the correct infusate, use of correct level for epidural positioning and appropriate timing of disconnection. Following the changes implemented as a result of these findings we carried out a study to assess our progress with PCEA. Data collection proved challenging on this occasion due to surgical services now being split over 2 separate sites with major abdominal surgery being performed at both. We also had concerns that post-operative epidural care on the wards had deteriorated since the segregation of emergency and elective abdominal surgery. The split site services meant that the pain team was more stretched by covering more wards, while also having to educate more junior doctors and ward nurses.

Methods

We conducted a prospective observational audit from June 2010 to February 2011 of 62 patients at the Churchill and John Radcliffe Hospitals who received post operative epidural analgesia. We investigated the number of attempts at insertion, the level of insertion, the surgical procedure and PCEA solution used. We also recorded when the infusate was started and whether this had impact on overall analgesic effect. Analgesia and side effects were assessed in recovery and on the ward each day post operatively by the inpatient pain team until the epidural was discontinued. Reasons for epidural discontinuation were also assessed to identify any inappropriate early cessation of the technique. We were then able to compare our current data with that from our previous audit to assess any change in practice.

Results

Our results show that 79% of patients received good analgesia upon arrival in recovery which, after rescue techniques, then rose to 91% on day 1. By day 2 this dropped to 68%. We believe this was because our sample group was small secondary to difficulties auditing across two sites and not due to fewer epidurals being performed. The vast majority of patients received the Trust’s standard prescription (0.1% bupivacaine with 5mcg/ml fentanyl). Eight patients experienced side effects on the ward including pruritus and motor block.

The accidental disconnection rate was 0%, an improvement from 12% found in the previous study. This may be due to the change in epidural sets being used. The most common intervention for a poorly working epidural was to increase the rate at which the infusate was running.

For major surgery, epidural infusions were run for up to 4 days post operatively.

Conclusion

PCEA remains a successful technique in our trust, and advice from the specialist pain service is sought and followed in most cases. However, with a smaller data set, we cannot make broad conclusions, but rather examine a sub-set of our patients. It appears difficult to audit split site services and greater encouragement of our anaesthetic colleagues is necessary in order to gather information and gain sufficient insight into our epidural performance. Interventions in recovery are a poor prognostic sign. Further education of surgical junior doctors and nursing staff is required to manage ward epidurals more effectively.

004

The impact of introducing a Trust-wide Pain Care Pathway for adult inpatients

Category: Acute Pain

Karin Cannons, Wendy Jardine

Frimley Park Hospital NHS Foundation Trust, Camberley, Surrey, UK

Background

In 2010 a Trust-wide care indicator compliance audit showed that, in some clinical areas, pain assessment was poorly done and documentation concerning analgesic efficacy was hard to locate or absent. Our aim was to improve documentation of analgesic efficacy, whilst also providing a prompt/educational resource to promote pain assessment and ensure safe high quality pain management. The Pain Care Pathway introduced by the Inpatient Pain Team, in collaboration with the Professional Development Team, was an A4 booklet whose front page contained information about pain assessment and actions to be taken based on that assessment. The subsequent 3 pages facilitated the documentation of care given by each bedside nurse on every shift including: analgesic efficacy, involvement of the Inpatient Pain or Palliative Care Team, and space to comment on the location of any pain with reasons for actions taken or not taken.

Methods

A monthly audit was performed by senior nurses across the Trust in all clinical areas using a series of questions about 10 key care indicators, including pain. 5 patients from each area were sampled. Each patient who reported pain was asked: ‘Do you think the staff did all that they could to control your pain?’ Documentation was then audited to ascertain if:

• Pain status assessed on admission

• Pain scores recorded with each set of clinical observations

• A Trust care plan evident for a patient requiring analgesia

• Patient reassessed when required

• Efficacy recorded for any analgesia administered

The answers were scored and collated into a matrix. The results from all clinical areas were then combined to provide a Care Indicator Compliance score for the Trust. Scores of 90% or over were considered ‘acceptable’/’green’; 75 to 89% ‘of concern’/’amber’; and 74% and below ‘unacceptable’/’red’.

Results

The Care Indicator Compliance score for pain in July 2010 was 75%. The pathway was piloted in August in the medical directorate (September score 83%), piloted in the surgical directorate in October (November score 85%) and launched Trust wide in December (January 2011 score 88%). By April 2011 (score 94%) the pathway was fully embedded and the December 2011 score was 97%. An audit of nursing staff opinion showed our staff welcomed the introduction of the tool, commenting that it served as an excellent summary of information required to ensure patient comfort and safe analgesic administration. Nurses used the pathway to structure their contact with medical staff to obtain analgesic prescriptions for patients with discomfort. The centralised contact information for the Inpatient Pain Team and Palliative Care Team facilitated staff obtaining support with complex problems, side effect management, or ongoing discomfort issues.

Conclusion

Pain is experienced by most hospital patients during their patient journey. Pain assessment is the means by which pain is discovered and treated. Many of the medications given for pain, such as opioids, have side effects which may present a risk to patient safety. It is essential that the effects of such medication are observed and recorded. The pathway empowered staff to continue to monitor the effects of analgesia once it had been correctly given. The ongoing presence of the pathway in every patient’s documentation ensures we are asking all patients about their pain, taking action and monitoring the effects.

005

Acute post-operative pain after caesarean section

Category: Acute Pain

Catherine Warnaby¹, Nicola Beale², Olga Kciuk¹, Nicola Brooks¹, Robin Russell², Irene Tracey¹, Jane Quinlan^1,2

¹Pain Imaging Neuroscience Group and FMRIB Centre, Nuffield Department Clinical Neurosciences, University of Oxford, Oxford, UK, ²Nuffield Division of Anaesthesia, Oxford University Hospitals, Oxford, UK

Background

Chronic post-surgical pain (CPSP) lasting for more than 3 months is well recognized and the incidence after caesarean section (CS) has been found to be 10-18%. Previous retrospective studies have shown that severe pain in the first week after surgery is a predictor of chronicity, but this may be confounded by recall bias. The Oxford Persisting Post-Operative Pain Study (OxPPOPS) is a prospective, longitudinal study to investigate the incidence of CPSP up to one year after surgery and identify predictive factors for its development. Among the factors under investigation are pre-operative psychology, surgical and anaesthetic techniques, acute post-operative pain, analgesic management and sleep. Early identification of at-risk individuals may enable the development of interventions to prevent conversion from acute to CPSP. We present early data from the OxPPOPS CS cohort detailing the trajectory of acute post-operative pain in the first month.

Methods

50 women (aged 18-45 years) undergoing planned CS after 34 weeks gestation were recruited. Women with pre-pregnancy painful or psychiatric conditions were excluded. Women were seen on the ward at 6h and 2 days after surgery, and were followed up by telephone interview at 7 and 30(±2) days post-operatively. Verbal and numerical (0-10) pain ratings at rest and on movement, information on the site of the pain and analgesia requirements were recorded at all time-points. Additionally, the ward/telephone interviews also contained the McGill Pain questionnaire, pain exacerbating verbal

descriptors, and a modified Pittsburgh Sleep Quality Index questionnaire.

Results

Using verbal descriptors, the frequency of women reporting pain at rest at 6h, day 2, day 7 and day 30 were 79, 65, 42 and 9% respectively. More women reported pain on movement with frequencies of 95, 100, 82 and 36% at the same time-points. At all time-points the numerical ratings on movement were significantly higher than at rest (all – p<0.0001). The severity of pain peaked at day 2 on movement: median (interquartile range) = 4(4). After day 2, the only two verbal reports of severe pain occurred on movement in two patients on day 7. At day 30, 6 of 50 women (12%) reported pain on movement of greater than 3/10, with 2 women also having pain at rest. Of these 6 women, the pain was located either in the wound (n=3), the wound and back (n=2), or the abdomen (n=1), for which 3 were taking simple analgesia.

Conclusion

The frequency and severity of pain at 6 hours is lower than day 2, potentially due to the residual effects of anaesthesia. Throughout the acute post-operative period, a distinction was found between pain at rest and on movement. Furthermore, we have identified outliers with elevated pain levels on movement in the acute post-operative period with an incidence consistent with previously reported CPSP after CS. Long-term planned follow up of the women in the CS cohort will reveal if the outliers do go on to develop CPSP, and whether pain on movement is a better predictor than pain at rest.

006

Wound infiltration catheters as part of our Enhanced Recovery After Colorectal Surgery program at Salford Royal Foundation Trust - do they make a difference? Our initial experience

Category: Acute Pain

Zara Townley, Rachel Meskell, Marie Murphy

Salford Royal Foundation Trust, Manchester, UK

Background

Enhanced Recovery After Surgery (ERAS) has become popular in a variety of surgical fields and wound infiltration catheters have been used as part of a multi modal analgesic approach in many enhanced recovery programmes. A recent systemic review by Liu et al demonstrated that wound infiltration catheters consistently reduced requirement for post op opioids and a reduction in post operative nausea and vomiting. They also showed that the catheters also reduced length of hospital stay with overall cost savings.

Rectus sheath catheters are commonly used for both open and laparoscopic colorectal procedures. As well as an initial bolus injection at the end of the surgery the placement of a catheter allows a continuous infusion which can be titrated according to the patient’s analgesic requirements.

Wound infiltration catheters were introduced at Salford Royal Foundation Trust in Nov 2010 as part of the enhanced recovery programme for lower GI surgery.

Methods

The aim of this study was to audit our first cohort of colorectal surgical patients to have wound infiltration catheters as part of their perioperative management looking specifically at their lengths of stay, post operative morbidity and also PCA usage. Since the wound infiltration catheters were introduced our Enhanced Recovery Nurse Practitioner has collected data for each patient - she was able to provide data for 22 patients who had wound infiltration catheters sited and 20 patients who did not. Further information about each patient and their surgery was obtained from the hospital database. The PCA usage for each patient was then obtained from one of our pharmacists. This data was then analysed and the two groups compared. We used Liu’s results as our standard.

Results

This study was able to demonstrate a shorter length of stay for the wound catheter group, although not statistically significant. However there was no difference in the post operative nausea and vomiting rates nor ileus rates and in fact the wound catheter group had slightly higher rates although again not statistically significant.

The wound catheter group also had a higher mean PCA use than the non catheter group but again not statistically significant.

There was no significant morbidity associated with the catheters themselves, however, one catheter snapped on removal from the patient.

Conclusion

There may be a number of explanations for these results and although the lengths of stay results are encouraging, the other results are less so and certainly our early experience of wound infiltration catheters does not match that of Liu et al. After discussion at the ERAS steering group meeting it was decided that wound infiltration catheters should continue to be used but in order to get a larger cohort of patients further data collection was required which would hopefully allow us to see some significant differences and make some comparison between different surgical procedures.

007

Fractured neck of femur analgesic bundle: reducing time to mobilisation post-operatively

Category: Acute Pain

Ingrid Seatter, Keir McIlmoyle, Ewan Jack

NHS Forth Valley, Forth Valley, UK

Background

Pain during the peri-operative period continues to be a major contributing factor towards morbidity and mortality in patients presenting with a fractured neck of femur (NOF). This patient group is often frail and elderly, and uncontrolled pain is an undue source of physiological and psychological stress. A recent randomised controlled trial showed that inadequate pain control increases the incidence of pneumonia, increases delirium and reduces time to mobilisation. Furthermore, recently published NICE guidelines on the management of hip fracture in adults highlight the need for a multi-system approach to pain relief, combining both regional and systemic analgesic techniques.

After feedback from the multi-disciplinary team and initial data collection in our unit, it was apparent that pain relief in this patient group was being managed sub-optimally, causing a delayed time to mobilisation and potential adverse effect on patient outcome.

Methods

The aim of our audit was to introduce a departmental analgesic bundle for all patients undergoing surgical repair of a fractured NOF. We speculated that introduction of the bundle would increase the number of patients receiving appropriate analgesia post-operatively, improve patients’ subjective pain scores and reduce the time to mobilisation.

The bundle highlighted four analgesic steps to be included. The steps were as follows:

1. Regional technique peri-operatively (neuraxial +/- regional block).

2. Regular oral or intravenous paracetamol.

3. Regular weak opiate (tramadol or dihydrocodeine recommended).

4. As required weak or strong opiate.

Data was collected over an eight month period (total 210 patients) after the analgesic bundle was initiated. Two patients were excluded due to severe cognitive dysfunction. Data collected included compliance with each step of the bundle and two measured outcomes: maximum documented pain score during the first 24 hours post-operatively and the time to mobilisation.

Results

Following the implementation of the analgesic bundle, the compliance with each step has increased. The number of patients receiving a regional block during their peri-operative management has increased by 19% and the percentage of patients receiving regular paracetamol has remained between 96-100%. Those receiving regular weak opiates and breakthrough analgesia have increased by 31% and 15 %, respectively. Resultantly, the percentage of patients complying with all four steps of the analgesic ladder has risen by 39% since introduction of the protocol.

The measured outcomes of maximum documented pain score in the first 24 hours and time to mobilisation have also improved. The percentage of patients mobilised on day one post-operatively has now risen by 42%, to 87% of patients. Additionally, 79% of patients now report nil or mild pain in comparison to 45% prior to implementation of the bundle.

Conclusion

By introducing an analgesic bundle, the number of patients prescribed appropriate analgesia has increased with a resultant improvement in pain control and reduced immobility post-operatively. This high risk patient group is known to have a mortality of approximately 5-10% at one month. Evidence would suggest that by reducing the time to mobilisation and improving pain control this may result in a reduction in morbidity, including the incidence of pneumonia and delirium. Data collection continues and we have now broadened the measured outcomes to include the incidence of delirium and the potential correlation with improved pain control.

008

Comparison of pain intensity in the first and second eyes during simultaneous bilateral lasik surgery

Category: Acute Pain

Dmitry Yakunchikov¹, Paul Dougherty², Harkaran Bains³, Gurpreet Sidhu⁴

¹HealthPointe Medical Centre, Edmonton, Alberta, Canada, ²Dougherty Laser Vision Institute, Camarillo, California, USA, ³CEROC, Paris, France, ⁴Alberta Health Services, Edmonton, Alberta, Canada

Background

Laser in situ keratomileusis (LASIK) is a safe and effective procedure for the treatment of refractive error. Intraoperative pain is frequently associated with LASIK, especially during application of the suction ring and translation of the microkeratome across the cornea to create the corneal flap. One of the authors of this study (PJD) observed anecdotally that patients noted greater pain in the second eyes compared with the first eyes during simultaneous bilateral LASIK surgery with a mechanical microkeratome. This study was designed to assess the occurrence of this phenomenon.

Methods

A prospective study was performed on 26 consecutive patients undergoing simultaneous bilateral LASIK (B&L Hansatome microkeratome/VISX Laser) by one surgeon (PJD). Immediately postoperatively, the subjects were asked to rate intraoperative pain in each eye on the numerical scale graded from 0 (no pain) to 10 (unbearable pain). The paired t-test was used to compare the mean pain score in each eye. P lower than 0.05 was statistically significant.

Results

The majority of the study cohort rated pain in their second eye as greater. The mean intraoperative pain score of 2.31 +/- 1.68 in the second eye was significantly higher (P lower than 0.05) than the mean intraoperative pain score of 1.36 +/- 1.41 in the first eye.

Conclusion

The incidence of increased pain intensity in the second eye during simultaneous bilateral LASIK surgery is high. The underlying mechanisms of this phenomenon are likely multifactorial and may involve such centrally mediated effects as anxiety-induced hyperalgesia, mirror-image mechanical allodynia and contralateral descending pain facilitation.

009

Mapping of central changes, using continuous arterial spin labelling, induced by post-surgical pain after third molar surgery before and after paracetamol infusion

Category: Acute Pain

Nadine Khawaja^1,2, Matthew Howard¹, Steven Williams¹, Tara Renton²

¹Centre for Neuroimaging Sciences, Institute of Psychiatry, King’s College London, London, UK, ²Oral Surgery Department, King’s College Dental Institute, London, UK

Background

Continuous arterial spin labelling (cASL), a perfusion MRI technique, provides quantitative measurements of regional cerebral blood flow (rCBF) throughout the brain. Previously we demonstrated the sensitivity of the technique to represent acute ongoing post-surgical pain. Here we intended to assess the sensitivity of cASL to represent changes in rCBF associated with a reduction in pain following administration of an analgesic. Intravenous paracetamol is one of the most commonly used analgesics in general surgery. However, its mechanism of action is not fully understood. This study examines the cerebral representation of paracetamol infusion resulting in attenuation of pain following third molar surgery (TMS).

Methods

Prior to and following TMS, 15 right handed males underwent a series of cASL scans during which they received saline and paracetamol infusions. VAS estimates of pain intensity were provided by participants during scanning.

Results

There was a marked reduction in pain scores following paracetamol infusion from 8/10 to 0.5/10. Preliminary results indicate that cASL detects a differential effect of intravenous paracetamol on pain following TMS. This is reflected by changes in rCBF between the saline and paracetamol infusions in brain regions including the anterior cingulate, somatosensory and insula cortices, and brainstem.

Conclusion

We provide early indications demonstrating that cASL is a sensitive marker for pharmacological modulation of brain activity as a result of attenuation of pain. This study provides scope for developing this technique as a pain biomarker in the development of novel analgesics. This study was funded by the Mildred B Clulow Award from the British Pain Society.

010

A survey of postoperative pain in a major hospital in Gaza: an initial step in a structured approach to the improvement of postoperative pain management

Category: Acute Pain

Rami Hamden¹, Gehad Al Gaeedy¹, Katherine Chatten^1,2, Atef Al-Tawafsheh^1,2, Basil Almahdi^1,2, Jeanne Frossard^1,2, John Beavis^1,3, Brigitta Brandner^1,2

¹Al-Shifa Hospital, Gaza city, Occupied Palestinian Territory, ²University College London Hospitals Trust, London, UK, ³International Disaster and Emergency Aid with Longterm Support, Kent, UK

Background

The World Health Organisation (WHO) has identified that the provision of pain relief with standardized policies is important in delivering an emergency and essential surgical service. Through collaboration with IDEALS (International Disaster and Emergency Aid with Longterm Support), SPIN (Specialists in Pain International Network), Al Quds Foundation for Medical Schools in Palestine, MAP (Medical Aid for Palestine) and UCLH ( University College London Hospital), it was possible to initiate a project at Al-Shifa Hospital, a major teaching hospital in Gaza, aiming to improve postoperative pain management. The initial step was to identify an anaesthetist and nurse to lead the project locally. The project uses a stepwise approach to the introduction of pain management tools, adapted from a UK based study (Gould 1992). This survey was designed to ascertain the adequacy of current postoperative pain management prior to the introduction of protocols for pain assessment and analgesic prescribing.

Methods

The survey was created as a simple tool to be administered within the first 24 hours postoperatively at Al-Shifa Hospital. Patients were asked to rate their pain on an 11 point numerical rating scale (0 = no pain and 10 = pain as bad as you can imagine) over the following time periods:

1. Worst pain in the past 24 hours

2. Least pain in the past 24 hours

3. Average pain in the past 24 hours

4. Pain right now

Patients were given the questions to read and circled their answers. The questions were written in English and Arabic. Participants unable to read or write for any reason were asked the questions verbatim and their answers were recorded by the anaesthetist completing the survey. Analgesia prescribed and received in the first 24 hours was documented. Data recorded were entered into a database and analysed using Excel.

Results

A total of 196 patients answered the survey over a two month period. Surgery included both elective and emergency operations. Operations were classified as General / Vascular (57%), Orthopaedic (16%), Obstetric (14%), Cardiac (5%), ENT (3%), Gynaecology (2%) and other (Plastics, Urology, Neurosurgery - totaling 3%).

Median pain scores were as follows:

1. Worst pain in the past 24 hours: 8

2. Least pain in the past 24 hours: 3

3. Average pain in the past 24 hours: 5

4. Pain right now: 2

Patients most commonly received diclofenac (75%) and tramadol (22.5%) intramuscularly. Morphine or pethidine were prescribed to be given in 9.2% as a rescue analgesic. Paracetamol was rarely given (1%), although available. The majority of patients did not receive all that they were prescribed.

Conclusion

This survey suggests that postoperative pain management at Al-Shifa Hospital can be improved. There are currently no formal hospital guidelines or protocols in place governing the frequency or type of assessments of postoperative pain. The intention is to introduce a pain assessment tool and an appropriate “pain ladder” to guide the systematic treatment of postoperative pain with available resources. Support and education to facilitate the introduction of this program is taking place with the Acute Pain Service at UCLH. This survey will be repeated in 6 months time to assess the impact of these changes.

011

The quality of pain scoring and analgesic prescribing in medical inpatients: cause for concern?

Category: Acute Pain

Graham Simpson, Mark Rockett

Plymouth Pain Management Centre, Plymouth, UK

Background

The prevalence and severity of pain suffered by medical inpatients is similar to that experienced by surgical inpatients. However we present evidence that the quality of pain management differs significantly between these two groups, despite the existence of evidence-based guidelines. In a recent national survey of acute pain service leads, 82% of respondents felt that pain management on medical wards was inadequate. Despite this, only 16% of UK hospitals have an acute pain service providing regular input into medical wards. The cornerstone of effective pain management is accurate pain assessment. In the study hospital, pain is recorded as the 5^th vital sign, using a nominal verbal rating scale (VRS) of none, mild, moderate and severe. Moderate and severe pain is considered significant and requires treatment. We compared the quality of pain scoring and prescribing practice between medical and surgical inpatients, in a UK Teaching Hospital.

Methods

All medical and surgical inpatients were asked to rate their worst pain in the last 24 hours using a four point VRS. Those with moderate or severe pain were invited to take part. Pain scores recorded on the participants’ observation chart within the last 24 hours were transcribed to the case report form (CRF), together with their self-assessed scores. Data were also collected from the participants’ inpatient drug charts and transcribed to the CRF prior to analysis.

Results

The prevalence of significant pain in medical inpatients (n=388) (M) and surgical inpatients (n=335) (S) was 19.9% and 16.7%. All group S patients had at least two appropriate analgesics prescribed. Of the group M patients, 35% had no regular analgesia prescribed and 38% were prescribed paracetamol only. Prescribing: Paracetamol (regularly S 97% v M 59%, as required S 0% v M 24%); Weak opiates (regularly S 24% v M 18%, as required S 23% v M 18%); Strong opiates (regularly S 5% v M 27%, as required S 68% v M 37%); Adjuvants (S 18% v M 18%). Overall group S received 94% of analgesic medications as prescribed, compared to 75% of group M. Assessment: Group M was commonly assessed as being pain free (M 47.2% v S 8.3%), having no pain assessment recorded (M 14.7% v S 5.5%), and having an incorrect pain score (M 80.6% v S 64%).

Conclusion

The data revealed that pain management for medical inpatients with significant pain was suboptimal. Pain scoring was frequently absent or inaccurate and prescribing practices did not follow local guidelines. Without the specialist skills of an acute pain service to provide adequate training and staff updates, the quality if pain scoring is poor. Subsequent to this audit, the nurse led acute surgical pain service has been replaced by a multi-disciplinary acute care team (ACT). The ACT is responsible for supporting every hospital ward, including medical inpatients. Audit will be undertaken to identify the impact of this new model on pain management.

012

Audit of inpatient pain referrals and development of an inpatient referral pathway for inpatient pain management

Category: Acute Pain

Ravi Kare, Suchitra Kanagasundaram, Tracy Taylor, Arun Seghal

Peterborough City Hospital, Peterborough, UK

Background

It has now been clearly demonstrated that pain is similar in prevalence and severity in medical and surgical patients (1). However its assessment and management in the non-surgical setting is often neglected (2). Peterborough City Hospital is a district general hospital for a population of about 300,000. The Acute Pain Service (APS) was established in 1999 primarily to improve pain following surgery. The acute pain service also received referrals for pain management in nonsurgical patients. A three-month audit of these referrals in 2008 revealed that referral pathway was sporadic and involved two systems. This resulted in confusion amongst referrers and delays in treatment.

In September 2010, the APS devised a referral pathway for pain management using an IT based referral system and made the referrals more accessible for clinicians and nursing staff.

We conducted a prospective audit of the inpatient pain referrals following this change to the referral pathway.

Methods

An audit of all inpatient pain referrals to the acute pain service using this new pathway was conducted over a period of 3 months from October 2011 to December 2011. All post surgical patients were excluded from this audit. The following information was collected prospectively using patient notes and self report; Patient demographics, referring specialty, presenting pain symptom, route of hospital entry, treatment offered by the acute pain service and follow up arrangements were prospectively recorded using a preformat. This information was compared with the information collected in 2008 prior to the establishment of this formal referral pathway.

Results

The comparison of data from 2011 showed that in addition to the routine postoperative work there was a 6-fold increase in number of referrals to the acute pain service. Of the referrals 55 (63 %) were from Medical specialties while the rest 31(36%) were from surgical specialties. Of the 86 referrals, the Inpatient pain team intervened in management of 72 patients, using a combination of medication changes and therapeutic spinal injections.

Further analysis of the patients who were admitted under the medical team showed that the most frequent presenting pain symptom was back pain (30%) followed by leg pain (24%) and abdominal pain (24%).

An unexpected finding was that the majority (75%) of the patients referred to the acute pain service were self-referrals via the A&E as apposed to GP referrals.

Conclusion

This audit shows that there was a six-fold increase in referrals to the acute pain service following the introduction of a formal referral pathway. The additional fact that 63% of these referrals were from the medical speciality suggests that pain was previously under reported in this speciality.

This audit confirmed the need, and provided the evidence to support and develop further the provision of pain management to patients from non-surgical specialities at our hospital.

013

Do postoperative patients receive laxatives with prescribed opioids following major orthopaedic, gynaecology and colorectal surgery during hospital admission?

Category: Acute Pain

Donald Graham, Ashok Elayaperumal

Doncaster Royal Infirmary, Doncaster, UK

Background

Strong opioids are frequently used for severe pain management but adverse effects are common. Opioid induced constipation (OIC) affects up to 90% of opioid-treated patients and is due to opioid receptor activation slowing propulsive peristalsis. Clinical tolerance does not develop. Consensus guidelines advocate a combination of stimulant and softener. Post-operative pain management frequently involves using strong-moderate opioids (by a variety of routes) in combination with co-analgesics. In our institution, initial post-operative opioids are principally prescribed in theatre by anaesthetic staff using our E-prescribing system (JAC). Likewise, ward staff may further prescribe on the same system. Currently, a subsection within this system contains a ‘pain’ section with pre-written analgesic prescriptions, but no similar system for laxatives. There is no benchmark by which to compare and match laxative prescribing with opioids for post-operative pain management. We analyzed prescribing patterns for opioids and laxatives using the e-prescribing system.

Methods

E-prescribing offers error free, accurate and understandable prescriptions from the healthcare provider to patient. In addition, through the enquiry icon (POENQ) prescribing for previous admissions is available for analysis. Over a similar period, patients admitted for elective major gynaecology (e.g. T.A.H.), lower limb arthroplasty (e.g. T.H.J.R.) and colorectal surgery (e.g. laparoscopic and open bowel surgery) were studied. Approximately 150 patients (equally divided between each group) prescription patterns were analyzed during surgical admission for all analgesics and laxatives. We applied a PDSA (Plan, Do, Study, Act) strategy to plan implementation of change to current practice. This Quality and Service Improvement Tool tests an idea and assesses its impact. This study analyzed current laxative prescribing for when patients are prescribed any moderate-strong opioid for post-operative pain management. The aim is to introduce a pre-written prescription of stimulant and stool softener for non-bowel surgery and Targinact (oxycodone/naloxone) for bowel surgery and re-evaluate.

Results

Data was collected for 144 patients (gynaecology 49, orthopaedics 48, colorectal 47). Demography: gynaecology (mean age 64), orthopaedic (mean age 65, male/female 45%/55%), colorectal (mean age 65, male/female 50%).

Opioids prescribed include codeine, tramadol, morphine, oxycodone, fentanyl and buprenorphine patch. Routes of opioid delivery include intravenous, oral, subcutaneous, epidural and transdermal. Laxatives include senna, lactulose, movicol and oxycodone/naloxone combination (Targinact).

Table of results:

% strong/moderate opioids prescribed as an in-patient

% laxative prescribed as an in-patient

In hospital % simultaneous prescribing of laxatives/opioids

Gynaecology N = 48

77 (37/48)

37 (18/48)

27(13/48)

Orthopaedics N = 49

94 (46/49)

49 (24/49)

47 (23/49)

Colorectal N = 47

95 (45/47)

8(4/47)

6 (3/47)

Conclusion

Strong/moderate opioids are frequently prescribed following major surgery. The incidence of G.I.-related side-effects is common and dose dependent. Laxative prescribing for gynaecology (37%) and orthopaedic (49%) patients is low despite opioid prescribing and the population age. Women routinely report more constipation than men. By convention, laxatives are avoided following colorectal surgery to avoid anastamotic complications. Simultaneous prescribing is < 50% in all groups. This may reflect the need for improved drug awareness and prescribing education by all prescribers (medical/nursing) for all patient groups. Future studies will analyze the introduction of pre-written laxative/Targinact e-prescriptions on prescribing behaviour in the future.

014

Continuous local anaesthetic wound infiltration in latissimus dorsi flap reconstruction after mastectomy

Category: Acute Pain

Carole Jellicoe², Venkat Harriharan², Kian Chin², Helen Lawrence¹

¹Oxford Brookes University, Oxford, UK, ²Oxford University, Oxford, UK

Background

Surgically placed wound infusion catheters (SPWIC) provide excellent postoperative analgesia for a variety of surgical procedures. Little is published about their use in oncoplastic breast surgery. We report the use of surgically placed wound catheters in women undergoing mastectomy with immediate and delayed lattissimus dorsi flap reconstruction.

Methods

We performed a retrospective review of 10 patients with surgically placed wound infusion catheters (SPWIC). 10 patients in whom SPWIC were not used acted as a control group. One Surgeon (KC) performed all surgery, with electrical diathermy and 3 surgical drains. A single SPWIC (ON-Q Pain Buster, Kimberley-Clark) was inserted in the subdermal layer of the mastectomy wound, with a Twin SPWIC inserted in the donor site. Catheters were primed with 30ml 0.25% Bupivacaine. Elastomeric pumps infused 0.25%Bupivacaine (n=8) or 0.125% Bupivacaine (n=2) at a combined rate of 9ml/hr for 48 hours postoperatively. Pain scores, analgesic requirements and length of hospital stay were reviewed.

Results

There were no complications associated with surgically placed infusion catheters. A trend towards reduced overall pain scores in the study group was noticed. Mean Morphine usage in the study group was 2.4mg (0 -10mg) compared to 45.5mg (0-100mg) in the controls. Mean hospital stay was 5.4 days in the study group and 6.4 days in the controls.

Conclusion

Surgically placed wound infiltration catheters provided good postoperative analgesia for latissimus dorsi flap reconstruction after mastectomy, with reduced Morphine requirements. They are simple to use, with anecdotal reports of high patient satisfaction in our study. A trend towards shorter hospital stay is noteworthy. A large, prospective study is needed to further evaluate surgically placed would infiltration catheters in this field.

Assessment & Measurement

0015

Current practice for managing pain from the perspectives of GPs, Primary care teams and Pain Clinics in older adults throughout the UK

Category: Assessment & Measurement

Geraldine Anthony¹, Patricia Schofield⁵, Denis Martin², Derek Jones³, Denise Gray¹, Amanda Clarke², Blair Smith⁴, Paul McNamee¹

¹Aberdeen University, Aberdeen Scotland, UK, ²Northumbria University, England, UK, ³Teeside University, Teeside England, UK, ⁴Dundee University, Dundee Scotland, UK, ⁵Greenwich University, England, UK

Background

Pain is common: the one month population prevalence of pain, in persons aged 18-65 years in the UK, has shown to range from around 8% in the abdomen in the abdomen to 28% in the low back pain area. In older persons, the occurrence of pain-especially disabling pain and /or pain at multiple sites-is a particularly important problem since it threatens the independent functioning & functional self -efficacy. Older patients themselves often have a strong desire to be a “good patient” one who does not complain, who accepts pain & the lack of treatment as normal. It has been shown that older adults rarely referred to pain management programmes.

Methods

A survey using semi-structured telephone interviews with practitioners working in pain clinics.

Results

Response rate 60.65(95.2%). Respondents included: nurse specialists 12(20%); consultant anaesthetists 11(18.3%), GPs 11(18.3%), Consultant Clinical psychologists 7(12.7%); Physiotherapists 5(8.3%); Occupational therapists 1(2); Chiropractor 1(2%); Instructor for pain management one (2%); head of physiological services one (2%) and one (2%) was a Medical director. Current practice for treating pain was the British Pain Society and NICE guidance, prescribing pain relief- majority no specific guidelines - a mixture of clinical experience and the British pain Society and NICE gridlines. Information leaflets - no different from information leaflets given to the normal population & most had designed their own leaflets on “patient centred care”. Frequencies of reviews- were inadequate &varied from patient to patient as often as weekly for complex cases. Most done face-to face and if patient stable by a follow up phone call. Pain assessment tools -British Pain inventory, visual analogue scale, numerical pain rating scale and hospital a anxiety and depression scale.

Conclusion

In general pain clinicians did provide a good level of service for older adults. However, this study highlights varied use of guidance on prescribing in older adults as well as scope for developing information leaflets for this population. The frequencies of reviews were identified as inadequate for this group.

0016

Cost-effectiveness of self-management of chronic pain in older adults: a systematic review

Category: Assessment & Measurement

Geraldine Anthony¹, Dwayne Boyers¹, Paul Mc Namee¹, Patricia Schofield², Denis Martin³, Amanda Clarke⁴, Blair Smith⁵, Derek Jones⁴

¹Aberdeen University, Aberdeen Scotland, UK, ²Greenwich University, England, UK, ³Teeside University, England, UK, ⁴Northumbria University, England, UK, ⁵Dundee University, Dundee Scotland, UK

Background

It is estimated that chronic pain accounts for £4.6 million. GP appointments each year in the UK, at a cost of £69 million. Back pain alone, the most common form of chronic pain, is estimated to cost the UK economy £12.3 billion annually in direct costs. It is often argued that self -management is a potentially cheaper form of pain management than alternative approaches, and may be at least as effective and cost-saving relative to interventions delivered by health care professionals. However, research evidence supporting these arguments is lacking.

Aim

To assess the cost-effectiveness of self-management strategies for older people suffering from chronic pain.

Methods

Systematic review of published randomised controlled trials (RCT) of self-management strategies amongst older people (aged 65 years or over, or mean age 60 years or over) with cost-effectiveness data and at least 6 months follow -up, up to December 2010.

Results

No RCT studies reported cost-effectiveness of self-management exclusively in the 65 years or over age group. Ten RCTs reported participants with an average age of 60 years or over, and met all other inclusion criteria. All of these studies measured cost-effectiveness as cost per improvement in primary outcome, seven of them using the Western Ontario and McMaster universities osteoarthritis index (WOMAC) pain score. Six studies reported Cost per Quality Adjusted Life Year (QALY) gain information, although statistically significant QALY gains (gain=0.01) relative to usual care were found in only one study.

Conclusion

There is evidence that self -management is an effective method of alleviating pain among older people with chronic pain sufferers alleviating pain among older people with chronic pain sufferers, as measured by pain-specific outcome measures such as the WOMAC. However, it is not possible to conclude from current evidence that self-management is cost-effective based on QALY outcomes. Due to lack of data amongst older populations (e.g those aged 65 years or over), there is also a need for further high quality randomised controlled trials evaluating the effectiveness and cost-effectiveness of a variety of potential self-management strategies amongst older age groups.

017

Relationship between pre-operative pain thresholds and long-term pain after knee replacement: a pilot study

Category: Assessment & Measurement

Vikki Wylde¹, Shea Palmer², Ian Learmonth¹, Paul Dieppe³

¹University of Bristol, Bristol, UK, ²University of West of England, Bristol, UK, ³Peninsula Medical School, Universities of Exeter and Plymouth, Exeter, UK

Background

Total knee replacement (TKR) is primarily performed to provide relief from long-term knee pain, most commonly caused by osteoarthritis (OA). Although TKR is an effective surgical intervention for many patients, there are a proportion of patients who continue to experience severe long-term pain in their replaced knee. A possible risk factor which may contribute to long-term pain after surgery is pain sensitisation. Pain sensitisation arises when continuous nociceptive input gives rise to changes within the nervous system, resulting in reduced pain thresholds. Pain sensitisation can be limited to local sensitisation in the nerves around the affected joint, as well as widespread sensitisation involving changes in spinal cord neurones and reduced pain thresholds at sites distant to the affected joint. The aim of this pilot study was to explore if there was a relationship between pre-operative pain thresholds and the severity of long-term pain after TKR.

Methods

QST was performed on the knee listed for surgery and the pain-free forearm of all participants. A digital Algometer was used to measure pressure pain thresholds (in KPa) and a MSA Thermotest was used to measure hot pain thresholds (in Celsius). Patients completed a WOMAC Pain questionnaire pre-operatively and then at 1-year after surgery. The WOMAC Pain score measures pain severity during 5 different activities to produce an overall score of 0-100 (worst to best). Correlations between pre-operative QST results and 1-year WOMAC Pain scores were tested using Spearman Rank correlation coefficients (CC).

Results

47 patients listed for a TKR because of OA participated in this study. Participants had a mean age of 68 years and 25 were female. Median WOMAC Pain scores improved from a median of 40 pre-operatively to a median of 90 at 1-year post-operatively. There was no significant correlation between pre-operative hot pain thresholds at the knee (CC 0.134, p=0.374), pre-operative hot pain thresholds at the forearm (CC 0.198, p=0.183) or pre-operative pressure pain thresholds at the knee (CC 0.236, p=0.123) and 1-year WOMAC Pain scores. However, there was a significant correlation between pre-operative pressure pain thresholds at the forearm (CC 0.291, p=0.047) and 1-year WOMAC Pain scores.

Conclusion

This study found evidence that there is a relationship between pre-operative forearm pressure pain thresholds and pain severity in the replaced knee at 1-year after surgery. Although the correlation was only small it suggests that widespread hyperalgesia may contribute to long-term pain after TKR. Based on these findings, a study of 600 joint replacement patients is currently underway in Bristol to determine if pre-operative pressure pain thresholds are significant and independent predictors of the severity of long-term pain after TKR.

018

‘I feel so stupid because I can’t give a proper answer…’ How older adults describe chronic pain: a qualitative study

Category: Assessment & Measurement

Geraldine Anthony¹, Amanda Clarke², Denise Gray¹, Blair Smith³, Patricia Schofield⁵, Paul McNamee¹, Denis Martin⁴, Derek Jones²

¹Aberdeen University, Aberdeen, Scotland, UK, ²Northumbria University, Northumbria, UK, UK, ³Dundee University, Dundee, Scotland, UK, ⁴Teeside University, Teeside, UK, ⁵Greenwich University, Greenwich, London, UK

Background

An increasing number of older adults experience chronic pain; figures suggest more than 50% of those living in the community are likely to be affected. Poorly managed pain threatens independent functioning, limits social activities and detrimentally affects emotional wellbeing. Despite this, the impact of chronic pain from the point of view of older adults is not fully understood. The aim of this paper, therefore, is to gain insight into how community-dwelling older adults with chronic non-cancer pain describe their pain, numerically and verbally. We will draw on data from the first phase of a broader study: Engaging with Older People and their Carers to develop interventions for the self-management of Chronic Pain (EOPIC).

Methods

Since the emphasis was on listening to older adults’ account of their pain, a qualitative narrative approach was chosen using semi-structured interviews. This method facilitates expression of the ‘lived’ and ‘told’ stories of individuals. Rather than simply reporting what they do, or what is done to them, it concerns how they feel. Men and women in NE Scotland participated in one or two interviews about how they ‘made sense’ of their chronic pain and its impact on their lives. We recruited through media advertising and contacts with groups and organisations. Individuals were included if they were aged 65 or over, had self-reported musculoskeletal chronic pain, and could give informed consent. All suitable volunteers were included. The sample comprised 23 men and women aged 66-89 years (mean = 73 years) of whom 16 (67%) were female. Sixteen participants were Caucasian. Data were transcribed verbatim and subjected to thematic and narrative analysis.

Results

Three themes specifically relating to descriptions of chronic pain emerged from our analysis: diversity in conceptualising pain using a simple numerical score; personalising the meaning of pain by way of storytelling; and, contextualising pain in relation to its impact on everyday activities. The findings demonstrate the value of describing pain verbally in the context of the individual’s life. Older adults were inclined to construct a narrative around their pain, even in response to ‘closed’ questions, and used this as the basis for much of their interviews, to give their pain some context and meaning. Participants also related their pain to physical or social activity as a means of indicating its severity and impact; for example, their ability to walk, on social activities and/or having to adapt these activities. Sometimes, the use of metaphor provided a useful vehicle to overcome initial difficulties in describing pain.

Conclusion

The findings of the study raise questions as to how best narrative medicine, as recommended and researched in other conditions, might be applied in pain assessment and management for older adults. Along with the judicious use of recommended numerical tools, this may require innovative methods to elicit verbal accounts. Our findings suggest the potential for encouraging the use of metaphors to help older adults to describe and discuss their experience, and the potential value of contextualising the effects of pain on activities that are important to the older person.

019

Assessing skill acquisition on a Pain Management Programme

Category: Assessment & Measurement

Catherine Plant, Rachel Atherton

NHS, Highlands of Scotland, UK

Background

Pain Management Programmes have an educational component in that they aim to teach participants a range of self management skills. The extent to which a patient benefits from the programme is thought to depend on the extent to which they adopt these strategies. Thus making the teaching and learning process more explicit should impact on the patients learning behaviour and enhance the outcome gained.

Pain Management Programmes have traditionally utilised a variety of validated measures to assess progress and measure outcome. However there has been limited attention to skill acquisition. Recent research demonstrates that outcomes selected by clinicians are often not those prioritised by patients who tend to value changes in skills highly. Furthermore, whilst traditional outcome measures often show change, there is a subset of patients who report a perceived benefit and high satisfaction which is not reflected in their outcome measures, disheartening for both patients and staff.

Methods

We were keen to clarify to patients which pain management strategies the Pain Management Programme would cover. Pain Association Scotland have designed an internet based self report questionnaire, PASpider, to measure how well patients understand and utilise pain management strategies. With their agreement and with some modification to meet our needs this was adapted to a paper measure.

This was utilised prior to and during the Pain Management Programme with participants rating their perceived current ability to understand and put into practice pain management skills.

Results

Initial results so far indicate that it has:

• Enabled participants to monitor their own progress

• Good face validity and easily completed by patients

• Allowed positive feedback and encouragement

• Highlighted areas that require further attention allowing us to tailor interventions to individual needs

• Demonstrated clear improvements which were not always reflected by their other outcome measures

Conclusion

In summary, self monitoring of skill acquisition on a Pain Management Programme may have benefits for patients; enable appropriate targeting of limited resources and provide evidence of clinically significant changes not captured by traditional outcome measures.

020

An early warning scoring system to detect complications of epidural analgesia

Category: Assessment & Measurement

James Day, Jane Quinlan, Mark Stoneham

John Radcliffe Hospital, Oxford, UK

Background

The NAP3 report of 2009 reviewing major complications of central neuraxial blocks cited delays in diagnosis and intervention as contributing to avoidable harm. Most of these complications occurred in epidurals used for postoperative analgesia where, arguably, epidurals may be of most benefit by reducing pain and enhancing surgical recovery.

Early warning scores have been well used in clinical medicine to identify early signs of patient deterioration. We have designed an early warning chart to identify epidural complications. The chart is similar in principle to other early warning systems with a number of domains each scoring separately. We felt the domains should include: Bromage score, high sensory block, days since insertion, fever, headache, back pain. If the patient scores highly in a single domain, or if the total cumulative score is high, then the nursing staff must follow a protocol to enable swift anaesthetic review and further intervention as necessary.

Methods

We carried out two simultaneous audits to test the validity of the epidural scoring system: a retrospective notes review to clarify the sensitivity of the tool in patients with epidural complications; and a prospective audit to assess its ease of use for nursing staff. Retrospectively we reviewed the notes of 34 patients who had been identified by the Acute Pain Service as having potential epidural complications. Of these, 15 warranted further investigation, so were scored retrospectively with our scoring system to see if the symptoms would have provoked appropriate senior intervention.

For the prospective audit we distributed the chart to one surgical ward for use on all postoperative patients with epidural analgesia. Over the next 5 months we monitored the use of the new chart while also using current assessment protocols. Cross checking with current tools allowed the identification of any complications not recognised by the new chart.

Results

The retrospective audit showed that the scoring chart had 100% sensitivity in identifying epidural complications. In 2/34 patients the early warning scoring system picked up abnormalities one day earlier than actually happened.

In the prospective audit, we received data from 49 patients who had received thoracic epidural analgesia for 2.8±0.9 days. This represents only a proportion of patients who received epidural analgesia, reflecting a lack of awareness of the new chart by some nursing staff. Seven patients (14%) ‘triggered’ the scoring system (total score ≥4 or any individual score >3). Of these, four triggered due to a sensory level above T4 in the first 24 hours postoperatively, possibly reflecting intraoperative bolus doses of local anaesthetic. No patient had a sensory level higher than T4 after the first postoperative day. The other three were patients with epidurals in situ for > 4 days. There were no adverse sequelae of epidural analgesia.

Conclusion

We are not aware of any current warning system to detect epidural complications. Our scoring system has high sensitivity to identify early signs of concern in patients with epidural analgesia. It is easy to use and does not require any extra monitoring than is routinely performed postoperatively by ward nursing staff. The numbers of patients ‘triggering’ the system does not appear to overwhelm the resources available; however the specificity needs to be such that potential devastating complications are recognised. We hope this will enable us to reduce the risk of rare but devastating complications of central neuraxial blockade.

021

Pain, mood and satisfaction - the outcome paradox of patients attending a chronic pain clinic

Category: Assessment & Measurement

Alexandra Ho, Bianca Kuehler, Carsten Bantel

Imperial College London, London, UK

Background

Chronic pain, defined by the British Pain Society as “continuous, long-term pain of more than 12 weeks or after the time that healing would have been thought to have occurred after trauma or surgery”, is reported to affect 7.8 million people in the UK(1). Despite its huge impact on quality of life and burden to society, with high rates of depression, unemployment and suicide(1,2), we are still in the process of establishing pain medicine and chronic pain clinics, as reflected by the fact that the first UK Pain Summit took place only in November 2011.

The summit concluded the need for chronic pain clinics, but to date, evaluation to comprehensively assess patient satisfaction with services and their impact on patients, is scarce.

Hence, this survey aimed to evaluate the impact of a chronic pain service on specific pain-related psychometric modalities, overall improvement, and corresponding patient satisfaction.

Methods

Between April - May 2011, 43 chronic pain-patients scheduled for follow-up appointments were randomly selected. They were given modified Brief Pain Inventories which assessed psychometric modalities (pain severity, mood, sleep, ability to work, enjoyment of life, effect on relationships). Additionally, it included general assessments of satisfaction with the service and its perceived impact on their pain.

Patients completed inventories privately to avoid a response bias whereby they might feel that answers that did not reflect well on their physician would negatively impact their care.

Assessments used 11-point numeric rating scales (NRS).

‘0’ in psychometric modalities represented no pain/impact and ‘10’ the most pain/negative impact. For general assessments however, ‘0’ indicated the most negative outcome and ‘10’ the most positive.

Follow-up (FU) questionnaires were compared with those completed at patients’ initial assessments (IA). Descriptive and non-parametric statistics were applied as appropriate and data is presented as means+/-SEM (demographics) and percentages (assessment).

Results

30 patients (16 male, 14 female) with an average age of 56(+/-2.29) years and a mean duration of pain of 5(+/-0.74) years were included in the final analysis. The conditions treated comprised mainly lower back pain, joint pain and chronic widespread pain.

Data on general assessment showed that 82% believed pain had lessened on follow-up, with 37% rating improvement >5/10, however 18% reported no benefit. Additionally, 74% believed the treatment prescribed was helping; 41% scored this benefit >5/10.

In contrast, scores for pain-intensity, ability to work, general activity, enjoyment of life, effect on relationships, mood and sleep showed no significant improvements when compared to baseline scores.

Despite this, all patients were satisfied with the service, 65% rated it >5/10 and 31% were “completely satisfied”. Furthermore, 96% would recommend the service to a friend, and all agreed the service was professional and the doctors compassionate.

Conclusion

High satisfaction and subjective progress but no improvement in psychometric tests, demonstrated in this survey, presents a paradox in chronic pain patients. Although this concurs with previous studies(3,4), evidence suggests that satisfaction can associate positively with clinical outcome(5,6).

These discrepancies reflect the inadequacy of using assessments of subjective experiences, which may be influenced by confounding factors(6,7), as measures of pain.

Due to the natural tendency to habituate, scores might vary considerably between assessments, resulting in a reduced reliability of the employed tools. There is thus ultimately a need for objective, reliable and specific biomarkers, to improve diagnostics in pain management(8).

References

(1) Chronic Pain Policy Coalition. About Chronic Pain. [Online]; 2010 Available from: http://www.policyconnect.org.uk/cppc/about-chronic-pain.

(2) Henry JL, Wilkins A, Uleryk EM, Wall E. A scoping study of the economic impact of chronic pain. Pain research management 2010;15(2).

(3) Carlson J, Youngblood R, Dalton J, Blau W, Lindley C. Is patient satisfaction a legitimate outcome of pain management? Journal of pain and symptom management 2003;25(3): pp. 264.

(4) Pellino TA, Ward SE. Perceived control mediates the relationship between pain severity and patient satisfaction. Journal of pain and symptom management 1998;15(2): pp. 110.

(5) Tan G, Jensen M, Thornby J, Anderson K. Are patient ratings of chronic pain services related to treatment outcome? Journal of rehabilitation research and development;43(4): pp. 451.

(6) McCracken L, Evon D, Karapas E. Satisfaction with treatment for chronic pain in a specialty service: preliminary prospective results. European journal of pain 2002;6(5): pp. 387.

(7) Smeets R, E. M. Beelen,Saskia.Goossens Marielle E.J.B.Schouten. Treatment expectancy and credibility are associated with the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. [References]. The Clinical journal of pain 2008;24(4): pp. 305-315.

(8) Borsook D, Becerra L, Hargreaves R. Biomarkers for chronic pain and analgesia. Part 1: the need, reality, challenges, and solutions. Discovery medicine 2011;11(58): pp. 197.

022

Helping to communicate the nature and impact of body perception disturbances in complex regional pain syndrome. The development and evaluation of a computer graphics application

Category: Assessment & Measurement

Ailie Turton¹, Mark Palmer¹, Sharon Grieve², Tim Moss¹, Jenny Lewis^1,2, Candy McCabe^1,2

¹University of the West of England, Bristol, UK, ²Royal National Hospital for Rheumatic Diseases, Bath, UK

Background

Patients with Complex Regional Pain Syndrome (CRPS) experience distressing changes in body perception. These are usually accompanied by strong negative emotions which commonly include a desire for amputation of the painful limb. These altered perceptions are difficult for patients to describe to clinicians as they do not match objective signs and they fear being disbelieved. Difficulty in communicating these altered body perceptions can further exacerbate their distressing emotional impact. Self portrait sketches are sometimes used, but this method is limited by the individual’s capacity to draw. Computer graphics offer an opportunity to provide an interactive tool to communicate perceptions of body image. The purpose of this project was to develop an application that patients will be able to use to create a 3D model of their perceived body image.

Methods

Using data from a previous exploratory study of body perception and consultation with a person with CRPS, the first prototype digital media application was developed. The application allows modification of an avatar to depict alterations in size, shape, colour or visible surface texture of multiple body areas. It has so far been tested with ten patients, admitted to an inpatient CRPS rehabilitation programme, who gave consent to participate in the research. Participants used the application in a consultation with the research nurse. Audio recordings were made of the participants using the application and participants were asked to complete a structured questionnaire to ascertain their views and experience of using the tool. Responses to questionnaires and audio recordings were subjected to content analysis to determine acceptability of the application and its limitations.

Results

The ten images produced are powerful illustrations of the distortions in body perception that patients with CRPS experience. All participants reported using the tool was an acceptable method for communicating their body perception and better than the drawings currently used in interviews with the Occupational Therapist. There were some additional features they identified to improve the usability of the application and reality of the final image e.g. adding the software capabilities to smaller sections of the limb such as each finger.

Participants described the positive impact for them of now seeing an image of a limb that they had previously only imagined and could now convey to others.

“It looks in human form exactly how I feel and I’ve never had that. I’ve sat and said this hand feels longer and feels wider from there. I know I can see it but this is the first time someone else can.”

Conclusion

This is the first time CRPS evoked disturbances in body perception have been captured in such a graphical manner. The quality of the graphics enhanced the reality of the image thereby helping patients to fully convey to themselves and others how altered their bodies seem to them. A computer generated image was shown to be superior to the drawings used in current practice within a clinical interview. Refinement of the software programme is in progress. We envisage that this tool could extend beyond being a very useful communication device between patients and clinicians, and also become a meaningful outcome measure.

023

A first step to improve the inpatient pain experience

Category: Assessment & Measurement

Atef Al-Tawafsheh, Ali Mofeez, Andrew Baranowski, Brigitta Brandner

University College London Hospitals Trust, London, UK

Background

At University College London Hospital (UCLH) a significant number of patients present with non-acute pain. These patients are frequently on high doses of opioids and/ or have complex pain issues that can make it difficult to be managed by the primary medical or surgical team. The admission often is prolonged with complications. The clinical work required for a successful outcome involves different teams and complex investigative procedures. The involvement of the inpatient pain team is poorly reflected in necessary time for assessment. The allocated time is often not reflected in the patient’s tariff by the referring authority. This significantly impacts on the quality of service that can be offered to patients. The aim of this audit is to identify the length of time spent by the pain team on each patient and to identify the main users of the service in a tertiary referral centre and develop an inpatient pathway.

Methods

A prospective audit was performed over a period of three months in UCLH. All adult chronic in-patients who had been referred to the in-patient pain team were included in the audit. The number of patients and the time spent on assessment and treatment for each specialty were computed. Data recorded were entered into a database and analysed using Excel. The inpatient pathway will be developed following the clinical pathway development process ¹.

Results

A total of 48 patients were referred to the pain team and these patients were reviewed in 144 visits. Of these, 16 patients (33.3%) were from the Gastroenterology, 8 (10.4%) Gynaecology or Haematology; and 4 (8%) Oncology, Urology or Rheumatology. A total of 3780 minutes were spent by the pain team. The longest time spent was on the gastroenterology patients (1295 minutes, 34%) followed by the haematology patients (420 minutes, 11.1%); 360 (9.5%) and 340 (9%) minutes were spent on the urology and rheumatology patients respectively; 330 (8.7%) and 275 (7.3) minutes were spent on gynaecology and oncology patients respectively.

Conclusion

The majority of clinical time was spent on the gastroenterology-patients followed by haematology, urology, rheumatology, gynaecology and oncology. The patients referred by gastroenterology had all been tertiary or quarterly referrals. The involvement of the pain team often was last after assessment by other specialties leading to significant delay in the discharge planning. This led to a meeting with the gastroenterology team to define an in-patient pathway for gastroenterology-patients who required admission for treatment and investigation. The introduction of a structured rapid assessment pathway with MDT and referral before admission will aim at improving effectiveness, outcomes and length of stay ².

024

Audit of effectiveness of repeat blocks and evaluation of a scoring system in chronic pain patients

Category: Assessment & Measurement

Karthikeyan Thanigaimani, Sarah Lewis, Michael Williams

Queen Alexandra Hospital, Portsmouth, UK

Background

NICE in 2009 published the clinical guideline on “Early management of persistent non-specific low back pain” in which they have advised not to offer injections of therapeutic substances into the back for non-specific low back pain of one year duration. The efficacy and benefits from repeated regional blocks for chronic pain patients has not been clearly demonstrated in RCT and there is a constant pressure from PCT’s to reduce the number of regional blocks for chronic pain patients. Therefore we decided to do a service improvement project to assess the effectiveness of regional blocks in chronic pain patients having repeat injections at the Queen Alexandra Hospital and to evaluate a scoring system for the review of patients following the block.

Methods

The scoring system was adapted from the article by Veemaraj et all in the Pain News 2009. Parameter measured were duration of effect (1-4), percentage pain reduction (0- 3), improvement of sleep (0- 1), improvement of mobility (0- 1), reduction of medications (0- 2), improvement of quality of life (0- 2) and ability to continue work (0 or 2). The duration of effect, percentage of pain reduction and score for the ability to work were modified. The total score ranged from 1 to 15.

Patients who came for a repeat injection between February 2011 and April 2011 were given a questionnaire to fill. Based on a scoring system the efficacy and benefits gained by the patients from the injections were assessed by an independent assessor. Outcomes for patients were also reviewed by looking into clinic letters and nurse led follow ups by an independent assessor. The two reviews were compared.

Results

A total of 122 patients had repeat blocks during the 3 month period. Lumbar epidurals, facet joint steroid injection, selective nerve root block and radio frequency denervations accounted for 63% of repeat injections. 74% of the patients had 2 or less blocks in a year. Out of the 122 patients 25 patients scored less than 7 and 97 patients scored greater than 7. The mean score was 8.9 with a SD of 3.0. 79% of the patients derived significant benefit from the block.

When the scoring system was compared with notes, clinic letters and nurse telephone reviews in 89% of the cases there was a good correlation in the assessment of the effectiveness of the block. In 6% of the patients there was no clear documentation in the notes and in 5% of patients the score and the clinician review were different.

Conclusion

Of the 122 patients 74% had 2 or less blocks in a year and 79% of patients had significant benefits from the block. The scoring system used was good in assessing the pain relief from the block and also the effect on sleep, mobility, work and quality of life. It is easy to use, more objective, can be administered over the phone and as the data is collected in a score format is easy to audit outcome. We have incorporated the scoring system in to the nurse telephone review at 3 months and 6 months following regional blocks.

025

Referral patterns and clinic outcomes from a tertiary pain clinic: can they inform service design?

Category: Assessment & Measurement

Rosalind Adam

NHS Grampian, Aberdeen, Aberdeenshire, UK

Background

The majority of chronic pain patients are never referred to a pain clinic. There is a drive to manage chronic pain services in the community but a community based approach may not be appropriate for all patients. It is likely that the source and reason for referrals to the tertiary pain clinic is changing over time in response to local and national factors, such as the availability of minimally invasive interventions, and the publication of national guidelines for chronic pain conditions.

Aberdeen Pain clinic is a tertiary referral service, accepting referrals from general practitioners and hospital specialists. Precision diagnostic blocks and target specific treatments are offered as part of a holistic and multi-disciplinary approach. We audited our new patient referral patterns and their clinic outcomes to inform the design of our services.

Methods

Prospective data collection was done over a period of 2 months. Pain physicians filled in an audit form for new patients who attended clinic between March 2011 and May 2011. The physician was asked to record the date of referral; the date of assessment; the name of the referrer; the location of the referrer; the reason for referral; and the outcome after clinic assessment. The referral reasons and outcomes were categorised to facilitate analysis. Data was transferred to an excel spreadsheet and examined qualitatively and using basic statistical techniques.

Results

Data was obtained for 83 new patients. Of them, 56.6% (47) were referred by their General Practitioner while 36 (43.4%) were referred by other specialists. The speciality requests ranged from orthopaedics, neurosurgery, rheumatology, Hepatobiliary Surgery, Urology, Vascular Surgery, Elderly Medicine and other pain clinics.

Of the referrals from General practice, 14.7% were made for specific reasons such as minimally invasive therapy, psychology input, or advice on pharmacotherapy, 8.4% was for alternative therapies while 68.08% was for general advice and management.

Of the referrals from Specialists, 47% was made for specific reasons such as minimally invasive therapy, Psychology input, or advice on pharmacotherapy, 2.7% was for alternative therapies while 44.4% was for general management advice.

Conclusion

Referrals to the pain clinic are primarily from General Practitioners for general advice. A variety of specialists are making referrals, often with a specific request for an intervention. Minimally invasive interventions are being offered as an alternative to invasive procedures and to aid diagnosis prior to surgery. Over a third of patients referred to the clinic were offered a minimally invasive intervention. This has implications for the capacity and design of our service. It will be vital to identify patients who can appropriately be managed in primary care whilst encouraging referrals for those who might benefit from specialist input.

026

The influence of pain on number sense

Category: Assessment & Measurement

Ashikur Rahman, Bianca Kuehler, Carsten Bantel

Imperial College London, London, UK

Background

Exposure to chronic pain has been shown to induce structural changes in the brain. Apkarian et al (2004) were the first to demonstrate a reduction in grey matter density within the prefrontal cortex and thalamus of patients with chronic back pain. Subsequent studies have revealed similar findings within the anterior cingulated, motor, parietal and insular cortices, secondary to other pain syndromes. Since the prefrontal and parietal cortices are known to be responsible for the human ‘number sense’ (Jacob et al, 2009) we hypothesise that pain, particularly chronic pain, significantly impairs patients’ abilities to perform numerical-spatial transformation tasks accurately. Therefore, this study was conducted to elucidate the degree of inaccuracy shown by acute and chronic pain patients in comparison to healthy controls when asked to translate a number into a spatial representation on a straight line.

Methods

An observational study was carried out at Chelsea and Westminster Hospital between September and December 2011. Volunteers aged over 18 years and free of neuropsychiatric and communication problems were selected and placed into one of three patient cohorts; pain-free controls, chronic pain (pain duration > 12 months) and acute pain (history of surgery in the last 24-48 hours). Each participant was asked to mark a series of six pre-determined numbers (6, 17, 29, 43, 61, 84) on to straight lines, as described by Siegeler and Booth (2004), with ‘0’ and ‘100’ demarcated at either end. The actual numbers marked by these spatial representations were then calculated and assessed for the degree of error in relation to the expected values. Mean errors for each value were calculated and statistical differences assessed thereafter, using one-way ANOVA followed by Tukey’s post-hoc test. A value of p < 0.05 was considered to be significant.

Results

A total of 24 individuals (17 females, 7 males), with an average age of 44 years, participated in this pilot study. Chronic pain patients (n = 8) were found to exhibit a greater degree of inaccuracy when tasked with transforming numerical values into spatial representations in comparison to healthy, pain-free individuals (n = 9; p < 0.05). The mean magnitude of error found within the control group was 4.14 ± 0.45 (SEM), compared with 6.06 ± 0.61 in the chronic pain cohort. The acute pain group (n = 7) also showed a greater magnitude in mean error relative to controls (4.63 ± 0.61); however this was not statistically significant. All three cohorts generally underestimated the straight line spatial transformation of the pre-determined numbers, although there was a trend for chronic pain patients to make more frequent overestimations relative to the other groups.

Conclusion

Results from this study suggest that patients suffering from a wide range of conditions giving rise to chronic pain have a significantly impaired number sense when compared with healthy, pain-free individuals. It can therefore be inferred that, when faced with tasks requiring quantification of abstract numbers, these patients will struggle to be accurate. As a consequence, this calls in to question the viability of both the visual analogue scale and the numeric rating scale - currently the gold-standard pain assessments tools - as meaningful instruments in the clinical management of chronic pain.

027

A survey of inpatient referrals to pain management unit

Category: Assessment & Measurement

Sabita Sreevalsan², Mike Bailey¹, Mike Lee¹

¹Ipswich Hospital NHS Trust, Ipswich, UK, ²Norfolk and Norwich University Hospital, Norwich, UK

Background

Patients with chronic pain are often hospitalized with severe aggravation or new onset pain prompting extensive investigation by the admitting medical or surgical team to rule out any readily reversible pathology. Pain in these patients is complicated by psychosocial issues and conventional analgesics often fail, triggering a referral to the Pain Management Unit (PMU). Referral prompts assessment by a Pain Consultant or Fellow, who makes recommendations for pain management to facilitate physical function. The eventual aim is discharge to primary or outpatient care, where the needs of the patients can be better met by the PMU in partnership with the General Practitioner (GP) or other appropriate specialty.

We conducted a process audit to review the following: (a) Number of inpatient referrals to PMU in our District General Hospital (b) The management by the pain team (c) To identify any aspects of care that can be improved.

Methods

In the absence of published guidelines, the clinical standards we proposed were (1) Review by pain clinician within 24 hours of referral. (2) Outpatient follow up at PMU within 06 weeks of discharge and (3) Adequate communication with the GP regarding medication, treatment aims and follow up arrangements.

All inpatient referrals logged by the secretaries at the Pain Management Unit during a two month period from 01/02/2011 to 31/03/2011 were audited. Case notes were retrieved and perused. Referring speciality, reason for referral, time to assessment by pain clinician, pain management and discharge and follow up data were collected. Findings were compared to the proposed standards.

Results

There were 20 inpatient referrals to the Pain Management Unit in a 2 month period.

The bulk of referrals were from orthopaedics. The most common cause of referral was acute exacerbation of chronic back pain, the other causes ranged from ischaemic leg pain to overdose. Management mainly involved judicious adjustment of medication. A very small proportion went on to have interventions or surgery.

Regarding standards of care, only 14/ 20 patients were seen by the pain team within 24 hours. Communication with the GP relied on the meticulousness of the junior doctor in the admitting team and occurred in 12/ 20 patients. Only 6/ 20 patients were followed up in the Pain management unit within 6 weeks of discharge. It was found on perusal of the notes that not all of these patients needed follow-up in 6 weeks. Some necessary appointments were not made due to administrative error.

Conclusion

The standard of early review within 24 hours was met only in 70 % of the patients. An intranet based referral logging system would ensure daily uptake of referrals by pain clinicians.

Communication with GP needed improvement. It would be prudent to dictate a letter regarding the inpatient pain management and future treatment aims directly to the GP.

Follow-up arrangements were inconsistent mainly due to oversight by the admitting team. It is recommended that the visiting pain clinician make decisions and arrangements regarding follow up at the time of initial inpatient consultation.

A re-audit is planned after recommended changes are implemented.

028

Can the Canadian Occupational Performance Measure be used to identify the minimum clinically important difference in walking performance?

Category: Assessment & Measurement

Mark Draper, Helen Ayling, Peter Murphy, John Tetlow

The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, Liverpool, Merseyside, UK

Background

The COPM is an individualised, client-centred measure designed for use by Occupational Therapists to detect change in a client’s self-perception of occupational performance over time. Law et al 2005 in the COPM manual proposed that a 2 point change in total score be considered clinically significant for research. 50% of patients assessed for our Pain Management Programme (PMP) select walking as a COPM item. The 50m walk and 5 minute walk test (5MWT) are also employed as outcome measures on our PMP (Harding et al 1994). Redelmeier DA et al in 1997 reported a 50m improvement in the 6 minute walk test is the minimal clinical important difference (MCID) among patients with chronic lung disease, but for chronic pain patients this threshold remains unknown. Booker et al 2010 proposed that the MCID in functional measures is ≥34% for PMPs.

Methods

We therefore set out to first establish if there was an correlation between the changes in COPM walking item score and the walk measures. If so, it could be inferred that ≥2 point improvement in that specific item on the 0-10 scale would indicate a MCID in 50m walk test or 5MWT. We used the data from an opportunistic sample of 102 heterogeneous chronic pain patients who selected ‘walking’ as a COPM item. The changes in the COPM walking item scores were calculated and the changes in both types of their walk tests were converted to absolute and percentage change values. Spearman’s rank coefficient correlation and Chi-Square test was used to calculate the degree of dependence between the 4 values using SPSS (v12).

Results

The median baseline COPM performance and satisfaction scores for walking were 3 and 1 out of 10 respectively. The median change was 2 and 4 respectively. The mean baseline 50m walk was 85.7s (SD=72.8 s) and 5MWT was 160.2m (SD=95.9m) compared to 167.68m for the entire group that year. The mean change in time to complete the 50m walk was -19.4s or -16.5% and in distance covered in the 5MWT was +77m or +90.3%. The Spearman’s rank coefficient demonstrated a positive but non-significant correlation between changes in COPM scoring for walking and both walking tests irrespective of how those changes were interpreted. Significance level (1 tailed) was reached for all correlations except those between COPM performance change and percentage speed change (p=0.139) and absolute speed change (p=0.271). Chi-Square test (2x2) only revealed a significant association between the COPM performance change and change in the 5MWT (7.55, p=<0.01).

Conclusion

We found that self-reported changes in walking performance and satisfaction as measured by the COPM were unreliable in predicting changes in observed walking. Interestingly a significant proportion of patients both overestimated and underestimated changes in their walking ability. We found a significant association between changes in COPM performance scores and the 5MWT, but not the 50m walk, indicating distance is more meaningful. Several authors have also identified discrepancies between objective and subjective improvements in chronic pain populations (Wittink 2003, Fisher & Johnson 1997, Christine Ellen Lee 2001). Incidentally, 52% of our patient sample achieved ≥34% improvement in the 5MWT.

029

Patient satisfaction, pain & quality of life after pain interventions

Category: Assessment & Measurement

Senthiil Vijayan, Jeremy Weinbren, Damien Smith, Bel Vadodaria

The Hillingdon Hospital, London, UK

Background

We wanted to assess the response to various interventions performed in our pain service and their impact on patients quality of life.

Patients were followed up 6 months following the interventions and changes in their pain scores and quality of pain were assessed.

Patients were given a questionnaire to complete in the 6 month follow up clinic. Data was collected from various pain clinics run by 3 consultants, one advanced pain trainee and one associate specialist. This is a busy Clinic, with an annual caseload of approximately 1300 new patients, 2500 follow-ups and 3400 procedures .

Methods

A simple questionnaire was distributed to a 3-week sample of patients who had received treatment for chronic pain conditions six months previously at our busy DGH Pain Medicine Clinic. The treatment combinations studied included prescription of medication, interventional treatment (injections), Acupuncture and TENS.

Simple linear scale measures of Pain and Quality of Life improvement percentages were collected as well as a binary satisfaction score.

Data were analysed using Excel (Microsoft Inc, Seattle), and descriptive statistical analysis as well as

correlation analysis for Pain and QOL change were performed.

Results

The number of patients surveyed was 150, with various treatment combinations.

There was a high correlation between Pain relief scores and QOL improvement scores (r2=0.954) and those with higher scores were more likely to report satisfaction.

Overall 81% of our patients in this sample were satisfied. The variation according to treatments is in Table 1.

Table 1.

Mean before procedure
Mean after procedure
Mean difference
P value
CI
Pain at worst
9
3.2
5.8
0.001
3.76 to 7.84
Pain at best
5.20
1.60
3.6
0.006
1.71 to 5.48
Pain at average
7.20
2.20
5.0
0.001
3.24 to 6.75
Anxiety
8.60
3.40
5.20
0.000
3.84 to 6.56
Mood
7.80
4.80
3.0
0.07
–0.51 to 6.51
General activity
8.60
4.60
4.0
0.03
0.60 to 7.40
Sleep
6.80
4.40
2.4
0.09
-0.71 to 5.51

Mean Pain (P) and QOL (Q) improvements were 12.1%(P,Q) if not satisfied and 61.9% (P) and 61.0% (Q) if satisfied. The overall mean Pain and QOL improvements were >50% in all groups.

The small number of patients whose treatment included TENS (n=9) were most satisfied (100%)

Analysis of Chi-squared goodness-of-fit showed high correlations for all indices (p<0.01) . Thus, Positive Predictive Value for 50% decrease in Pain score for Injection is 0.70. PPVs for each treatment are shown graphically. 95% confidence intervals were all >0 for Pain relief except TENS and Medication for 90% relief.

Conclusion

The results demonstrate a high level of patient satisfaction and improvement in our Clinic.

In this sample, the average improvements were >50% and Positive Predictive Values for

each of the treatments to achieve this mean score were high. This suggests that we are

assigning the correct treatments.

Of our patients in this sample who had injection treatment a high percentage were satisfied.

Overall, all treatment groups had high percentages and amounts of

improvement and satisfaction.

We feel that further study would more clearly define which elements of satisfaction and

improvement are linked to specific treatment combinations.

030

Patient experiences of pain management - do chronic pain patients feel differently?

Category: Assessment & Measurement

Adnaan Qureshi, Rajiv Malhotra, Michael Goulden, Fran Ion, Ruth Wheelhouse, Janet Beattie

Royal Liverpool University Hospital, Liverpool, UK

Background

Chronic pain patients experience greater involvement with healthcare providers and are often seen by numerous physicians / therapists including specialist chronic pain clinics. We suggest that owing to their previous experiences with complex pain management problems and numerous previous interactions with the health care system, they would pose a greater challenge to staff during hospitalization and so would have lower levels of satisfaction with their pain relief as compared to the non chronic pain population. In addition, the chronic use of analgesics including strong opiates leads us to hypothesise that pain management will be more challenging on the wards where it may not necessarily be overseen by specialist pain doctors and nurses, leading again to a subjective perception of inadequate pain relief.

Methods

Over 4 weeks in November / December 2011, every medical and surgical ward in an adult university teaching hospital was visited (excluding critical care areas). A member of the pain team randomly selected 4 males and 4 female for survey. Ward type (medical or surgical) was recorded. Each patient was asked the following:

1. Were you admitted in pain?

2. Do you take regular analgesia at home?

3. Do you have longstanding pain?

4. If so, was this longstanding pain the reason for your admission?

5. Do you think hospital staff do all they can to control your pain?

6. How satisfied are you with your pain management in hospital? (0-100%)

7. How long is there between asking for and receiving analgesia?

Data was collected anonymously. A 10% absolute difference in mean values was chosen to represent statistical significance.

Results

226 records were obtained. Not all patients provided answers to all questions.

We identified 95 chronic pain patients and 100 non chronic pain patients. 82.1% of chronic pain patients were admitted with any pain. 45.3% of chronic pain patients said it was their longstanding pain that prompted admission. 82.1% of chronic pain patients were on regular analgesia at home vs 15.6% of non chronic pain patients. The mean satisfaction score for chronic pain patients was 88% vs 93.7% for non chronic pain patients. 93.4% of chronic pain patients felt staff did all they could to control pain vs 95.6% of the non chronic pain patients.

Of chronic pain patients, 80% said they received analgesia within 15 minutes, 14.4% within 30 minutes, 2.2% within an hour and 3.3% after an hour. This compares with figures of 87.5%, 7.5%, 0% and 5% respectively for the non chronic pain patients.

Conclusion

Both qualitative and quantitative means of assessing satisfaction with the pain relief failed to show a significant difference. There were no significant differences in the times taken to give analgesia once patients had asked for it. This suggests that contrary to the initial hypothesis, chronic pain patients were not significantly less satisfied with their pain relief. This is despite the significant increase in the use of regular analgesics at home by the chronic pain patients (82.1% vs 15.6%) and hence the hypothesis that chronic analgesic use that can lead to difficulties in acute pain management will affect patient satisfaction.

031

Pain benchmarks: what are we recording?

Category: Assessment & Measurement

Alison Moss, Tanya Carr, Rozanna King, Caroline Keighley-Elstub, Jeremy Cashman

St George’s Hospital, London, UK

Background

Our aim was to establish, according to pain benchmarks, that all patients have access to pain management through documented pain assessment, implementation and evaluation. A snapshot audit gives us a baseline impression of current practice across the trust. We wanted to review how pain was managed throughout our hospital and whether there were large variances in medical and surgical wards.

Methods

Six patients on each ward were randomly selected and audited on a single day. No interaction had occurred between the patient and the Acute Pain Service. Inclusion required verbal consent. Exclusion comprised confusion/disorientation, inability to speak English and hospital admission within the previous 24hrs. Nursing documentation, medical notes and drug chart were inspected. Comparisons were made between pain scores recorded and actual pain scores reported at that time. Student nurses assisted in data collection, they were given an hour’s training on the performa, the results were then reviewed by a specialist panel and amended where incompatible statements occurred.

Results

The sample size was 156, comprising 83 males and 73 females. Average age was 61 years, range 17-93. There were 73 surgical patients, and 83 medical. Patients in surgical wards were more likely than patients in medical wards to be asked about their pain both by doctors (73% versus 64%) and by nurses (89% versus 63%). The recording of pain by doctors and nurses was generally poor; we found evidence of documentation of pain in only 1/3 of patients, worse in medical wards. 1 in 5 patients had pain documented as none/mild, but our enquiry found 17% of these to be false negative, 20% being in medical wards and 10% in surgical wards.

Conclusion

Nurses and doctors do assess pain, however documentation of this is poor. Poor documentation interferes with continuity of care and directly affects pain management. Surgical wards are better at assessment and documentation than medical wards, but the documentation of this is still sub standard. Of concern is the under assessment of pain, and the false negative associated with this particularly in medical wards, where a higher incidence of persistent pain exists. This needs to be addressed and improvements introduced.

032

Pain benchmarks: what are we doing?

Category: Assessment & Measurement

Alison Moss, Tanya Carr, Rozanna King, Caroline Keighley-Elstub, Jeremy Cashman

St George’s Hospital, London, UK

Background

Pain benchmarks have been used to ensure a high standard of assessment, documentation and treatment of pain. In an accompanying abstract we highlighted deficiencies in the assessment and documentation of pain. In this second abstract, we investigate the response to and treatment of pain.

Methods

A sample of six randomly selected patients from each adult inpatient ward verbally consented to take part in the study. Only patients who were not under the care of the Acute Pain Team were approached. Patients were excluded if were confused/disorientated, didn’t speak English or had been an inpatient for less than 24hrs. Student nurses assisted in data collection, they were given an hour’s training on the performa. Medical case notes, nursing documentation and drug charts were inspected. A 5-point pain verbal rating scale was used. The data was reviewed by a specialist panel and incompatible statements were corrected.

Results

We reviewed 156 patients, 83 males and 73 females. Average age 61 years (range 17-93). There were 73 surgical patients and 83 medical patients. Although documented severe pain in the medical wards was 15% vs 19% in the surgical wards, in actuality (patient reported), it was 11% and 19% respectively. Both the documented and the actual response to severe pain were more pronounced in surgical compared to medical wards. Nevertheless documentation remained poor. We noted that medical wards had more patients who had experienced pain for >3 months, 41% vs 32%. Patients in surgical wards had a far greater probability of being prescribed analgesia, 96% versus 48%. Also prescriptions in the surgical wards were more likely to adhere to WHO analgesic ladder guidelines. But in surgical wards 15% of patients declined their analgesia compared with just 6% in medical wards.

Conclusion

We found somewhat higher levels of severe pain on surgical wards, with a greater propensity towards chronic pain on medical wards. But patients on surgical wards were more likely to have a documented response to pain and to be given pain medication. Prescribing habits identified a profound difference between surgical and medical wards’ responses to pain. It is noteworthy that patients on the surgical wards were far more likely to decline their medication triggering the question “Do surgical units over prescribe analgesia?”

033

An exploration of the PainDetect® questionnaire as a potential screening tool in oro-facial pain

Category: Assessment & Measurement

Abdouldaim Ukwas¹, Joanna Zakrzewska², Rachel Leeson¹

¹UCL Eastman Dental Institute, London, UK, ²Eastman Dental Hospital UCLH NHS Foundation Trust, London, UK

Background

PainDetect® is a simple, patient-based, questionnaire that was developed and validated by the German Research Network on Neuropathic Pain. In this study the questionnaire was used with various orofacial pain conditions to explore its diagnostic ability.

Methods

The study was conducted prospectively at the Eastman Dental Hospital (EDH) between May and August 2011. New patients were recruited randomly from consecutive referrals to the hospital.

For validity exploration, 113 patients were recruited. Every patient was asked to complete a copy of the questionnaire before the clinical assessment. The total score was calculated and compared with the clinical diagnosis, the ‘gold standard’ in this study.

For reliability exploration, 21 patients were recruited. Every patient was given two copies of the questionnaire to complete (i.e. one prior to the clinical assessment and another afterwards). Patients’ answers on both occasions were analysed statistically.

Results

The total questionnaire scores of all patients diagnosed with neuropathic pain were compared with total scores of all those diagnosed with non-neuropathic pain using Cohen’s kappa (K) at two different score cut offs. The kappa (k) results were 0.340 and 0.321 respectively.

Similarly, the total questionnaire scores of all patients diagnosed with neuropathic pain were compared with total scores of patients diagnosed with TMD and dental pain separately. The kappa value (k) was 0.324 and 0.197 respectively. The questionnaire sensitivity was 44.4% whereas specificity was 71%.

Lin’s concordance correlation coefficient value was 0.914 (95% CI 0.843-0.984). Furthermore, the British Standards Institution repeatability coefficient was 5.4 and P value was 0.0044. The Bland and Altman diagram demonstrated that the mean of the difference between each pair of score readings was positive.

Conclusion

This study showed that PainDetect® questionnaire was of limited accuracy in determining which patients did or did not have neuropathic pain and was of low reproducibility over time when applied to OFP.

034

A preliminary investigation into the relationship between body fatness and pain sensitivity response

Category: Assessment & Measurement

Caite Conner, Osama Tashani, Mark Johnson

Leeds Metropolitan University, Leeds, UK

Background

Obesity and pain represent a considerable public health problem. Obesity is related to increased low back pain and fibromyalgia although is difficult to explain by increased biomechanical load alone. Obese individuals appear to have increased sensitivity to painful stimuli when applied to the body. The aim of this study is to investigate the relationship between body fatness and pain sensitivity response in healthy volunteers.

Methods

Twenty unpaid healthy university students were screened for inclusion as potentially obese or normal weight using body mass index (BMI). Participants attended our laboratory for one 2 hour experiment which measured percentage body fat (Durnin/Womersley Caliper Method) and sensory detection threshold, pain threshold and pain tolerance to thermal (Thermal Sensory Analyser, Medoc inc., Israel) and mechanical stimuli (von Frey, pin prick (weighted needles), pressure algometry (Somedic inc., Sweden) at three different body sites in the right side of the body: thenar eminence of the hand, medial aspect of tibia at mid point between lower boundary of the knee cap and medial malleolus, and mid point between iliac crest and bottom of lower rib (waist).

Results

There was greater percentage of total body fat in the obese group than the normal (Obese n=10, 5 women, mean (SD) age = 23 (6) years, BMI= 28.5 (2.3), body fat % =31 (6.5); normal n=10, (5 women, mean (SD) of age=22.6 (2.7) years, BMI= 21.6 (1.9), body fat % =22.2 (7.9), P<0.05, t-test). Obese participants scored higher than normal group in heat pain threshold (mean difference =3.3 C, p=0.050, t-test) and mechanical detection threshold (pin prick, mean difference= 1.6 g, p=0.038, t-test). There were no significant differences between groups for all other somatosensory measurements. Percentage total body fat was correlated with warm detection threshold (-0.54, p=0.01), heat pain threshold (-.056, p=0.01) and heat pain tolerance (-0.55, p=0.02) over the tibia, and with heat pain threshold (-0.053, p=0.02) over the hand and pressure pain threshold (0.48, p=0.04) over the waist.

Conclusion

Overall our results suggest that individuals who were obese were more sensitive to contact heat pain than those with normal weight in at least two different body sites: over the hand and over the tibia. Further research in the relationship between obesity and pain sensitivity response using biomarkers of fatness is needed.

Audit

035

A survey of patient satisfaction in pain clinics

Category: Audit

Senthil Vijayan, Jeremy Weinbren, Damien Smith, Bela Vadodaria

The Hillingdon Hospital, London, UK

Background

1. Patient experience is a key component of our service.

2. The operating framework 2011 states that there needs to be a better collection of data on patient experience and feedback.

Methods

Patients were given a feedback form at the end of their outpatient consultation. The first 100 responses were collected and analyzed

Results

All the patients were happy about the information given on the appointment letter. 98% agreed the doctor was polite and introduced himself or was already known to the patient. 62% were seen by a Consultant and the remaining by the pain fellow. 30% strongly agreed they were listened to and 53% agreed with the same. 67% strongly agreed they were involved with the decision making. 83% agreed the doctor was empathetic towards them. 98% stated they will definitely recommend this service to family and friends. 89% were satisfied overall with the consultation.

Conclusion

The main reasons for dissatisfaction were the doctors did not listen to them and sometimes they had to wait too long to see the doctor. Those patients who were actively involved in the decision making process had high satisfaction scores.

It is clear that patient experience is an integral part of the overall care in our clinics. We believe listening to patients and involving them in the decision making process makes a positive impact on their lives.

036

Survey of opioid prescriptions in chronic back pain

Category: Audit

Shravan Tirunagari¹, Peter Cole¹, Tudor Phillips¹, Mike Lee^2,1, Kyle Pattinson^2,1

¹Oxford University Hospitals NHS Trust, Oxford, UK, ²University of Oxford, Oxford, UK

Background

Over the past decade, deaths in the USA from opioid overdose in chronic non-malignant pain (CNMP) have increased from ~3,000 to ~14,000 p.a. Death rates have increased in parallel with steadily increasing opioid prescription rates. The risk of overdose death is increased 4.6 times with morphine equivalent dose of 50-100mg/d and 7.18 times above 100mg/d.

There is little evidence that long-term opioids are efficacious. Most randomised trials of opioids for CNMP are short term efficacy studies. Current recommendations for opioids in CNMP are based on consensus or supported by only low quality evidence.

We are interested in assessing the potential for opioid-induced harm in UK patients with CNMP. We have therefore surveyed opioid use in a cohort of chronic back pain (LBP) patients from an NHS pain clinic in a pilot study that will inform the design of a more comprehensive assessment of opioid risk in UK practice.

Methods

We surveyed all patients attending our university teaching hospital pain clinic between Nov 2011 to Dec 2011 over a 2 1/2 week period. We collected patient age, sex, cause of pain, drug treatment for pain, dose, and duration of treatment. We studied in more detail patients suffering with low back pain (LBP), as this is an extremely common condition. We calculated daily dose of various opioids they were taking and converted and added all opioid doses together to morphine equivalent dose (MED) per day using established methods. We further analysed patients with LBP taking less/equal to 50mg/d, 51-100mg/d, more than 100mg/d of MED and those taking no opioids.

Results

Out of 104 patients surveyed, we had 50 (48.06%) patients who were suffering with chronic low back pain (LBP), 45 (43.27%) with other persistent chronic pain.

Opioid dose and adjuvant treatments as below:

Morphine equivalent 0mg: total 20 pts (40%), benzodiazepines 3pts, gabapentin 4 pts, antidepressants 4pts.

Morphine equivalent 0-50mg: total 17 pts (34%), benzodiazepines 3pts, gabapentin 5 pts, antidepressants 9pts.

Morphine equivalent 50-100mg: total 8 pts (16%), benzodiazepines 2pts, gabapentin 2 pts, antidepressants 3pts.

Morphine equivalent >100mg: total 5 pts (10%), benzodiazepines 1pt, gabapentin 1 pt, antidepressants 1pt.

Opioids prescribed were as follows (number of patients in parentheses: Codeine (14), Dihydrocodeine (1), Co-proxamol (2), Tramadol (9), Buprenorphine (1), Meptazinol (2), Fentanyl patch (1), Oxycodone (1), Oramorph (1), MST (1).

Of these 50 patients with back pain, some were on multiple opioids- 1 was prescribed three and 5 were prescribed two different opioids.

Conclusion

Although limited by sample size and hospital setting, our data suggest that a significant proportion of patients with chronic back pain are receiving potentially harmful opioid doses. Since efficacy data for chronic opioid analgesic therapy is limited, the known risks associated with high opioid use must be weighed against clinical benefit on pain and physical function. Careful screening and regular assessments are necessary if long-term opioid therapy is to be employed safely in patients who live with chronic pain. These preliminary data reveal the need for a more comprehensive UK-wide assessment of opioid prescribing in chronic non-malignant pain.

037

Service provision and the challenge of contextualising patient feedback

Category: Audit

Hannah Williams^1,2, Anthony Davies^1,3

¹Plymouth Hospitals NHS Trust, Plymouth, Devon, UK, ²University of Exeter, Exeter, Devon, UK, ³Peninsula College of Medicine and Dentistry, Exeter/Plymouth, Devon, UK

Background

The white paper ‘Equity and Excellence - liberating the NHS’ advises service providers to focus on ‘world class health outcomes and the quality standards that deliver them.’ This will inevitably require robust feedback from service users. Measuring care quality within the context of chronic pain is challenging due to the complexity of issues that impact on management. As well as diagnostic difficulties and intertwined psychosocial considerations, there are additional complexities in relation to expectation management when a curative option is not feasible.

The purpose of this study was to explore the concept of service quality within the context of chronic pain management and investigate the determinants of patient satisfaction and dissatisfaction. The research was informed by dimensions of service quality identified in previous studies, including the SERVQUAL scale already developed for the for-profit sector, to identify discrepancies between patient expectations and perceptions.

Methods

Written confirmation was obtained from the local ethics committee that this study was defined as service evaluation rather than research and hence did not require formalised ethics approval. This research project took a hybrid approach, adopting quantitative and qualitative approaches to explore different aspects of the concept of service quality in pain management. The context was a specialist centre for pain management in an NHS hospital in South West England.

The methodology adopted a modified SERVQUAL strategy, incorporating assurance, empathy, reliability, responsiveness and tangible elements of service delivery. Supplementary questions included patients’ initial expectations, defining sources and whether these expectations were met. Three hundred consecutive patients were surveyed following their initial specialist appointment. Qualitative research included in-depth patient interviews evaluating views on service quality, expectations and the determinants of satisfaction.

Results

A 41% response rate was achieved. Quantitative client feedback was extremely positive, with over 75% responding with a score of 8-10/10 on overall satisfaction. Over 30% gave a maximum rating to the overall service experience. However, this data indicated a clear link between dissatisfaction and the tangible elements of service delivery. This included concerns relating to waiting times, poor clinician time-keeping and lack of information.

Qualitative analysis identified several extra drivers relating to perceived service quality. This in particular showed that the empathy and assurance aspects of service delivery in healthcare have a profound impact on overall patient satisfaction.

Conclusion

Most service user evaluations focus on a quantitative satisfaction survey. This study highlights the limitations of this particular single approach. By adopting a hybrid approach, incorporating both quantitative and qualitative analysis, service providers can obtain a more accurate and in-depth evaluation of the experiences and expectations of this challenging patient group.

References

Department of Health, (2010), ‘Equity and Excellence - liberating the NHS’, http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf

Parasuraman, A., Zeithaml, V. A., & Berry, L. L., (1988), ‘SERVQUAL: A Multiple-Item Scale for Measuring Consumer Perceptions of Service Quality’, Journal of Retailing, 64, 1, 12-40

038

Quality of life improvements in chronic pain patients with laxative-refractory opioid-induced constipation treated with oxycodone/naloxone fixed dose combination tablets

Category: Audit

Vivek Mehta, Sami Alawad, Sanjay Kuravinakop, Serge Nikolic

St Bartholomew’s Hospital, London, UK

Background

In chronic opioid usage, constipation remains a challenge. While analgesia is predominantly attributed to central opioid actions, constipation is more peripherally (enteric mu receptors) related, leading the development of oral fixed dose opioid agonist-antagonist combination (oxycodone and naloxone) to counteract the resulting constipation. The naloxone counteracts the action of oxycodone locally in the gut but is almost completely eliminated by first pass metabolism, resulting in effective analgesia equivalent to that observed with oxycodone alone.

Methods

After regulatory ethics committee review, 23 outpatients (on long term opioids for non cancer chronic pain) with laxative refractory opioid induced constipation (LR-OIC) were recommended an opioid-equivalent dose of fixed dose oxycodone/naloxone combination (Targinact^®, Napp Pharmaceuticals Limited) as per standard clinical practice. Data were gathered at baseline and at 1 and 4 weeks using the Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire (Johnson and Johnson), a standardized, validated, patient-reported outcomes measure evaluating the quality of life impact of constipation, and Bowel Function Index (BFI, Mundipharma Research Limited) a validated, 3-item questionnaire to assess constipation.

Results

All 23 patients completed a questionnaire for week 1 and 18 patients for week 4.The mean decrease from baseline in overall PAC-QOL score was 13.96 (95% CI 24.04-3.87) P= 0.013 and 12.22 (95% CI 19.8-4.64) P= 0.006 at week 1 and 4 respectively.

Subscale analysis reported statistically significant mean decrease from baseline for all subscales at week 1 and week 4:

worry and concerns: week 1=8.22 (95% CI 14.52-1.91) P=0.018, week 4=5.28 (95% CI 9.89-0.66) P=0.039 at week 4

physical discomfort: week 1=3.35 (95% CI 5.48-1.21) P=0.006, week 4=3.28 (95%CI 5.11-1.44) P=0.003

psychosocial discomfort: week 1=3.70 (95% CI 6.50 -0.89) P=0.017, week 4=4.22 (95% CI 7.16-1.29) P=0.012

satisfaction: 3.57 (95% CI 5.76 -1.37) P= 0.004 at week 1, 4.11(95% CI 6.341.88) P= 0.002 at week 4.

Mean BFI improvement was 24.42 (95% CI 40.21-8.63) P= 0.006 and 23.43(95% CI 37.53-9.32) P= 0.005 at week 1 and 4 respectively.

Conclusion

For patients with laxative-refractory OIC, oxycodone/naloxone offers statistically and clinically significant improvements in bowel function and quality of life, helping to improve outcomes for patients with chronic non-malignant pain.

039

Audit of constipation in chronic pain patients on analgesic medication

Category: Audit

Joanne Rugen

Royal Cornwall Hospital, Cornwall, UK

Background

Constipation is a common problem in chronic pain patients. This may be related to reduced mobility or certain medications prescribed more commonly for chronic pain patients such as opiates. The aim of this audit was to establish the number of patients attending our general pain clinic who were also suffering from constipation, in how many this problem may be related to their analgesic medication intake and to see if they have been given simple advice/treatment to manage this problem.

Methods

Over several days a total of one hundred patients (both new and follow-up) attending a general pain clinic were asked to complete a questionnaire about analgesic use and bowel related symptoms.

Questions included regular pain medication intake & duration, medications avoided; bowel issues and duration of time experienced (constipation defined by the Rome criteria); Additionally they were asked about methods used to manage bowel symptoms and if they have they asked anyone for any advice about these symptoms?

Methods employed were compared with those recommended in the Map of Medicine health guide for Chronic Constipation (Primary Care).

Results

All 100 patients completed the questionnaire. Eight of them were taking regular analgesics.

Forty eight patients attending clinic experienced symptoms of constipation. Forty one patients believed their bowel symptoms were related to their analgesic medications. 14 patients avoided codeine based medications due to constipation. 37 patients were taking weak opioids, 11 in combination with strong opioids.

Of the 48 patients who fitted the criteria for constipation, 21 patients used no methods to improve their symptoms. Others used a combination of methods - 25 diet, 5 exercise and 27 various medications. 34 had seen their GP for advice but 10 not sought advice from any source .

Conclusion

Many patients attending our pain clinic experienced symptoms of constipation.

Constipation is only rarely associated with life-threatening complications, however the impact on sufferers may be significant.

Many of our patients have symptoms that could managed effectively with simple measures including hydration and diet. However many have not discussed this problem with a health professional.

The audit suggests that patient awareness and self management could be improved. This could be highlighted using information posters and leaflets. Those with troublesome symptoms should discuss this with their GP or Pain Physician during their review.

040

Service evaluation of high volume acupuncture clinic in Ysbyty Gwynedd

Category: Audit

Sarah Bowcock, Fiona Owen, Rhian Lewis

Bangor Gwynedd

Background

Since the introduction of acupuncture into the 2009 NICE guidelines for the management of chronic low back pain, NHS centres throughout the UK have reported practical problems delivering this service on a large scale. In an attempt to overcome these issues, the Royal London Homeopathic Hospital devised a new model of delivering acupuncture in high volume acupuncture clinics (HVACs). Promising results were reported with 79% of patients showing an improvement in pain, and 67% showing a ‘moderate’ or ‘substantial’ improvement enough to affect quality of life.

Based on this trial, a nurse specialist in chronic pain (FO) working in Ysbyty Gwyedd decided to implement this model in their chronic pain service. This project is an evaluation of the first year results of this service, and aims to assess how well the current model is working and to potentially identify areas for improvement.

Method

The service was set up in Bryn-y-Neuadd hospital (Bangor). Patients were selected based on having widespread chronic pain and fulfilling the usual acupuncture safety criteria. Each group consisted of up to six patients and was run for one hour, once a week for four weeks. In the first session, four acupuncture points were used (LI4 and LV3 bilaterally), however extra points were used in subsequent sessions if patients had specific areas of pain which could be needled safely in a chair.

At the start of the first session patients answered an audit questionnaire asking about pain, sleep, mood and activity. These questions were then answered again at the end of the last session, as well as two extra questions about side effects and their views of the group.

Data was coded from qualitative to quantitative data before being entered into an Excel spreadsheet to allow analysis of results.

Results

40 patients were available for analysis 30% male, 70% female. 40% of patients demonstrated a reduction in pain levels after the group. Although this is lower than the 79% demonstrated by the London HVAC study there were differences in our studies which would explain this.

40% of patients demonstrated an improvement in mood and 42.5% demonstrated an improvement in sleep. This shows that the psychosocial benefits of acupuncture are not impaired by delivering acupuncture in a group setting.

27% of patients demonstrated an improvement in activity, this is low compared to the other measures however I feel that this is still significant given that the patient sample were selected based on their resistance to other forms of treatment.

Patients seemed to find the group beneficial and enjoyable, with 67.5% stating that the group had been ‘good’, ‘very good’ or ‘excellent’ at helping them to manage their pain.

Conclusion

In summary, I feel that these initial results show positive and satisfactory outcomes for the group. It has demonstrated that this service is working well and that any initial concerns about the lack of individual attention or the use of standardised acupuncture points in a group have been shown to not impair acupunctures effects. Although most of the results were not as good as those demonstrated in the current literature, there is only one other study which has looked at HVAC groups to properly compare it to and there were several differences in our methods which would explain this.

041

Why do patients miss (DNA) and cancel their pain management clinic appointment?

Category: Audit

Arasu Rayen, Tracy Wong, Bethany Fitzmaurice, Alice Rogan, Sharnaz Akthar

Department of Pain Management, Sandwell and West Birmingham NHS Trust

Background

Missed and last minute cancellation of hospital appointments are detrimental to the National Healthcare and lead to unnecessary wastage of NHS resource in the form of clinic time and man-hours, which increase waiting time. It is estimated that NHS looses at least £600 million by missed appointments. There are studies by governmental, non – governmental organisations and hospital specialties like HIV clinics, paediatrics to find out the reasons for the non - attendance. So far, there is no such published study in chronic pain management clinics. So, we have decided to do a study to find out the reasons for patients missing pain clinic appointments and last minute cancellations and if possible, implement necessary changes to improve the attendance.

Methods

The data was collected with the help of questionnaire with 16 possible reasons for DNA and cancellation like sudden ill health, unsure of having the procedure or its benefits, ‘forgot about it’, need more time to think, no longer wanted or needed the procedure, childcare or work related issues, date and time didn’t suit, distance need to travel, religious reasons etc.

We collected the information for both pain clinic and procedure list. With the help of the Hospital IT system, details of the patients who missed the appointments and dates of DNA and cancellation were collected for the period of April to September 2011. One of our team members telephoned the patients to find out about the reasons for missed and cancelled appointments. Patient’s demographic details also were collected. The preliminary data was analysed with SPSS.

Results

DNA

43 patients missed their clinic appointments and 25 patients missed their procedure appointments.

Top 5 reasons for missing the clinic appointments are

1. ‘Forgot it’ (13 patients)

2. Sudden ill health (12patients)

3. Other reasons (11 patients)

4. Time and date did not suit (4 patients)

5. No longer needed the procedure (2 patients)

Top 5 reasons for missing the procedure lists are:

1. Sudden Ill health (5 patients)

2. Unsure of having the procedures (5 patients)

3. Unsure of the benefits of the procedure, not enough information about the procedure was given, needed more time to think about it, Others causes, forgot about it, (4 patients each)

4. The time date/time/day of the procedure didn’t suit you (2 patients)

Cancellation

82 patients cancelled the pain clinic appointments. The commonest reason quoted for cancellation was sudden ill health (34). 14 patients told us that the time didn’t suit them.

During the study period, there are 85 patients cancelled their procedure appointments. Majority (27) told us that they cancelled because of sudden ill health. Nine of them told us that the time and date did not suit (even though it was mutually arranged). Some of them (7) felt that they no longer needed the procedure. Six patients had to cancel the appointment because of work related issue.

Conclusion

There are some factors which are common in the missed and cancelled appointments in both clinic and procedure list – sudden ill health, forgetting the appointment dates and time and day not suiting the patients. Reminder letters, text messages and reminder calls should improve the attendance.

Patients not sure about the procedures and their benefits are the main reason for missing the procedure list appointments. Explaining the procedure, leaflets and injection class may improve the situation.

Patients not sure about the procedures and their benefits are the main reason for missing the procedure list appointments. Explaining the procedure, leaflets and injection class may improve the situation.

042

Efficacy and adverse effects of buprenorphine patches in chronic pain patients

Category: Audit

Vinay Siddannagari Anjana Reddy, Jillian Davies, Shiva Tripathi

Central Lancashire Teaching Hospitals NHS Trust, Preston, Lancashire, UK

Background

Buprenorphine patches are used when patients are not responding to WHO step 2 analgesia. It is available as Butrans and Transtec patches. Butrans is available in 5, 10 & 20mcg/hr patches and each patch works for 7 days. Transtec is available as 35, 52.5 and 70 mcg/hr and are effective for 4 days. Recent communication form ‘Central Lancashire Primary Care Trust’ (PCT), indicated that prescription of Buprenorphine patches increased by 230%. In 2006, The ‘Scottish Medicines Consortium rejected the use of Butrans/Trasnstec patches in chronic pain on the grounds of lack of evidence in comparative efficiency with clinically relevant treatment for chronic pain, available in Scotland.

Our aim was to report to Central Lancashire PCT & Napp (Pharmaceutical company), identifying appropriate prescriptions, based on the source from which prescriptions originate i.e. Primary/Secondary care. Also to identify incident rates of adverse reactions and efficiency of Buprenorphine patches

Methods

Prospective audit was conducted over a 5 month period at Central Lancashire PCT (UK). Patients were seen in consultation clinics, with follow-up consultations ranging from 6 weeks to 6 months. A Pain Audit Collection system (PACS)/ Brief Pain Inventory (BPI) Assessment form was completed when a patient first attended the clinic and again at subsequent follow up appointments. The results collected for each patient from both initial and follow up appointments were compared. Data included age, gender, current pain problem and type of pain, duration of pain, current medication, dosage of Buprenorphine patch, who initiated the prescription (primary/secondary care), duration of the follow up, number of patients still using the patch at follow up, reason for discontinuation if any, adverse effects noted, strength of patch at follow up and pain relief and general well being after using

Buprenorphine patch.

Results

Audit comprised 51 patients, age ranging from 20-90 years with an average of 61 years (80% female, 20% male). 43% indicated pain duration of more than 5 years. 29 (56%) patients suffered from back-pain. During follow up, 33/51 (65%) were using patches, 13 (25%) discontinued, 5(10%) did not indicate.13 (25%) patients had their dose increased at some point. 95% of patches were prescribed by Pain specialists at secondary care. Reasons for discontinuation included no pain relief or increased pain during usage of patch and adverse effects associated with patches. 50% noted more than 50% pain relief with the patch and only 4 (8%) indicated no pain relief and remaining (46%) indicated some pain relief. More than 50 % patients indicated that, general well being improved. Adverse effects were noted in 18/51(35%) patients. Skin irritation was seen in 7(14%) patients, and others had low incidence of drowsiness, constipation and headache

Conclusion

From our audit we concluded that majority (95%) of the prescriptions are initiated or advised by secondary care (Pain Medicine physicians). Buprenorphine patches are indeed effective in chronic pain management. Significant number of patients experienced reasonable pain relief and also general well being was improved in many patients. Buprenorphine patches need to be considered if the patient is not responding to WHO Step 2 analgesics. Adverse effects are common problem with 35% experiencing it. Skin irritation contributes to 39 % of all adverse effects and has overall incidence of 14%, which is more than quoted by Napp.

Cancer Pain

043

Percutaneous cervical cordotomy for non-cancer pain in a patient with terminal oesophageal carcinoma: a case report

Category: Cancer Pain

Jacquelyn Lewin¹, Heino Hugel², Manohar Sharma¹

¹The Walton Centre Foundation Trust, Liverpool, UK, ²Woodlands Hospice, University Hospital Aintree, Liverpool, UK

Background

The interventional pain procedure cervical cordotomy is mainly reserved for patients with intractable unilateral cancer pain below the C4 dermatome, with a prognosis of greater than 3 and less than 12 months.

Intractable non-malignant pain is generally considered to be a contraindication to cordotomy, because only 40% of patients still have pain relief 2 years post procedure, and there is a known incidence of severe neuropathic pain once the effect of cordotomy has worn off.

Recent experience of this technique in non-malignant pain syndromes is limited. A 2008 review produced 11 case series, published between 1957 and 1990. In general, pain relief was improved post-operatively, but the benefits declined with time.

We describe a case where the procedure was successfully used for medically refractory non-cancer pain, in a patient with terminal metastatic disease.

Methods

A 67 year old man with a 10 year history of rheumatoid arthritis on maintenance dose of methotrexate suffered with persistent pain in his right hip and buttock following total hip replacement in 2006.

He had been diagnosed with moderately differentiated squamous cell carcinoma of the oesophagus in 2006 and had received chemotherapy, oesphagectomy and subsequent radiotherapy for later superior mediastinal recurrence. 2 months after this treatment he developed severe, constant, worsening low back, right hip and buttock pain; further imaging ruled out metastatic disease as the cause, and a diagnosis of mechanical low back and hip pain was made. Mobility was severely restricted and the pain was uncontrolled with opioid and adjuvant medication; drowsiness prevented opioid increase, and lumbar medial branch blocks did not help the pain. He was keen to consider an interventional pain management option and was admitted to the hospice.

Results

Implantation of an intrathecal drug delivery system was considered unsuitable due to the increased risk of infection in a patient on methotrexate. Because of the combination of a severe unilateral pain problem and the presence of malignancy, cervical cordotomy was considered, but would only be an option if life expectancy was less than 12 months. Repeat CT scans of the chest and abdomen showed stable oesphageal disease, but also two new low volume lung metastases; the oncologists felt that he had a prognosis of 6-12 months.

The nature and limitations of the procedure and its specific role in patients with a limited life expectancy was discussed. The patient was fully counselled regarding the potential risks and benefits and was keen to proceed. Pain relief was immediate and he stopped oxycontin prior to his discharge 4 days later. He died 11 months later with no recurrence of the right sided pain.

Conclusion

Our patient had a confirmed life expectancy of 6-12 months and an intractable non-malignant pain syndrome which resolved completely with cordotomy. This case highlights that in well selected patients, cordotomy can also be useful in non-malignant pain syndromes, where life expectancy is limited and pain is refractory to conventional medical management.

044

The role of percutaneous cervical cordotomy in the management of severe cancer pain: results from a prospective case series

Category: Cancer Pain

Heino Hugel¹, Manohar Sharma², Jacquelyn Lewin²

¹Woodlands Hospice, University Hospital Aintree, Liverpool, UK, ²The Walton Centre Foundation Trust, Liverpool, UK

Background

Percutaneous cervical cordotomy (PCC) is a neuro-destructive procedure for severe refractory unilateral cancer pain associated with mesothelioma and other cancers.

We wanted to assess the impact the procedure had on pain scores, morphine equivalent usage and global impression of change scale, and also to document any side effects related to the procedure.

Methods

Data was collected prospectively for 39 consecutive patients who underwent percutaneous cordotomy at a large regional pain centre in the Northwest between February 2008 and June 2011. The patients were all seen in a joint pain services/palliative care clinic.

Patients’ pain scores were assessed on three occasions: at one day prior to, and two days and four weeks post procedure.

Data collected: Average and maximum pain scores on a numerical rating scale (NRS) 0-10 at 24 hours pre-procedure and 48hrs and 28 days post procedure; global impression of change scale; morphine equivalent 24hrs prior to and percentage reduction after procedure; side effects from procedure.

Results

• 39 patients underwent PCC, most commonly for pain associated with mesothelioma (19 patients) and bronchial carcinoma (10 patients).

• 29 patients had chest wall pain.

• The mean maximum pain score 24 hours prior to the procedure was 8.5 (SD 1.7); mean maximum pain score 48 hours post procedure was 1 (SD 2.1) and at 28 days post procedure was 2 (SD 3.1).

• Average pain scores at these stated times were 6.5 (SD 1.8), 0.85 (SD 2.1) and 1.9 (SD 2.98).

• The median equivalent morphine dose pre-procedure was 140mg and there was a 50% reduction post procedure.

• 48 hours post procedure, 9 patients felt very much better and 23 patients felt much better on the global impression of change scale.

• There were no irreversible procedure related side effects.

Conclusion

Percutaneous cervical cordotomy is a highly effective procedure for unilateral refractory cancer pain associated with mesothelioma and other cancers in well selected palliative patients.

045

Compliance in the use of oral medication during follow-up in cancer pain outpatients

Category: Cancer Pain

Rajesh Gupta, John E Williams

Department of Anaesthesia and Pain management Royal Marsden Hospital, London, UK

Background

Low compliance to prescribed medications is an ever present and complex problem, especially for patients with a chronic illness (Vermeire E 2001). It has been observed for a long time (Marsten M 1970) and has been noted across all age groups. The use of oral medications for chronic conditions has made patients take control of their disease. Health practitioners all too often assume that drug therapy and other therapeutic regimens are automatically followed but too often patient compliance is not adequately monitored(Christensen DB 1978). Without a clear idea of drug intake, it becomes difficult to titrate the dose of prescribed drug or to add or delete a medication. The royal college guidelines propose compliance of at least 70% as standard. The purpose of the audit was to assess the compliance with medications in cancer pain clinic and the reasons for non compliance.

Methods

Patients attending outpatient’s cancer chronic pain clinic were included in the study. All those patients who had their first follow up were assessed for the compliance with the medications. An arbitrary time of 3-6 weeks was chosen as this is the average follow up time for patients for their second visit. A total of 107 patients were included in the audit over a period of 2 months. A patient information leaflet was given explaining the nature of the audit. Only those patients who gave consent for the interview were included in the audit. The data was conducted only through the patient information. The patients who did not attend the follow ups were not included in the study for the simplicity of the audit. They were asked about the analgesics prescribed, medications taken at 6 weeks. Reasons were ascertained for taking suboptimal doses or discontinuation of medications.

Results

A total of 107 patients were interviewed for compliance of medications on their follow up visit. 77.5 %( n=83) of patients were compliant and were taking medications as prescribed. 15% (n=17) were taking suboptimal doses and 6 %( n=7) stopped the medications prescribed. The reasons observed were fear of toxicity, side effects and no benefit. Out of the 7 patients who stopped medications, 3 stopped due to side effects, 3 due to no beneficial effects and 1 due to fear of addiction. 7 out of 17 patients were on suboptimal doses as they wanted to avoid addiction whereas 6 patients decreased the doses because of side effects and 4 patients decreased the doses as they were on multiple medications. 26% (n=22) of the patients who were compliant (n=83) did not feel adequate pain relief but were still taking analgesics at the prescribed doses.

Conclusion

The compliance with medications was at 78.6% which is less than that found by Miaskowski et al (2001). Smaller sample size could be the reason but a similar large sample size has shown the compliance to be at 41 %( Valeberg et al 2008). Our audit showed that women, those with multiple comorbidities and those on multiple medications were less likely to be compliant, similar to the results earlier observed (Sung JCY et al 1998). The main factors hindering use of analgesics were side effects, fear about addiction and ineffectiveness which is concurrent with the findings of Kraybill BM (1999).

046

Intra-thecal analgesia for pain control in palliative medicine

Category: Cancer Pain

Kerry McWilliams¹, Alison Mitchell¹, Jonathon McGhie²

¹Beatson West of Scotland Cancer Centre, Glasgow, UK, ²Stobhill Hospital, Glasgow, UK

Background

Intra-thecal (IT) delivery of analgesics is used to control pain in cancer patients where other analgesics have been unsuccessful or titration has been limited by systemic side effects. IT drugs can be delivered at much lower concentrations with fewer systemic side effects. Our IT service has been running since May 2007 and is a joint venture between chronic pain and palliative care teams in a tertiary referral oncology centre. Patients are jointly assessed and if suitable proceed initially to an external infusion. Patients have a tunnelled intra-thecal catheter inserted in theatre which is then connected to an external CADD-Legacy pump. Patients then undergo a period of dose titration, aiming for pain control without compromising mobility or sphincter control. After the titration phase, patients who are suitable return to theatre for the second stage of implantation, an Archimedes pump, which requires to be refilled on a fortnightly basis in outpatients.

Methods

We audited data for all19 patients who have undergone IT insertion in our service since 2007. We retrospectively reviewed patients’ case notes. The data collected included patient characteristics such as age, gender and primary tumour site. We audited the responsiveness of the service by collecting data on time from initial referral to first review and time from decision to go ahead with IT to initial implantation, and time between first and second stage of implantation. The effectiveness of IT drug delivery as a method of pain control was audited by comparing best, worst and average pain scores over a 24 hour period before and 1 day, 1 week and 8-12 weeks post insertion. We have also collected data on the oral morphine equivalent (OME) dose of analgesia prior to IT insertion and IT drugs and doses used in all patients. Mortality data and place of death is included where available.

Results

Of 19 patients, 11 proceeded to full implantation, 2 had external infusion removed, 2 are awaiting full implantation and 4 remained on external infusion. OME prior to IT insertion was 1257 (270-4500) mg/day. No patient remained on regular systemic opioid 1 week post insertion. Worst and least 24 hour pain scores pre-insertion, day 1 and 1 week post insertion were compared: Worst 9.2 vs 5.8 vs 4.3, Least 4 vs 1.2 vs 1.4. Initial IT doses were morphine 4.55(0.6 - 10.8) mg/day and Levobupivicaine 12.45 (8.64-16.8) mg/day. Final doses for 13 patients who had IT in-situ at death were morphine 21.76 (1.8 - 58.2) mg/day and Levobupivicaine 45.9 (12-83.1) mg/day. 62% had Clonidine in pump mixture. For these 13 patients the average time with IT in place was 137.5 (10-292) days. The most common immediate complication was post-dural puncture headache (PDPH) in 4 patients (21%), 2 requiring blood patches.

Conclusion

IT analgesia is known to be effective in controlling pain at end of life. Our data shows IT analgesia is also an effective treatment in patients with a prognosis of months. At one week post intrathecal insertion no patients required regular systemic opioids, a significant advantage for those experiencing systemic side effects. Rates of PDPH were high and two cases serious enough to require a blood patch. Few other complications were seen, none of them serious. We would conclude IT drug delivery should be considered for suitable patients with poorly controlled cancer pain, not just those at end of life.

047

Screening for pain in an outpatient setting: a qualitative study to explore the views of patients with head and neck cancer enrolled in a pro-active pain management programme. What helps and hinders pain control?

Category: Cancer Pain

LM Robinson¹, JE Williams¹, FEM Murtagh², JR Ross¹

¹Royal Marsden NHS Foundation Trust, London, UK, ²Cicely Saunders Institute, King’s College London, UK

Background

Head and neck cancer accounts for 5-10% of malignancies worldwide. Pain associated with head and neck cancer has been shown to be more prevalent and severe than pain from other types of cancer, and affects up to 70% of this cohort. A new model of care comprising of screening for pain and immediate instigation of a pain management programme in the outpatient head and neck cancer setting, is currently being evaluated in a large randomised controlled trial (RCT). This qualitative study complements the RCT and aims to explore patients’ views of this proactive screen and treat protocol. In addition, facilitators and barriers to pain control within the head and neck cancer population have been explicitly sought.

Methods

This qualitative study consisted of semi-structured in-depth interviews. The interviews were conducted using a topic guide designed both to explore patients’ views of the “screen and treat” pain management programme and also to gain an understanding of barriers to pain control in this population. Patients randomised to the intervention arm of the RCT were sequentially approached over a three month time period and invited to contribute to in-depth interviews. The interviews were audio- recorded, field notes taken and the interview transcribed verbatim. A thematic analysis of the data was conducted aided by the Framework method. This is a matrix based analytic method that facilitates rigorous and transparent data management.

Results

Six participants (four female), from intervention group of thirteen during the three-months, were interviewed. Key themes were: views of the “Screen and Treat” system; physical pain is only one component of the cancer experience; significance of head and neck cancer as a visible cancer; societal values presenting a barrier to effective pain control; regaining control and normalisation as an important coping strategy. Participants were positive about the programme and expressed that being listened to and having additional contacts outside of the outpatient setting, was valuable. Physical pain was often not prioritised as a symptom. This may be due to the context of pain secondary to potentially curative anti-cancer treatments and the presence of other distressing symptoms including physical disfigurement following surgery. Re-gaining control and normalisation were often prioritised at the expense of pain control through the development of personal management strategies of which pharmacological interventions were only one component.

Conclusion

Complex barriers to pain control exist within the head and neck cancer population. A pain management programme for patients with head and neck cancer needs to recognise the converging evidence that cancer pain and its impact are multidimensional. Therefore, a “total pain” model which incorporates physical, psychological, social, emotional and spiritual elements should provide the basis for pain management within the head and neck cancer population. Triangulation of this study with the RCT adds breadth and depth to its findings as well as providing insight into the challenges of effective pain management within this complex population.

Education

048

Advanced Pain Training – a satisfaction survey of the current trainees - 2011

Category: Education

Sumit Gulati¹

¹University College London Hospitals, London, UK, ²Leeds Teaching Hospitals, Leeds, UK

Background

Training in Pain Medicine has seen a major transformation in the last few years under the Faculty of Pain Medicine, which was established in April 2007 to appropriately represent the professional, educational and training needs of Pain Medicine doctors. The anaesthetic trainees currently undertake a 12 month advanced training in the final two years of their Specialty Registrar training. While the training programme is underpinned by the guidelines set by the Faculty, differences remain in its organisation, delivery and quality because of various factors. An inherent variation in the practice of Pain Medicine, an ongoing reorganisation of services in NHS and geographical factors are some of the causes known to influence the training delivered.

I set out to objectively identify the satisfaction levels in various aspects of training from the current cohort of Advanced Pain Trainees in June 2011 to which I belonged at the time of this survey.

Methods

A single A4 sheet questionnaire was distributed to all Advanced Trainees attending the lunchtime trainee meeting in the British Pain Society ASM of 2011 in Edinburgh. Anonymity was maintained and they were encouraged to complete and return the form before the end of day. An 11-point satisfaction scale was employed where 0 signified extremely dissatisfied and 10 fully satisfied. A total of fourteen questions encompassed four aspects of training and working. Four questions addressed working and employment, four questions looked at clinical supervision and encouragement for career development, three questions looked at skills training and another four questions explored experience in subspecialties and allied specialties. One final question looked at overall satisfaction levels.

A basic binary analysis of satisfied/not satisfied was performed for score being 4-10 or 0-3 respectively, followed by further detailed analysis looking at grade of satisfaction (0-3, 4-6, 7-10), modal distribution and range as appropriate.

Results

Seventeen advanced trainees returned completed questionnaires out of a maximum twenty-five in the meeting, which makes it a response rate of 68%. 100 percent trainees reported an ‘overall satisfaction score’ of more than 4 with their training programme as was also the case with the ‘Psychology/Pain Management Programme’ aspect of training. A modal class of 10 was reported in ‘EWTD compliance’, ‘Supervision’, ‘Encouragement for teaching and undertaking audit’, ‘Acute pain’ and ‘Cancer pain’. 76% trainees reported high levels of satisfaction (score 7-10) with basic interventional procedures, while they were moderately satisfied with ‘Advanced procedures’ and ‘Neuromodulation’ training.

‘Paediatric pain’ training and ‘Access to radiation protection’ reported the worst satisfaction scores with a mode of 0 and 60 percent trainees reporting a score less than 5. British Medical Association recommends a 100% adherence to ‘induction for junior doctors’ that seemed to be lacking with 24% reporting overall dissatisfaction.

Conclusion

Overall the current cohort of trainees is satisfied with their Advanced Pain Training programmes. It is encouraging to see that trainees are generally satisfied with the ‘bread and butter’ aspects of clinical practice including Acute pain, Basic interventional procedures, Cancer pain and Pain management programmes. They feel well supported and encouraged in Teaching, Management and Audit/research. However, Advanced interventions, Neuromodulation, Paediatric pain and Radiation protection training needs greater attention. The shortcomings of such a survey and its analysis are appreciated, as it is a small cohort with potential bias of reporting and a lack of validation of the scoring system.

049

Survey of Pain Fellowship training

Category: Education

Sabita Sreevalsan¹, Karim Shoukrey²

¹Norfolk and Norwich University Hospital, Norwich, UK, ²Addenbrooke’s Hospital, Cambridge, UK

Background

The most common route to fellowship of the Faculty of Pain Medicine is the successful completion of Advanced Pain Training. The aim of this survey of training in pain medicine was to explore the attitudes of former pain fellows throughout the UK towards different aspects of the fellowship.

Methods

The addresses of 300 registered members of the British Pain Society (BPS) from all over the UK were obtained. A survey questionnaire was sent to each member assessing various aspects of pain fellowship training. Members were asked not to respond unless they had finished their pain fellowship within the last five years. The responses were collected and analysed.

Results

A total of 40 responses were received, of which only 20 fulfilled the survey criteria. Although few, the responses covered 12 regions in the UK. Most responders finished their fellowship in their 4^th year of registrar training. The majority rated their training in cervical procedures, neurolytic procedures and spinal cord stimulation as ‘poor’; whereas training in lumbar procedures, radiofrequency procedures and trigger zone injections was mostly ‘good’. Nearly all responders felt that they had enough exposure to supervised and independent clinics, as well as supervised intervention lists; however, exposure to independent intervention lists was not as good. Experience in other disciplines was variable. All responders found it easy to get study leave for pain courses, but only 50% had fixed formal in-hospital teaching sessions. Nearly all had on-call commitments and most felt that they had adversely affected their training. All responders went on to pursue a career in pain medicine.

Conclusion

Although responders were generally satisfied with their training, they felt that they could have benefited from further exposure to cervical, autonomic and neurolytic procedures, independent intervention lists and other disciplines related to pain management (e.g. palliative care, psychology, neurology, rheumatology, radiology, TENS, acupuncture, etc.). On-calls and elective anaesthetic lists adversely affected fellowship training. At the end of their fellowships 35% of responders felt that they could still do with more training before applying for a consultant post.

050

Chronic pain: is it as internet savvy as the rest?

Category: Education

Rajiv Malhotra¹, Sara Kelly¹

¹Royal Liverpool University Hospital, Liverpool, UK, ²Warrington Hospital, Warrington, UK

Background

There has been a huge rise in the amount of health information on the internet, increasing knowledge and awareness amongst the public and health care professionals¹. The use of the internet to raise awareness and assist in the management of chronic medical conditions is well documented². Chronic pain is an often under recognized condition that has a significant impact upon the population³. Indeed, knowledge is often limited even amongst health care professionals⁴. It is possible that the reduced awareness of chronic pain compared to other chronic medical conditions is due, in part, to a reduced internet presence. If true, increased utility of internet resources could improve knowledge and understanding of chronic pain.

Methods

The term “chronic pain” was searched for on Google, Youtube, Twitter and mobile phone applications (apps), with the number of results being noted. The term was also searched for on Facebook and the highest number of members on any group was documented. Similar internet searches were made with the following chronic medical conditions: “Diabetes mellitus”, “Hypertension” and “Asthma.” Searches were made each day from 21/11/11 - 28/11/11 with the highest number being accepted.

Results

Chronic pain had the fewest number of google searches and mobile phone applications (9% and 15% of the most popular condition respectively), compared to the other chronic medical conditions. It had only the third most YouTube clips and Facebook members, and the second most Twitter searches.

………………	Google	YouTube	Apps	Facebook	Twitter
Pain	29400000	47800	121	7180	121
DM	299000000	188000	829	139965	176
HTN	67400000	17700	194	1195 58
Asthma	99300000	76800	240	9116	107

(where DM = diabetes mellitus, HTN = hypertension)

Conclusion

Compared to other chronic medical conditions, chronic pain is under-represented on the internet, particularly with Google searches. It is likely that, by expanding the internet footprint of chronic pain, public and professional awareness will follow. Other areas of expansion include mobile phone applications to assist chronic pain management and YouTube clips showing chronic pain procedures. As the influence of the internet in health care continues to grow, it is crucial that chronic pain specialists ensure that chronic pain is at the forefront.

References

1. Andersson G, Ljotsson B, Weise C. Internet-delivered treatment to promote health. Curr Opin Psychiatry (2011). 24: 168-72

2. O’Connor DB, Warttig S, Conner M, Lawton R. Raising awareness of hypertension risk through a web-based framing intervention: does consideration of future consequences make a difference? Psychol Health Med (2009). 14: 213-9

3. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life and treatment. Eur J Pain (2006). 10: 287-333

4. Ali N, Thomson D. A comparison of the knowledge of chronic pain and its management between final year physiotherapy and medical students. Eur J Pain (2009). 13: 38-50

051

A national survey of radiation safety knowledge and practice amongst pain physicians in the United Kingdom

Category: Education

Helen Makins, Murli Krishna

North Bristol NHS Trust, Bristol, UK

Background

Ionising radiation is frequently used to direct pain procedures. Whilst radiation safety is currently included in the UK Medical School Undergraduate Curricula and is a requirement according to the European Commission Guidelines on Education and Training in Radiation Protection (2000), it is not listed amongst the competencies required for Advanced Training in Pain Medicine by the Faculty of Pain Medicine, Royal College of Anaesthestists, UK. Internationally, there have been initiatives amongst other non-Radiologist Doctors to improve post-graduate training in this area but not so far within the field of Pain Medicine. Our aim is to assess the current knowledge and safety practices amongst Pain Specialists in the UK and to ascertain the need for improved training.

Methods

Pain physicians practicing in the United Kingdom were emailed and asked to follow a link to an anonymous internet based survey containing 10 questions. After 2 months the results were collated and analysed.

Results

104 responses were received (99 pain consultants). Some responders did not answer all the questions.

40/102(39%) were performing 5 or fewer radiation requiring procedures weekly; 35/102(34%) 6 to 10; 11/102(11%) 11 to 15; 8/102(8%) 16 to 20 and 8/102(8%) greater than 20 procedures weekly.

55/101(54.5%) were aware of the ALARA (As Low As Reasonably Achievable) principle. 104/104(100%) of responders use lead aprons; 65/104(62.5%) thyroid protectors; 52/104(50%) radiation badges; 5/104(4.8%) X-ray screen.

26/102(26%) do not routinely attempt to reduce the radiation dose to the patient.

Of those who attempt to limit dosage, the most commonly used methods were avoidance of real time screening 51/82(81.7%), low dose setting 43/82(52.4%) and pulsed mode function 30/82(36.6%).

23/103(22.3%) of responders denied ever receiving any radiation training; 40/104(38.5%) did not feel that their knowledge of ionising radiation was adequate. 83/103(86%) felt that radiation training should be a mandatory part of Advanced Pain Medicine training.

Conclusion

This survey highlights the variation in basic knowledge and practice amongst Pain Physicians in the UK. Over one fifth of respondents to this survey are not aware of having received radiation training to date, despite the majority feeling that it should be a mandatory requirement for advanced training in pain management. At a time when changes to training and examination for Fellowship of the Faculty of Pain Medicine are evolving, this may represent an important addition to the post-graduate curriculum with a resultant potential improvement in safety for both patients and clinic staff.

052

Pain Training for Anaesthetists - does intermediate level training meet RCoA curriculum requirements?

Category: Education

Fauzia Hasnie

Lewisham University Hospital, London, UK

Background

Pain Medicine is a compulsory part of Anaesthetic training. Trainees must undergo basic and intermediate level training in Pain Medicine in order to achieve the core competencies required for the CCT in Anaesthesia¹. Intermediate competencies, which are usually achieved during the Specialty Registrar (StR) Years 3/4 of training, build on those acquired during basic level training as a Core Trainee (Years 1/2). They include competence in the assessment and management of acute surgical and non-surgical pain, as well as chronic and cancer pain; understanding of the importance of managing acute or chronic pain in a timely manner; and competence as an effective member of the acute pain team. It is preferable that this training is gained as a dedicated ‘block’. This retrospective study compares the Intermediate level Pain training offered at Lewisham University Hospital (LUH) with the competences required by the Royal College of Anaesthetists (RCoA) in the 2010 Curriculum².

Methods

The number of Pain training sessions during an 8 week dedicated Pain Medicine ‘block’ at LUH was calculated retrospectively for trainee X (April - May 2011) and trainee Y (October - November 2011). Of these, the number dedicated to Acute Pain was noted. Similarly, the number of ward rounds, clinics and theatre sessions in Chronic Pain was also noted. The 2010 RCoA Curriculum for a CCT in Anaesthetics was reviewed with regard to those competences that relate specifically to Acute Pain and those that relate to Chronic Pain. A comparison was then made to identify whether a satisfactory proportion of time had been dedicated to each to allow these competencies to be achieved. Recommendations for improvement in training requirements were made and implemented prior to examining Trainee Y’s experience.

Results

Trainee X was noted to have had 25 dedicated Pain training sessions out of a possible 42 Anaesthetic training sessions during the 8 week ‘block’. Of these, only 2 sessions (8%) were dedicated to Acute Pain, compared to 23 sessions (92%) to Chronic Pain (8 Clinic; 11 Theatre; 3 Ward Round; 1 Nurse-led). Notably, only 32% of total time was spent in clinic compared to 44% in theatre. In comparison, Trainee Y completed 44 Pain training sessions out of a possible 52 Anaesthetic training sessions. Of these, 7 sessions (16%) were dedicated to Acute Pain, compared to 37 (84%) to Chronic Pain (22 Clinic; 12 Theatre; 3 Ward Round). Notably, 50% of total time was spent in clinic compared to 27% in theatre. Overall, time spent in Acute Pain had doubled, whilst there was a 56% increase in clinic time and a 39% decrease in theatre time for Trainee Y.

Conclusion

The RCoA 2010 Curriculum for Intermediate Level Pain training outlines an equal weighting in competences that relate to Acute Pain and Chronic Pain. It further stresses the importance of achieving competency in the basic assessment and management of chronic pain patients, best accomplished in the clinic environment, rather than attaining practical skills in theatre. Following recommendations for improvement in training needs: (1) Not to be moved from Pain sessions during the 8 week dedicated ‘block’; (2) More Acute Pain sessions; (3) More sessions in Chronic Pain Clinic; Trainee Y achieved a more balanced training experience.

053

The effect of education on the prevalence of pain in a large London private hospital

Category: Education

Katharine Wall

The Wellington Hospital, HCA International, London, UK

Background

Evidence supports continuing education to improve knowledge, attitudes and understanding towards pain management¹. This study investigates whether an intense educational programme launched in conjunction with a new Pain Clinical Nurse Specialist role, could reduce the prevalence of severe pain, in a large 190 bedded private London hospital.

Not only is it paramount to manage pain to prevent post-operative complications but to also prevent Chronic Post Surgical Pain². In order to manage pain, pain assessment must be the 5^th vital sign³, and the organisation must support proposals that fewer than 20% should experience severe pain after surgery⁴.

Early audit pilot data (n=23) showed a deficit in regular pain assessment but a prevalence of moderate-severe pain of 26%. Patient feedback at this time included comments; ‘I wasn’t asked if

experiencing any pain’ or ‘my pain level was never asked or recorded’.

Methods

Following the pilot study (n=23), a teaching programme was initiated, concentrating on 5^th vital sign pain assessment, myths, misconceptions and addiction. 148 nurses attended the training and a separate session was delivered to the Resident Medical Officers and a standard was agreed within the organisation to achieve none-mild pain for all patients.

A prospective survey of 84 medical and surgical patients, examined the prevalence of routine ‘5^th vital sign’ pain assessments who had not been referred to the Pain CNS. Patients were asked to rate their worst pain experience in the previous 24 hours on a scale of none; mild; moderate; severe. Patients then participated in a ‘correct’ pain assessment at the time of the audit to ascertain the prevalence of moderate to severe pain. The pain scores were then compared to the documented pain score to explore the accuracy of the nurses’ assessment of pain.

Results

Demographics were insignificant regarding gender 51% female; 77% were surgical patients and 42% had pre-existing pain conditions. Pain existing at time of audit had reduced from 78% in pilot to 40%.

Fifty% of the patients with severe pain on movement were medical patients. Significantly patients with high pain levels (moderate-severe) were predominantly patients with pre-existing pain (68-80%), the majority back pain.

The frequency of 5^th vital sign pain assessment improved to 79% of the time, (61% pilot). A further 20% of patients had evidence of some pain scoring (17% pilot).

Patients’ reporting severe pain within previous 24 hours reduced from 44% to 17%. However, the accuracy of the documented pain assessment remained low; 67% (61% pilot), significantly so when severe pain was reported. Of the 17% reporting severe as the worst level of pain in 24 hours, more than half had a lower pain score documented by the nurses.

Conclusion

The prevalence of moderate - severe pain in comparison to previous studies⁵ remains modest, although not as low as the recommendations in the 1990s. The results indicate that the frequency of 5^th vital sign pain assessment within this private healthcare facility has improved following education, although the accuracy of transcribing patients’ report of pain intensity onto the nurses’ documentation remains subjective. This deficit requires further investigation; do some nurses still not feel able to believe their patients, or do fears and misconceptions continue to exist regarding decision making, opioid administration or challenging care decisions ?

054

Developing competencies for physiotherapists working in pain management

Category: Education

Linda Knott¹, Gail Sowden^2,3, Phillipa Newton-Cross¹

¹South Devon Healthcare Foundation Trust, Torquay, UK, ²Interdisciplinary Musculoskeletal Pain Assessment and Treatment Centre, Stoke-on-Trent, UK, ³Arthritis Research UK, Keele University, Staffordshire, UK

Background

Chronic pain patients account for 4.6 million general practitioner (GP) appointments a year, at a cost of £69 million to the UK economy. Physiotherapists, whether working in musculoskeletal outpatient settings, or as part of interdisciplinary pain teams are likely to have a range of generic knowledge and skills, however, pain management is a specialist field, requiring specific training, knowledge and skills. The Chartered Society of Physiotherapy (2002) states “physiotherapists shall only practise to the extent that they have established and maintained their ability to work safely and competently”. However, the amount of training, supervision and support available to physiotherapists working with chronic pain patients, varies greatly. It is therefore important that competencies are developed to set a benchmark for developing and assessing knowledge and skill sets. This poster briefly describes the process undertaken and competencies so far identified.

Methods

The development of these competencies was initiated by interdisciplinary pain management staff in South Devon, to support rotational physiotherapy staff. These physiotherapists have no previous clinical experience of pain management. It was agreed with the Physiotherapist Pain Association (PPA) that these competencies would be further developed through consultation with committee members and identified specialist physiotherapists in the UK. Members of the International Association for the Study of Pain involved in reviewing the undergraduate pain curriculum were also consulted. Key documents were identified and consulted to inform the process. Wider consultation was mainly by e-mail. Feedback was incorporated and re-circulated to responding collaborators. The authors of this poster compiled the final version of the competencies and have invited feedback from the wider physiotherapy community via the PPA website where the competencies have been posted (http://www.ppaonline.co.uk). Feedback will be reviewed by the authors and the proposed competencies amended accordingly prior to publishing.

Results

Two documents have been produced. The first document introduces the process and describes the competencies under the headings: Domain; Descriptor; Mode of review; KSF/Skills for Health competencies; and Indicators. A table provides an example of the layout and content for the first competency domain: health safety and security. The domains are further subdivided into ‘Descriptors’ and ‘indicators’ which describe the knowledge and skills required. A section corresponding to each descriptor called the ‘Mode of Review then indicates different ways in which the acquisition of skills or knowledge may be monitored and/or supported, for example via formal teaching, supervision, observing/being observed with patients or groups; or by attending multidisciplinary team (MDT) meeting.

The second document, which is designed to facilitate discussion between the physiotherapist and supervisor, has a section that is left blank to allow feedback/summary comments from the physiotherapists and/or supervisor.

Conclusion

The issue of competencies is a complex one. However despite the challenges there are a number of potential benefits to the development of a competencies framework and it is a widely held view that the development of competencies is beneficial for patients, clinicians and purchasers/commissioners of services. The authors have demonstrated that it is possible through a pragmatic iterative process to develop a set of competencies for physiotherapists in pain management. It is hoped that this article and the associated documents will be viewed as a useful first step in a complex area.

055

Survey of advanced pain training opportunities in the North of England

Category: Education

Karthikeyan Dhandapani¹, Sanjeeva Gupta¹, Ganesan Baranidaran²

¹Bradford Royal Infirmary, Bradford, UK, ²Leeds Teaching Hospitals, Leeds, UK

Background

Advanced pain training (APT) is offered by many centres in different training regions in the UK. Guidance on providing advanced training in pain medicine was issued by the faculty of pain medicine of the Royal College of Anaesthetists. ¹ The training offered by different centres in the region are different and forms part of the advanced pain training which may be offered in one or more centres in the region. A survey of the details of the advanced pain training in different centres would help streamline the training offered.

Methods

Pain physicians who attended the third Annual North England pain medicine group meeting participated in the survey. Participants were from the Yorkshire, North West, North East, Merseyside and other training regions. A questionnaire containing questions on various aspects of advanced pain training was used to collect the data. 30 of 72 forms were returned.

Results

Training blocks are administered as 12 months block or as 6 monthly blocks in all the regions. The number of centres providing APT in different regions varied from 1 to 5. Allied specialty training and training in pain management programmes were offered by all the regions. The case load in different centres was very variable with some centres barely offering the minimum requirements for APT and other centres offering training in a wide variety of specialised areas in pain medicine. Regular teaching sessions and audit opportunities were not offered in all the centres providing APT.

Conclusion

The differences in training offered by different centres are apparent from the survey. Although some of the centres offer more training opportunities than others, the overall training received within the region should be balanced. Interestingly, not all centres providing advanced pain training have regular teaching sessions and audit meetings. The introduction of exams for APT trainees reiterates the need for more formal teaching sessions within the training programme. This regional survey will be followed by a national survey to obtain data from other training regions of the country.

056

Training in Pain Medicine: a survey among anaesthetic trainees in the Northern Deanery in UK

Category: Education

Kiran Kumar Koneti^1,2, Sailesh Mishra², Paul Wilkinson², John Hughes³

¹Northern Deanery, Newcastle upon Tyne, UK, ²Royal Victoria Infirmary, Newcastle upon Tyne, UK, ³James Cook University Hospital, Middlesbrough, UK

Background

Pain Medicine is a key part of the intermediate level of training in anaesthesia. The process of delivering this training and informing about the career options in Pain Medicine can be variable among deaneries and may vary among the hospitals within the same deanery. This is a survey to access the trainee’s information; self reported competency and satisfaction from their training in Pain Medicine in the Northern Deanery in the UK.

Methods

The online questionnaire consisted of 10 questions with single best response with option to comment in free text. The hyperlink to the questionnaire was sent by email. Of the 206 trainees who were sent the questionnaire, 76 responded.

Results

The response rate was 37%. Among the 76 respondents, 24 were in basic pain training, 14 were in intermediate stage and 38 were in higher specialist training. 47(63%) had completed the intermediate Pain Medicine. In case mix, 19(28%) trainees reported good mixture of acute and chronic pain management while 18(27%) had only chronic pain management, without any exposure to acute pain. About 27% respondents felt the need for more sessions in pain medicine and better organization of the module. 54(72%) of the trainees were unaware of the recent changes in Advanced Pain Medicine training. 63(84%) were unaware of the regional chronic pain study day organised for the trainees preparing for the final FRCA examination. Regarding introduction of FFPMRCA by examination 47(65%) felt it to be non influential in making a career choice while 7(10%) found it discouraging and 16(22%) found it as an encouraging influence in making a career choice.

Conclusion

The need for better organisation of the pain module and exposure to both acute and chronic pain management was identified in the survey. This is vital for improving trainees’ satisfaction of the module. Many trainees were not aware of the recent changes to advanced pain training although introduction of FFPMRCA examination was not seen as a deterrent for making a career choice by most of the respondents. A structured organisation of pain module across the Trusts along with a balanced mix of acute and chronic pain management exposure are likely to improve the trainee’s confidence and satisfaction from the module.

057

Is adequate pain tuition given to undergraduates at Peninsula Medical School (PMS) before they begin work as junior doctors?

Category: Education

Anand N Mehta², Suzanne Blowey¹, Mark B Taylor¹, Roy J Powell²

¹Plymouth Pain Management Centre, Derriford Hospital, Plymouth, Devon, UK, ²Peninsula College of Medicine and Dentistry, Exeter, Devon, UK

Background

A previous study in South West England showed a lack of knowledge amongst junior doctors regarding the management of post-operative pain ^[1]. We wanted to know if current undergraduate training in South West England has addressed this deficit and if current graduates about to start work as junior doctors also showed a lack of relevant pain knowledge. At the Peninsula Medical School (PMS) medicine is taught in a patient-centred approach. Students are in contact with patients throughout the five years of their undergraduate studies. As a result they regularly see patients who are in acute or chronic pain. As a Foundation Year 1 doctor, PMS graduates will have to meet competency standards in pain assessment, prescribing adequate analgesia and re-evaluation of patients experiencing pain ^[2]. Therefore, it is essential medical students appreciate various forms of pain, can adequately assess patients experiencing pain and understand how such patients should be managed.

Methods

To determine whether this is the case, following ethical approval and a pilot study, we developed a questionnaire based on the ‘Outline curriculum on Pain for Medical Schools’ produced by the International Association for Study of Pain (IASP) ^[3]. Our questions tested medical student’s knowledge of the definition, assessment, physiology and pharmacology of pain in addition to pain management in various clinical scenarios. Questionnaires were given to 1^st - 5^th year PMS students. The same questionnaire was also given to newly qualified PMS graduates who were about to start working as Foundation Year 1 junior doctors, during their induction week. A statistician analysed the data utilising non-parametric (Kruskal-Wallis and Mann Whitney U) tests and SPSS.

Results

Analysis of student scores from completed questionnaires showed the percentage of questions answered correctly improved sequentially between the five cohorts, but dropped upon graduation. Median scores improved from 7% correct in year 1 cohort, to 27% in year 2, 40% in year 3, 47% in year 4 and 53% correct in the Year 5 cohort. This shows student’s understanding of pain improves as they progress through the medical school. However, there are clear discrepancies between what they should know ^[2-3], compared to what they actually do know. On their induction day as newly qualified doctors, PMS graduates about to start working as junior doctors obtained a decreased median score of 47% correct. Students in all years had a tendency to under-estimate pain and prescribe inadequate analgesia. 96% of respondents felt they needed more pain teaching. All results were statistically significant (p<0.001).

Conclusion

This study shows graduating PMS students have a basic understanding of pain and pain assessment, but still have significant discrepancies in their knowledge base, including basic prescribing. Additional pain teaching should be provided to meet current competencies expected of them as junior doctors ^[2]. Reassuringly, medical students’ pain knowledge increased throughout their undergraduate training. However, it is worrying that pain knowledge of newly qualified doctors from PMS dropped to levels of 4^th year students. To determine whether this knowledge deficiency / inadequate pain teaching is restricted to PMS, this study should be replicated among undergraduates at other UK medical schools.

058

Trainee doctors and opioid prescribing

Category: Education

Namita Arora, Deepak Malik, Jonathan Tring

University Hospitals of Leicester NHS Trust, Leicester, Leicestershire, East Midlands, UK

Background

In our tertiary referral centre we are encountering large number of A & E admissions of patients with opioid seeking behaviour. We are analysing the data to flag up these frequent attendees and design a management plan should they have a subsequent A & E admission.

An article in BMJ (Sept’11) on “The prescription opioid crisis” highlighted that deaths involving opioids have increased in UK. It emphasised that more deaths are occurring in North America from prescription opiates than from heroin & cocaine combined together. Addiction to prescription opioids has been found to be a problem in almost all countries. All Party Parliamentary Group on drug misuse in the UK has expressed concern that UK may face a similar epidemic like North America in 5 to 10 years.

We therefore decided to audit our opioid prescription practice for non-malignant pain on the wards.

Methods

Our aim was to assess the understanding of opiate prescription amongst the trainee doctors on the ward and address the gaps in their knowledge and training if found. We designed a questionnaire and carried out a spot survey of 50 junior doctors on the ward. The questions looked at the junior doctors understanding of which of the drugs were opiates, their frequency of prescribing opiates and their experience of prescribing opiates. The questions also focussed on the understanding of the doctors in terms of the equipotent strengths of different opiates and the conversion of one opiate to another. We also asked them if they had completed the trust e-learning pain management module.

Results

We surveyed different grades of doctors ranging from FY1 to ST7. About 60% doctors felt they had enough experience with prescribing opiates and morphine. All the doctors were aware that Ibuprofen, Naproxen & Diclofenac are not opiates and Morphine & Diamorphine are opiates.

% Doctors aware

Which are opiates

96%

Oxycodone is an opiate

88%

Fentanyl is an opiate

82%

Tramadol, Codeine, Dihydrocodeine, Buprenorphine & Pethidine are opiates

62%

BuTrans is an opiate

14%

TransTec is an opiate

In terms of equipotent doses to morphine conversion only 20% correctly converted codeine, 14% correctly converted tramadol and 8% correctly converted Oxycodone to morphine. 44% trainees prescribe opioid patches on their own of which only 8% knew morphine equivalent of buprenorphine patch and 2% knew morphine equivalent of Fentanyl patch.We found that 86% doctors had not completed e-learning pain module designed for the trust.

Conclusion

Number of trainees failed to appreciate that fentanyl, dihydrocodeine, codeine, tramadol, pethidine etc are opiates. We feel that this shows that in our hospital the group of doctors who most frequently prescribe opioids tend to demonstrate low levels of understanding of opioid dosing, equivalence and potential for abuse.

Elderly

059

Exploring how knowledge users become aware of the on-line resource Understanding Pain in Persons with Dementia and their evaluation of this resource

Category: Elderly

Cary A Brown, Ashley Schmidt

University of Alberta, Edmonton, Alberta, Canada

Background

There is compelling evidence that pain is often unrecognized and therefore untreated in persons with dementia. This leads to unnecessary suffering, decreased function, increased behavioural problems, and caregiver distress. Since August 2009 the Understanding Pain and Dementia website, developed as an evidence-based knowledge translation (KT) resource to educate family members, has been widely accessed. Dissemination activities focused on diverse public awareness strategies (for example postcards, Wikipedia entry, newspaper articles and television news stories). Extensive education was provided to healthcare professionals and reinforced that the website was specifically designed as a resource for family caregivers. The analysis of basic registration data provided by users of the website showed that, after 1 year, the majority of users were healthcare providers. Family caregivers who had used the website state they heard about it primarily through web-searches. Less than 5% of families stated they were referred to the website by a healthcare provider.

Methods

To better understand this apparent breakdown in the flow of information to family caregiver of persons with dementia we surveyed healthcare providers who had accessed the http://www.painanddementia.ualberta.ca/. We asked for their evaluation of the website’s usefulness, accessibility and suitability for family members of persons with dementia. The follow-up survey was emailed to healthcare providers to determine 1) do they refer family members of persons with dementia to the website? 2) Why or why not? We also collected basic demographic data (service type, location and discipline of healthcare provider). Qualitative data exploring what respondents perceived as website strengths and limitations, and recommendations regarding both the website and vehicles for dissemination were also collected.

Results

The survey closes February 2012. Preliminary findings as of December 2011 indicate that >80% of health care providers rate the website as useful and accessible to family members. However < 50% had referred any family members to the resource. It appears that “time to tell families about resources” and “remembering that there is a resource and how to access it” are key limitations for healthcare providers regardless of discipline. Most healthcare professionals indicated they would prefer PDF posters and other printable materials to place in waiting rooms and offices to aid in the referral process. More specific details will be available as the study concludes.

Conclusion

Undetected pain in persons with dementia has significant consequences for both patient and family caregivers. There are effective interventions to manage pain but without awareness of the need the problem goes unaddressed.

Lack of family member and healthcare provider pain and dementia health literacy is evident. Understanding healthcare providers’ perceived barriers to referring family members to this educational resource and their knowledge translation (KT) preferences for how to receive this type of information will help researchers target KT stratgies to best address the problem of unrecognized and untreated pain in persons with dementia.

060

Attitudes and approaches to chronic pain management amongst practitioners, older adults and their carers (Phase II of the EOPIC study)

Category: Elderly

Geraldine Anthony¹, Derek Jones⁵, Patricia Schofield³, Dennis Martin², Blair Smith⁴, Amanda Clarke⁵

¹Aberdeen University, Scotland, UK, ²Teeside University, Teeside, UK, ³Greenwich University, London, UK, ⁴Dundee University, Scotland, UK, ⁵Northumbria University, Northumbria, UK

Background

Older adults are more susceptible to the experience of pain than any other group in society. A range of interventions are delivered by pain services, however this varies across the UK and may not be easily available and accessible to older adults. Misconceptions around pain in later life may result in sub-optimal management. Extant literature has suggested that both older adults and health care professionals expect pain to be a part of ageing and subsequently the expectation is to ‘live with it’. Anecdotal evidence suggests that older people tend not to be referred to multidisciplinary pain management services, and one study suggested that older adults were not referred as it was believed that they would not do as well as their younger counterparts . To dispel such misconceptions, we need evidence to optimise the management of pain in older adults drawing upon older people’s own experiences and needs.

Methods

The following methods were used to explore attitudes and approaches to chronic pain management amongst practitioners, older adults and their carers.

To investigate professionals’ attitudes and management approaches a survey of practitioners working in pain clinics (identified through the British Pain Society) and General Practitioners (identified using the Comprehensive Research Networks in two centres in the UK were recruited (n=300). The data were analysed using descriptive statistics.

1. A telephone interview with a sub-sample of practitioners (n=-60) who participated in the survey was used to explore issues in more depth. The data were subject to content analysis.

2. Focus groups were conducted with older adults attending two pain clinics within age cohorts (50-60, 60-70 70-75, 75+) in order to explore their experiences of pain management and the impact of pain upon their lives and their families. Data were transcribed verbatim and subjected to thematic analysis.

Results

Preliminary analysis will be presented indicating age is not a barrier to referral of older people to pain clinics by the GPs surveyed. There was no evidence of widespread negative attitudes towards older people with chronic pain.

Telephone interviews indicated: the frequency of patient reviews (although undertaken face to face) was often low; pain assessment was informed by British Pain Society (BPS) guidelines and recognised measures were commonly used; pain management was also informed by (BPS) and NICE guidelines; in the case of prescribing the majority of interviewees used clinical experiences combined with BPS and Nice guidance; patient information leaflets were utilised but tended not to be targeted at specific age groups and ‘in-house’ design of leaflets was common.

Themes identified from preliminary analysis of focus group data are: complex routes to pain clinics referral; activity restriction; the lifelong nature of pain; multidimensional impact on relationships; social isolation.

Conclusion

From the analysis to date a number of tentative conclusions can be drawn. Overall referral to pain clinics appears adequate and pain clinics provide a good level of service. This study highlights varied use of guidance on prescribing in older adults and scope for developing information leaflets for this population. The frequency of reviews appears inadequate. Older people felt there is lack of support and access to services; living with chronic pain isolated them and they relied heavily on their carers for support. More analysis will be carried out before final recommendations can be made.

061

Pain in context: the experience of persistent pain and co-morbidity in older age

Category: Elderly

Fiona MacKichan¹, Joy Adamson², Rachael Gooberman-Hill¹

¹University of Bristol, Bristol, UK, ²University of York, York, UK

Background

The experience of persistent pain in older age rarely occurs in isolation: the successes of preventive and curative treatments have meant that the co-occurrence of morbidity is increasingly the rule rather than the exception. Multi-morbidity may have significant impact on the individual and epidemiological data suggest comparatively poorer functioning and quality of life. Increasing case complexity also presents new challenges to the delivery of healthcare, where services have traditionally focussed on individual disease. Importantly, it has been suggested that older adults may selectively report pain when experiencing multiple conditions, and may underreport pain. This may contribute to the under-management of pain in this population. Evidence from the accounts of older adults experiencing co-morbid pain has the potential to provide insight into how older adults perceive and manage pain within their wider health context.

Methods

A qualitative interview study was conducted as part of a mixed-method project investigating older adults’ management of persistent pain. The 31 participants in the qualitative interview study were purposively sampled from a community-based cross sectional survey (n=583) in South West England. The qualitative sample was demographically diverse. In-depth interviews included open-ended questions and used ‘life grid’ methodology to elicit retrospective accounts of participants’ illness careers. Interviews took place in participants’ homes and, with written consent, were audio-recorded. Interviews were transcribed, anonymised and analysed using the constant comparative method to inductively derive common themes within the data. The software Atlas.ti facilitated data management and coding. Analysis relating to the context of pain within participants’ wider health conditions, complexity and concern is presented here.

Results

Participants were 31 people (aged 67-92 years; 16 women, 15 men) who reported intermittent or continuous pain for three months or more. Their experience of illness was often complex: some described having an index pain condition and distinct non-painful co-morbidity, most had multiple pain conditions or sites which could be difficult to distinguish. Interviewees drew on biomedical concepts to describe their pain and other conditions, and referred to medications to distinguish between them. Narratives implicitly situated pain within a wider health context. For example, if other conditions were perceived as more serious this could result in participants normalising pain and giving it lower priority. This was particularly the case for musculoskeletal pain. Polypharmacy was commonplace, but pain medications could be seen as less ‘necessary’, contributing to poor adherence. However, consulting for other conditions presented opportunities to discuss pain problems which might otherwise go unreported.

Conclusion

The significance given to pain by older adults is, in part, related to the widespread experience of ‘pain elsewhere’ and distinct morbidity. Older people may place their pain within a hierarchy of multi-morbidity, which has bearing on the ways in which they interpret and act upon symptoms. The ‘placing’ of pain is related to issues such as differential levels of interference, which may fluctuate. The wider context of pain in later life has bearing on pain reporting, assessment and management, including patterns of help seeking, communication in healthcare and adherence.

Epidemiology

062

A retrospective cohort study into the association between complex regional pain syndrome and chronic widespread pain

Category: Epidemiology

Thomas Birley¹, Andreas Goebel^1,2

¹Aintree University Hospital, Liverpool, UK, ²Walton Centre For Neurological Care, Liverpool, UK

Background

Complex regional pain syndrome (CRPS) and fibromyalgia (FM) are two primary chronic pain conditions in which the aetiology and biochemical basis is poorly understood. It is the aim of this study to assess whether there is any association between these two conditions. It possible that patients with CRPS also have FM or chronic widespread pain (CWP) but this is not observed by clinician as the focus is placed upon assessing and treating CRPS.

Methods

Information was gathered from the clinical letters of a consultant pain specialist from 2007 to 2011. Information was recorded on whether or not the patient met the CRPS Budapest criteria the duration of CRPS, the type of trauma resulting in CRPS, whether CRPS affected the upper or lower limb, the signs/symptoms of CRPS, past medical history and other pain conditions (e.g. migraines). Those patients who also had CWP/FM were analysed further with information gathered on the temporal relationship between CRPS and CWP/FM and the significance of CRPS relative to CWP/FM. Observations of the similarities in the clinical histories of this subgroup of patients were noted.

Results

The letters of 166 patients were analysed (female vs. male 113:53). 140 patients met the Budapest criteria (mean age: 44.9 years, median duration of symptoms: 18 months). Only 10(7.1%) had CRPS affecting more than one limb. 16 (11.4%) patients were identified who met the Budapest CRPS criteria and had CWP/FM. Of these patients 10 had CWP/FM prior to developing CRPS and 6 had CRPS before CWP/FM. Of the patients did not meet the criteria, 6 out of 26 (23.1%) also had CWP/FM. Signs of sweating/swelling and colour/temperature change were less commonly seen in the in patients with CRPS and CWP/FM than those with CRPS but not CWP/FM but this was not statistically significant. Of the 16 patients with CWP/FM and CRPS, 8 found both types of pain roughly significant, 2 found the CWP/FM pains worse and for found CRPS pains worse but the CWP/FM roughly significant.

Conclusion

Although the number of patients with CRPS and CWP/FM was not statistically significant, as over ten per cent of patient with CRPS had significant CWP, assessing CRPS patients for CWP/FM should be routinely done. It may be possible that this figure is an underestimate as patients are not always asked about widespread pain or have widespread pain misdiagnosed as spreading CRPS. Nearly a quarter of patients who were thought to have CRPS but did not fulfil the Budapest criteria had CWP/FM whereas the objective signs of sweating/swelling and skin/temperature change were less common in those with CRPS and CWP.

063

Working towards a pain free hospital: pain prevalence and management in a major London teaching hospital

Category: Epidemiology

C. Hogan, M. Quinn, K. West, S. Raveendran, R. Blevings, C. Bantel, P.-Y. Kuo

Chelsea and Westminster Hospital

Background

Inadequate treatment of dynamic pain (pain on movement) negatively impacts on patient satisfaction and impairs mobilisation and ultimately discharge from hospital. There is some evidence to suggest that dynamic pain remains a major problem in hospitals, and that this issue is not confined to post-operative patients, with a significant number of medical patients also reporting pain on movement (Whelan et al., 2004; Vallano et al., 2006).

We postulated that differing habits and patterns of analgesic prescription may underlie any difference in pain prevalence and severity between surgical and medical wards. In particular, we explored the use of a multimodal approach in pain management. Using multiple analgesic agents simultaneously is an effective way of for instance reducing opioid consumption, and the incidence of induced side effects (Hartick, 2004). This pilot study sought to highlight discrepancies in pain management and provide valuable insight into how to improve.

Methods

This prospective cross-sectional survey of all medical and surgical inpatients in Chelsea and Westminster Hospital was conducted over a single day by a team of five clinical medical students co-ordinated by the acute pain service. All inpatients on 4th May 2011 over 18 years old were included in this study, with the exception of specialist wards (A&E, intensive care, obstetrics, psychiatrics and paediatrics). Data were collected from the patient records regarding analgesic prescription: class of medication, frequency and dosage prescribed, and prescription of adjunctive medication.

Participants were also questioned on pain severity (using a locally used 5 point verbal numeric rating scale; NRS-5; 0 = no pain and 4 = very severe pain) and modality.

Descriptive statistics, uni- and multivariate analyses were formulated using the statistical package SPSS v.19. Confidence was expressed with 95% intervals, and p-value significance was defined as p<0.05.

Results

132 of 196 eligible patients participated in the study (67%). 65 (49%) reported pain on movement; with surgical patients at a 2.4 fold increased risk of this (OR=2.4; CI 1.18-4.88, p=0.02).

All surgical patients and 68% of medical patients were prescribed analgesics, a significant difference (χ2=58.774, df = 3, p<0.05). 89% of surgical patients were prescribed an opioid, compared with 27% of medical patients. 7% of patients were prescribed adjunctive analgesics.

122 patients received non-opioid analgesics, either alone or in conjunction with opioids. 97 of these (79.5%) received paracetamol, 1 (0.8%) an NSAID and 24 (19.7%) both medications. The odds of receiving both paracetamol and an NSAID compared to just one were not influenced by being a surgical or medical patient, at 0.754 (CI=0.30-1.91).

Of the 70 patients prescribed opioids, 67 (96%) were prescribed at least one non-opioid analgesic concurrently, and 21 (31%) were prescribed both paracetamol and an NSAID.

Conclusion

A multimodal approach to pain management is utilised extensively. However, pain prevalence was still found to be unacceptably high.

With regards opioid-sparing analgesics, only 20% of patients received both an NSAID and paracetamol, which achieves optimal analgesic efficacy and opioid sparing (Ong et al., 2010). This, with a paucity of adjuvant analgesic prescription, may explain the high prevalence of pain. A multi-centre study would examine whether these data reflect wider trends in inpatient pain management.

This study highlights the continuing need for improvements of pain assessment and management. Further education initiatives may reduce both pain prevalence and reliance on opioids.

064

The prevalence of pain and pressure ulcers in hospitalised patients: results of a national survey

Category: Epidemiology

Michelle Briggs¹, Jane Nixon¹, Michelle Collison¹, Lyn Wilson¹, Carly Rivers¹, Elizabeth McGinnis⁴, Carol Dealey², Julia Brown¹, Suzanne Coleman¹, Nikki Stubbs³, Rebecca Stevenson¹, Andrea Nelson¹

¹University of Leeds, Leeds, UK, ²University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Hospital, Birmingham, UK, ³Leeds Community Healthcare, Leeds, UK, ⁴Leeds Teaching Hospitals NHS Trust, Leeds, UK

Background

A pressure ulcer (PU) is described as a “localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear” (EPUAP and NPUAP 2009). Pain has been reported by patients to be a major factor associated with PUs with particularly painful times being during dressing changes (Gorecki et al 2011). Experience of pain or discomfort may also be a precursor to pressure damage. A number of cohort studies have assessed the relationship of potential risk factors to pressure ulcer development and key variables have emerged including mobility, nutrition, factors affecting tissue perfusion, skin condition and age (Nixon and McGough, 2001). We sought to determine the prevalence of localised pain at pressure areas sites and explore whether there was an association between skin pain and degree of skin damage.

Methods

We undertook a cross-sectional study in 3 acute hospital NHS Trusts (9 hospital) in England to establish pressure area pain prevalence. Pain Questions were added to the routine annual PU prevalence audits undertaken in the NHS Trusts. The target population was “all inpatients of18 years of age or older who were in hospital on the date of the participating Trust’s PU prevalence audit”. Research nurses visited all eligible patients as part of the PU audit and assessed them for inclusion in the pain prevalence study. All patients were included if they were judged to be able to answer questions about the localised skin pain. Patients were excluded from the pain prevalence study where it was considered ethically or clinically inappropriate by the ward nurse/clinical team, for example, those where death was consider to be imminent. Data were collected on one identified day in each Trust during 2009 -2010.

Results

A total of 3,397 patients were included in PU prevalence. The mean age/ gender was 65.8 (SD 19.23) (18-103) and 48.7 % male (n =1655). A prevalence of 14.8% for PU was estimated (with 502 having pressure damage of Grade 1 or above). Participation in the pain survey was 59.2% (2010/3397). The main reasons for non-participation were i) off the ward ii) unable to disturb iii) had cognitive and/or communication difficulties. Of the 2010, 327 (16.3%) indicated they had pain on “at risk” skin site and that the pain was due to pressure. 241 (of 2010) had a PU. PU pain prevalence in this group was 42.9% (104/241). Out of the 327, only 104 had evidence of pressure damage on inspection. The remainder (n=223) reported pain at an at risk site but were not displaying any other evidence of skin changes which would indicate pressure damage.

Conclusion

The scale and scope of PU related pain and pressure area related pain in hospitalized patients are high, indicating that pain is a common symptom experienced by patients. The results provide an indication for the development of clinical practice in an area which is a priority for patients and impacts upon their quality of life.

065

Opioid use among low back pain patients in primary care: is opioid prescription associated with disability at 6 month follow-up?

Category: Epidemiology

Julie Ashworth, Daniel Green

Keele University, Keele, Staffordshire, UK

Background

Low back pain (LBP) is among the commonest non-malignant disorders associated with prescribed opioid use in primary care. Whilst opioids are an accepted treatment for LBP, in the longer term there is limited evidence of efficacy and the epidemiological literature raises concerns about potential harms. An association between early opioid prescription and greater longer term disability in acute LBP has been also reported (Webster 2007, Franklin 2008); although the studies were confined to Workers Compensation claimants in the US, using wage replacement benefits as a surrogate measure of disability, and were unable to adjust for a number of potential confounders. We sought to describe opioid use among a broader UK population of primary care consulters with low back pain and to explore the relationship between opioid prescribing at baseline and self-reported disability at 6 month follow-up controlling for important potential confounders using propensity score analysis.

Methods

We conducted a secondary analysis of data from a previously published prospective cohort study (Foster 2008)of 1591 patients (18-60 years) consulting in UK primary care with LBP. Our analysis included 715 participants for whom both prescribing records and 6 month follow-up data were available. The primary outcome was disability (Roland and Morris Disability Questionnaire RMDQ). Data regarding 15 important baseline characteristics likely to influence disability including socio-demographics, pain characteristics (intensity, duration, leg pain), ‘distress’ (Hospital Anxiety and Depression Scale (HADS), fear of movement (Tampa Scale of Kinesiophobia TSK), coping style (Coping Strategies Questionnaire CSQ-24) and optimistic self-beliefs (Self Efficacy Scale) were used to create propensity scores estimating the likelihood of opioid prescription. Data regarding prescribed opioids were obtained from prescribing records. Baseline opioid prescription (yes / no), baseline RMDQ score and propensity scores were entered into the final linear regression model to predict 6 month RMDQ.

Results

The 715 participants had a mean (SD) age of 45.8 (9.8) years, 60.6% were female. 164 (22.9%) of participants were prescribed opioids in the baseline period. The majority, 124 (17.3%), were classified as low dose (1-19 mg MED / day), 26 (3.6%) as moderate dose (20-49mg MED) and 14(2%) as high dose (≥ 50mg MED). Univariate analyses indicated that on average those prescribed opioids at baseline reported higher pain intensity (p < 0.001) and higher disability (p <0.001) at 6 month follow-up. In the final linear regression model, opioid prescription at baseline significantly predicted higher disability at 6 months after adjusting for baseline disability and propensity score (likelihood of being prescribed an opioid given baseline characteristics). The final model accounts for 51% of the variance in disability (RMDQ) at 6months with a 3.025 unit increase in 6 month RMDQ if opioids are prescribed at baseline (p< 0.001).

Conclusion

This study suggests that opioid prescription at baseline is a risk factor for higher disability at 6 months in UK primary care patients with LBP. This is consistent with findings from previous studies in US workers. The observational nature of the study does not permit causal inferences to be made and, although the analysis adjusted for a substantial number of important demographic, pain-related and psychosocial patient characteristics, the possibility remains that opioid prescription is a marker of other patient or prescriber characteristics affecting disability. Further research is required to explore the relationship between opioids and functional outcomes in real-life settings.

066

Long-term opioids in chronic non-malignant pain

Category: Epidemiology

Alison Kearsley, Dietmar Hartmann

Ninewells Hospital and Medical School, Dundee, UK

Background

In January 2010 the British Pain Society published Opioids for Persistent Pain: Good Practice. This document states that “the safety and efficacy of long term opioid use is uncertain” and lists adverse effects as constipation, nausea, itching and dizziness as well as the risk of long term endocrine and immunological effects.

It recommends that patients are comprehensively assessed before prescribing of long term opioids, that treatment should be reviewed monthly and patients on doses greater than 180 mg morphine daily (or equivalent) should be referred to a pain specialist. It states that “there are no high quality data published that inform prescribers of the safety and efficacy of higher doses”.

Methods

We reviewed consultation letters written for the patients who attended our consultant led chronic pain clinics (new or review) at a large teaching hospital over a 1 month period in 2009. We identified all patients in that period who had either been on strong opioids at time of attending clinic, or for whom trial of strong opioids had been suggested to the GP. We did not include patients taking only tramadol, codeine or dihydrocodeine.

We applied for Caldicott Guardianship approval to access prescription information for these patients. This was granted and details of opioid prescriptions from January 2009 until June 2011 was obtained from the Health Informatics Centre (HIC).

Results

93 patients attended in January 2009. 17 (18.3%) of these were already on strong opioid analgesics, and for an additional 9 (7.5%) patients trial of strong opioids was suggested to the GP.

Of the 9 patients for whom consideration of strong opioids was suggested, 5 of these were being prescribed strong opioids 6 months later. This dropped to 4 patients at 1 year and 2 patients at 2 years.

At 2 years from clinic appointment we had prescription information for 22 of the 26 patients. At this time 6 (27.3%) of these patients were on a higher equivalent dose of regular opioid than they had been 2 years earlier when they attended clinic, 5 (22.7%) patients were on the same dose and 3 (13.6%) patients were on a reduced dose. 2 patients were now on strong opioids who hadn’t been initially, and 1 patient was no longer being prescribed strong opioids.

Conclusion

This project has increased our awareness of the high number of patients currently on chronic long term opioids for non-malignant pain, often at high doses. As far as we are aware these patients are not being regularly followed up or assessed for changes in endocrine or immunological function, or other adverse effects. We hope that this work will support the setting up of a Trust wide monitoring system.

067

Gender differences in the association between back pain and mortality in older adults

Category: Epidemiology

Gareth Jones¹, Rachael Docking¹, Jane Fleming², Jun Zhao², Carol Brayne², Gary Macfarlane¹

¹Aberdeen Pain Research Collaboration (Epidemiology Group), University of Aberdeen, Aberdeen, UK, ²Public Health and Primary Care, University of Cambridge, Cambridge, UK

Background

A number of studies have examined the relationship between chronic pain and mortality. Some have shown increases in all-cause, cancer-related and cardio-respiratory mortality. However, results are equivocal and others have reported null or non-significant effects.

The majority of work in this area has studied working-age adults. There are, hitherto, no studies examining the association in older adults where the prevalence of co-morbidity is higher, and the impact of disability will be greater. Women report more pain than men (and poorer self-rated health generally) although, paradoxically, experience a lower age-specific risk of mortality. To date, there is little data examining the relationship between pain and mortality for men and women separately.

The aim of the current study was to examine the relationship between back pain and mortality in older adults, specifically to (a) examine the association with disabling and non-disabling pain separately; and (b) to examine the relationship stratified by gender.

Methods

The Cambridge City over 75 Cohort Study is one of the longest and largest population-based prospective studies in the very old. In 1985-87, all men and women aged >=75yrs from a selection of geographically and socially representative GP practices in Cambridge were contacted; 95% participated. Successive interviews and assessments have since been carried out, notably in 1988-89, when 68% participated in Survey 2. At this point, participants answered interviewer-administered questions on back pain (BP) and were classified as having:

[1] No BP;

[2] Non-disabling BP; or

[3] Disabling BP (i.e. BP that interfered with daily tasks within the last month).

The cohort was followed up until death, and the association between pain and mortality was examined using Cox proportional-hazards regression and, thus, is expressed as a hazard ratio (HR), and adjusted for socio-demographic factors and potential markers of disease (e.g. arthritis/rheumatism; use of medication; chest pain; shortness of breath; falls).

Results

1158 persons provided data on BP. The mean age of participants was 83yrs (range: 77-100yrs) and 65% were female. The prevalence of disabling and non-disabling BP was 6.0% (95%CI: 4.6- 7.3%) and 23.0% (20.5-25.4%) respectively. While there was no difference in age with the reporting of non-disabling BP, the prevalence of disabling BP increased with age: those who were ≥90yrs were 2½ times more likely to report disabling BP than participants aged 77-79yrs (risk ratio: 2.6; 95%CI: 1.1-6.2).

A significant association was found between disabling BP and mortality (hazard ratio: 1.5; 95%CI: 1.2-2.0), this association remained, although slightly attenuated, following adjustment for socio-demographic variables and potential markers of disease (1.3; 1.01-1.7). Individuals with non-disabling BP were not at increased risk of mortality (1.0; 0.9-1.1).

Women with disabling BP experienced a 40% increase in the risk of mortality (1.4; 1.1-1.9) whereas no such increase was observed in men (1.0; 0.5-1.9).

Conclusion

These findings confirm those from younger populations regarding a relationship between pain and an increase in the risk of mortality. Further, we present new data to suggest that this association may be limited to disabling pain, and also limited to women. Clinicians should be aware of, not only the short-term implications of disabling BP in older adults, but also the longer-term effects. Future research should attempt to understand the mechanisms underpinning this relationship, including further examination of specific conditions causing disabling BP, with a view to considering secondary prevention; and to determine why the relationship differs in men and women.

Evidence & Guidelines

068

Survey of current UK practice in use of fluoroscopy, contrast material and steroids in neuraxial injections

Category: Evidence & Guidelines

Liza Tharakan¹, Sanjeeva Gupta², Rajesh Munglani³

¹Ipswich Hospital, Ipswich, UK, ²Bradford Teaching Hospitals NHS Trust, Bradford, UK, ³West Suffolk Hospital, Cambridge University Teaching Hospitals NHS Trust, Bury St Edmunds, UK

Background

Patients with acute and chronic pain have received steroids in neuraxial blockade for many years. There has been recent controversy about their efficacy but also about the possibility of neurological complications associated with the use of particulate steroids such as methylprednisolone, triamcinolone and betamethasone. In contrast dexamethasone is a non-particulate steroid with less platelet aggregating properties.

In particular, inadvertent intra-arterial injections of particulate steroids are thought possibly to lead to spinal cord ischaemia by blocking of small arterioles and secondary catastrophic neurological and other complications.

The use of contrast has also been suggested to minimise inadvertent intravascular injection.

Thus the aim of this study was to investigate the current UK practice in the use of fluoroscopy, contrast medium and non-particulate steroids in neuraxial injections.

Methods

Clinicians in pain medicine in the UK were sent an online questionnaire. They were asked a set of questions about their practice of neuraxial injections in chronic pain. These questions were followed by a second set if the respondents chose to change their practice after reading abstracts of five articles focussing on the use of contrast-enhanced fluoroscopic guidance to prevent inadvertent intravascular injection and the use of water-soluble steroid preparation such as Dexamethasone to prevent spinal cord infarction.

There were 135 completed responses of which 85.8% (115) were Consultants.

Results

More respondents performed injections in lumbar spinal level (around 85%) than in cervical or thoracic level (40-60% depending on type of injection). All respondents who performed facet joint injection or medial branch block or TFESI or NRB at any spinal level always used Xrays. Less than 85% used Xrays for interlaminar epidural injections. Majority of clinicians used contrast medium to confirm position of needle for TFESI or NRB, less than 75% used contrast for interlaminar epidural injection. More respondents used dexamethasone in cervical region (about 50% of responses) than in thoracic and lumbar region (about 20% of responses).

Only 21.5% (29) respondents changed their responses after reading the five published abstracts. Of the ten who would use contrast medium for procedures, three hadn’t used it in any procedure before.

Of the 14 who would use dexamethasone only for procedures they performed, 11 had not used it before. Out of the 9 clinicians would use dexamethasone in addition to other steroids, 5 had not used it before.

Conclusion

There is growing awareness of possible problems associated with particulate steroids which explains differential use of dexamethasone between different areas of the spine. We can surmise that significant numbers continue to use particulate steroids in cervical region, including for TFESI or NRB.

The relatively small number of catastrophic neurological complications compared to the large number of injections performed has led to considerable controversy over whether particulate steroids should be used. The clinical efficacy of dexamethasone as an alternative non-particulate steroid has been questioned.

Should we change practice now or wait for more clear evidence of harm or otherwise from particulate steroids?

069

Establishing the evidence base for treatments of pain: the Pain, Palliative and Supportive Care (PaPaS) review group of The Cochrane Collaboration

Category: Evidence & Guidelines

Yvonne M Roy¹, Jessica R Thomas¹, Christopher Eccleston^1,2

¹Cochrane Pain Palliative and Supportive Care Review Group, Pain Research Unit, Oxford, UK, ²Centre for Pain Research, University of Bath, Bath, UK

Background

We aim to i) describe the organization and functioning of the Pain, Palliative and Supportive Care Review Group (PaPaS) ii) report on analysis of the scope of the reviews, and on the popularity of different published reviews. Establishing the evidence for the effectiveness of treatments offered in response to pain and suffering is an important and necessary aspect of modern health care systems. One goal of PaPaS is to publish high quality systematic reviews in acute, chronic, and neuropathic pain. A systematic review is designed to reduce biases inherent in narrative reviews, in particular the bias of selection or ‘cherry-picking’ the more available or interesting studies for inclusion. One main way authors can reduce this kind of bias is by writing a comprehensive, reproducible search strategy which can be adapted for a wide range of databases which will identify all studies which may satisfy strict and explicit inclusion criteria.

Methods

As a worldwide organisation we acquire authors from all over the world who wish to publish a review in a particular topic area. Our task is to aid authors in the writing of a Cochrane review using Cochrane software and guidance from the Cochrane Handbook for Systematic Reviews of Interventions and the Cochrane Policy Manual and finally to publish the review on The Cochrane Library. We undertook a historical analysis of the The Cochrane Library for all studies related to pain and published by PaPaS and also assessed reports of the access to published reviews from our publisher Wiley to provide an index of the popularity of our systematic reviews and which are considered important.

Results

In January 2012 PaPaS has 21 new titles registered for development into protocols, 10 protocols underway towards publication, 66 published protocols progressing to new reviews for publication,17 reviews due for publication and in The Cochrane Library the group has 155 fully published and completed reviews. Of all of the published reviews the most popular 10 Pain systematic reviews accessed in 2010 are reported and displayed, and the position of the most popular 10 PaPaS reviews reported. In addition, the position of the 10 most popular PaPaS reviews, and the 10 most popular Pain reviews accessed are reported in the context of all reviews accessed in the Library as a whole up until December 2010.

Conclusion

Conclusion: The Cochrane Collaboration is a major worldwide source of best evidence for treatments in acute and chronic pain. PaPaS alone has enabled the publication of 155 reviews and is supporting the publication of a further 114 at the present time. The groups top 10 PaPaS most accessed reviews are amongst the top 200 of over 7,000 titles accessed on The Cochrane Library, and the groups top 10 Pain reviews amongst the top 400 accessed.

Funding acknowledgements: The Cochrane Pain, Palliative, and Supportive Care Group is funded by the Department of Health, National Institute for Health Research, UK

070

Sodium channel blockers in the management of chronic pain - what are we all doing?

Category: Evidence & Guidelines

Roxaneh Zarnegar, Dan Mihaylov, Sumit Gulati

Royal National Orthopaedic Hospital, Stanmore, Midddlesex, UK

Background

Sodium channel blockers (Na-blockers) were one of the earliest classes of drugs to be used to treat chronic pain. With the exception of trigeminal neuralgia, there is a paucity of good quality scientific literature to support their use. This is particularly true in the case of oral agents. Although better quality evidence does exist for the use of intravenous (IV) lidocaine infusions for treating neuropathic pain, optimal treatment regimes remain elusive. Systematic reviews of IV lidocaine have included studies in which a range of doses and infusion times have been used.

We set out to find how Na-blockers are being used in chronic pain management centres in the UK.

Methods

We distributed questionnaires to UK pain medicine specialists attending the 2011 Joint British and Canadian Pain Societies Annual Scientific Meeting during the breaks between sessions. We asked the clinicians whether they used oral or IV Na-blockers and their accepted indications (giving the options: central neuropathic pain, peripheral neuropathic pain, complex regional pain syndrome type I &II, fibromyalgia, pelvic pain, visceral pain, headache and other). If using lidocaine, we asked them to specify their IV infusion regimen and their choice of management following the first infusion. If using oral agents, we enquired what their first line oral Na-blocker was.

Results

Thirty nine clinicians (25 consultants, 14 trainees) from 30 pain departments were captured. In 9 departments where 2 clinicians participated, there was internal consistency in the answers in 7. In one centre consultants in the same department had different protocols for lidocaine administration.

Eight of the pain clinicians who responded never use Na-blockers. Twelve use only oral agents, 8 use only IV lidocaine and 11 use both. The first and second commonest indications are neuropathic pain and fibromyalgia.

Considering variations in dose and infusion time, 13 regimens were quoted in the responses. The most consistent was 3 mg/kg over 60 minutes; used by 4 clinicians from different centres. Two clinicians (different centres) aimed to induce side effects during the infusion.

The preferred oral blocker is carbamazepine. Intravenous lidocaine is not always used as a ‘trial’ before starting oral agents. Some respondents have different indications for lidocaine and oral blockers.

Conclusion

There is considerable variation in all aspects of use of Na-blockers for the management of chronic pain. This may reflect clinicians’ difficulties in interpreting the current evidence which is at best mixed for these agents.

We found the greatest variation in the use of IV lidocaine. Of note, the commonest dose used in research protocols is 5 mg/kg which was not quoted by any of the respondents. Although current literature supports this intervention, much work is needed to determine an evidence-based regimen to ensure that an unknown proportion of patients are not being sub-optimally treated.

Experimental (Basic) Science

071

The relationship between gender role expectations of pain, pain-related anxiety and cold pressor pain responses in healthy white British volunteers

Category: Experimental (Basic) Science

Oras Alabas^1,2, Osama Tashani^1,2, Mark Johnson^1,2

¹Leeds Metropolitan University, Leeds, UK, ²Leeds Pallium Research Group, Leeds, UK

Background

Gender role expectations of pain (GREP) and anxiety predict sex differences in experimental pain (Jones et al. 2003; Alabas et al., 2011). The GREP questionnaire consists of 12 items measuring an individual’s perception of their own response to pain to a typical man/woman and their stereotypical perception of the response to pain of a typical man compared with a typical woman and vice-versa within three main dimensions of pain response: i) pain sensitivity; ii) pain endurance; and iii) willingness to report pain. The Pain Anxiety Symptoms Questionnaire the short form (PASS-20) measures; i) cognitive anxiety; ii) escape/avoidance; iii) fear; and iv) physiological anxiety. This study investigated the effect of sex-related stereotypic attributions of pain and pain-related anxiety on cold pain response in healthy white British volunteers.

Methods

Fifty university students (25 women, mean±SD =22.31±4.17 years) participated in an experiment where they completed two cold pressor pain tests followed by a GREP (Robinson et al., 2001) and a PASS-20 (McCracken and Dhingra, 2002) questionnaires. During each cold pressor test, the non-dominant hand was immersed in a warm bath maintained at 37ºC for 3 minutes and then transferred to a bath containing crushed ice and water, maintained at 1-2ºC. The following measures were taken: Pain threshold (time taken to declare the first sensation of pain in the hand); pain tolerance (time taken before removing the hand from the cold bath because they could no longer tolerate pain); and pain intensity and unpleasantness ratings (100mm VAS).

Results

There were no significant differences between men and women for pain threshold (Mean+SD women=12.39± 7.12s, men=13.66±6.73s, p=0.520, unpaired t-test), pain tolerance (women=46.19±42.33s, men=54.47±39.76s, p=0.479) and pain intensity (women=63.98±13.58mm, men=63.16±16.76mm, p=0.850). Women reported higher pain unpleasantness than men (women=75.12±11.11mm, men=67.34±15.62, p=0.048). One-way ANOVA on GREP found that men perceived themselves to be less sensitive to pain and less willing to report pain than a typical woman (F=4.50, p=0.040 and F=7.37, p=0.009 respectively). Men perceived themselves to tolerate pain more than a typical man (F=9.55, p=0.003). Individual Pain Endurance of GREP was positively correlated with pain threshold (r=0.31, p=0.030, Pearson Correlation) and pain tolerance (r=0.31, p=0.026). Individual Willingness to Report Pain of GREP was positively correlated with pain intensity (r=0.29, p=0.041) and pain unpleasantness (r=0.31, p=0.029). PASS-20 total score was negatively correlated with pain threshold (r=-0.38, p=0.008), although there were no differences between men and women in PASS-20 (p>0.05, 1-way ANOVAs).

Conclusion

There were significant relationships between measurements of pain sensitivity response to cold-pressor pain, GREP and PASS-20 scores. Individuals who believe that they tolerate pain more than the typical man/women showed higher pain thresholds and pain tolerances and those who considered themselves more willing to report pain than the typical man/woman reported higher pain ratings. Anxious individuals exhibited lower pain thresholds. However, there were no differences to cold pressor pain between men and women.

072

Anti-neuronal antibodies in complex region pain syndrome

Category: Experimental (Basic) Science

Leda Lignos¹, Rosemary Pettingill¹, Philippa Pettingill¹, Andreas Goebel², Franz Blaes³, Angela Vincent¹

¹Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford University, Oxford, UK, ²Pain Research Institute, Department of Translational Medicine, Liverpool University, Liverpool, UK, ³Neurologische Klinik, Kreiskrankenhaus Gummersbach, Gummersbach, Germany

Background

Complex regional pain syndrome (CRPS) is characterized by severe pain, allodynia and hyperalgesia, with additional autonomic and motor dysfunction. The pathophysiology is complex but there is growing evidence for a role of autoimmunity. For instance, a small RCT showed that treatment with intravenous immunoglobulin reduced pain scores in long-standing CRPS (Goebel et al 2010). CRPS sera bound cultured autonomic neurons and differentiated neuroblastoma cells (Kohr et al 2009), and a cardiac myocyte model demonstrated antibodies to specific autonomic receptors (Kohr et al 2011). Furthermore, passive transfer of purified CRPS IgG to mice caused motor impairment and behavioural changes (Goebel et al 2011). As pathogenic antibodies are likely to bind to cell-surface antigens, we concentrated on antibodies binding to the surface of neuronal cell lines and spinal cord neurons and to a newly-discovered antigen, contactin-associated protein 2 (CASPR2), which is associated with painful extremities in patients with Morvan’s syndrome.

Methods

CRPS patients’ sera were applied to cultured neuroblastoma cell lines (SKNSH, IMR 32 and SH-SY5Y) looking for cell surface binding of IgG antibodies after incubation with serum diluted 1:20 for 2 hours and IgG detecwith fluorescent-anti-human IgG. Immunostaining with CRPS sera was performed on 40μm paraformaldehyde-fixed rat spinal cord tissue sections. The sera were applied to free floating sections with serum concentrations of 1:50, 1:100, 1:500 and 1:1000. Fluorescently-labelled antibodies specific for human IgG were used to detect bound CRPS antibodies. Selected samples were also screened for antibodies to CASPR2 using a cell-based assay.

Results

Binding of antibodies to neuroblastoma cells: fifty-one sera were applied to SKNSH and IMR 32 cultured cells. Two sera showed extra-cellular binding of IgG to SKNSH cells. No visual evidence of binding was found with IMR 32 cells. One of 30 sera was positive for binding to SY-SY5Y cells. Immunostaining of spinal cord sections: provisional results from the 14 serum samples tested show specific binding to the superficial laminae of the spinal cord, producing a band within lamina 1 and II in one serum. CASPR2 antibodies were not found in any of the sera tested.

Conclusion

There were only a few sera showing detectable binding to the neuroblastom cells or the spinal cord sections, but the results depended on visual observation of the cells; FACS analysis of the cells lines and differentiated cell lines should be performed in the future. The possibility of binding of CRPS serum IgG antibodies within the superficial laminae of the spinal cord where primary afferents terminate and synapse with second order neurons is interesting, and future work will include cultured spinal cord and dorsal root neurons to see whether there is binding to the surface of specific neurons.

Interventional Pain Management

073

How effective are interventional pain procedures: a single centre’s experience

Category: Interventional Pain Management

Mark Alexander-Williams¹, Stephen Shepherd²

¹Broomfield Hospital, Mid-Essex Hospitals NHS Trust, Chelmsford, Essex, UK, ²Barts and The London School of Anaesthesia, London, UK

Background

It is well recognised that anatomical abnormalities and pain do not always correlate.^1-3 The origins of pain may be multi-modal, necessitating a multi-modal therapeutic strategy.⁴ Interventional pain procedures involve a wide variety of measures with intended therapeutic benefit, including facet joint injection, epidural analgaesia and trigger point injection. Their effectiveness varies significantly, being limited by the complex neuropsychology of chronic pain, unclear anatomical basis and unclear definition of success.^5-7 We set out to audit the effectiveness of our own departmental practice.

Methods

All patients who underwent any kind of interventional procedure performed between March 2009 and March 2011 were included. Face-to-face or telephone-based follow-up was performed in both nurse-led and physician-led clinics utilising a standardised pro-forma which included a number of domains relating to pain reduction, mobility, quality of life and changes in medication alongside standard demographic data and intended utility of the procedure. These domains were weighted against an overall scoring system producing a maximum total of 12 for the procedure and the following set as departmental standards of ‘success.’

• All patients will be followed up within twelve weeks.

• All patients should score at least 6 out of 12 domains.

Results

1148 patients were potentially included for analysis but only 866 patients included due to incomplete datasets. 94% of procedures were therapeutic rather than diagnostic. The average duration for follow up was 11.7 weeks (mode 10 weeks). Most procedures were neuraxial: the most commonly performed interventions being lumbar facet joint injection followed by caudal epidural injection and lumbar facet radiofrequency ablation. 37% of patients described a greater than 60% reduction in pain with only 1% reporting no benefit. 40% of patients perceived a reduction in pain for greater than 8 weeks and a further 40% lasting 4-8 weeks. Sleep was improved in 48%, mobility in 58% and quality of life in 62%. Overall, 57% of patients achieved a score of 6 or greater, thereby being considered as having a successful outcome. There appeared to be no difference in the reported success between face-to-face or telephone follow up.

Conclusion

More than half our patient cohort undergoing interventional procedures achieve a measurable benefit from the procedure. A multi-modal approach to patient management seems both logical and necessary in the model of chronic pain, therefore it would appear that in our patient group these procedures have a therapeutic role.

074

Evaluation of splanchnic nerve radio frequency ablation for chronic pancreatic pain

Category: Interventional Pain Management

Deepak Kumar, Sheikh Shahbaz, Philip Hu, Camillus Power

The Adelaide and Meath Hospital, Dublin, Ireland

Background

Radio frequency ablation (RFA) of the splanchnic nerve is a potential treatment for Chronic pancreatic pain[1]. It uses a high frequency alternating current to heat tissue leading to thermal coagulation with predictable accurate lesion (as compared to phenol and alcohol).

1. Garcea, G., et al., Percutaneous splanchnic nerve radiofrequency ablation for chronic abdominal pain. ANZ J Surg, 2005. 75(8): p. 640-4.

Methods

In our pilot study, 5 patients were recruited to receive percutaneous splanchnic nerve RFA for chronic pancreatitis pain over a period of 12 months at our centre. Using visual analogue score, pain, anxiety, mood, general activity, interpersonal relationship and sleep quality were assessed both before and after the procedure. Statistical analysis was performed using SPSS version 18.

Results

Splanchnic nerve RFA led to decrease in pain score, opiate analgesia, and it also resulted in improvement of other parameters of chronic pain (Table 1). These changes were statistically significant post procedure and maintained at 3 months (Fig 1). There were no major complications.

Conclusion

Splanchnic nerve RFA is potentially an effective procedure to treat chronic pancreatic pain. A larger formal study is needed to investigate further.

075

Radiofrequency denervation of lumbar facet joints: a clinical audit

Category: Interventional Pain Management

Colin Patterson, Saravanakumar Kanakarajan

Dept of Anaesthesia, Aberdeen Royal Infirmary, Aberdeen, UK

Background

Chronic lower back pain is a common condition in the developed world. Back pain can be very difficult to manage successfully, and so the condition carries a large socio-economic burden. In a number of patients, the Zygapophyseal (or Facet) joint acts as the pain generating site. Alongside a multi-modal approach, many of these patients can be helped with specific denervation of the medial branch of the dorsal rami that innervates the Zygapophyseal joint. However data from the literature has shown conflicting outcomes. Medial Branch denervation is routinely carried out in our centre, but data on the patients outcomes has not been audited. We report our local findings on the outcomes of patients with chronic Zygapophyseal joint pain.

Methods

Following approval from the local Clinical Effectiveness department, patients were identified through theatre lists. Data was collected from hospital notes, specific chronic pain notes and a database held and maintained by the local chronic pain services (data on attendances, procedures, pain scores and follow up). Retrospective data was extracted on the patients demographics, duration of symptoms, timing of diagnostic blocks, Brief Pain Inventory (BPI) scores (before and after procedure), the procedure carried out and levels involved. The data was recorded and analysed using a Excel spreadsheet. We defined ‘success’ as a patient who reported 50% reduction in pain eight weeks after the procedure.

Results

33 radiofrequency denervations were identified, carried out by one clinician over a 34 month period. There were 26 unique patients (seven patients having 2 procedures), all of whom had two sets of diagnostic blocks. Ages ranged from 33 to 79, with patients reporting a mean duration of symptoms of seven years. There were no recorded complications. 24 of the 33 cases (73%) fitted our criteria for ‘success’ (50% improvement in pain at eight weeks post denervation), although an additional 3 (9%) did not attend for follow-up. In the ‘success’ group’s follow-up BPI there a improvement in pain scores (2 point median improvement in ‘maximum’, 1 point median improvement in ‘average’ and 1.5 point median improvement in ‘current’ pain scores, with a larger improvement in the physical (9 point median improvement), psychological (8 point median improvement) and sleep (3 point median improvement) segments of the BPI noted.

Conclusion

Although denervation of the Medial Branch Block is commonly performed for chronic lower back pain originating from the Zygapophyseal joint, there is conflicting evidence regarding the efficacy of this treatment. This audit demonstrated good pain relief in the majority of patients eight weeks post procedure, adding to the evidence in support of the treatment. The patients reported not only an improvement in pain symptoms, but also an improvement in physical, psychological and sleep interference.

076

Is refractory angina a risk factor for haemodynamic changes after stellate ganglion block?

Category: Interventional Pain Management

Rajiv Malhotra¹, Rubina Ahmad², Hoo Kee Tsang¹

¹Royal Liverpool University Hospital, Liverpool, UK, ²National Refractory Angina Clinic, Liverpool, UK

Background

Stellate ganglion blockade is a commonly used treatment modality in chronic refractory angina¹. However, it can be associated with haemodynamic changes, including severe hypotension and hypertension². The quoted incidence of haemodynamic changes is less than 1% (hypotension 0.59%, hypertension 0.3%) and risk factors include the female gender and age over 50 years². It is possible that patients with refractory angina are at higher risk of cardiovascular changes, due to alterations in autonomic balance and increased sympathetic tone, and also the widespread use of beta blockers³. It is also likely that this subset of patients would be poorly tolerant of haemodynamic changes⁴.

Methods

A retrospective review was performed on patients with refractory angina who underwent stellate ganglion blockade. Blood pressure measurements before and for up to one hour after the procedures were collected. Episodes of mild (0-10%), moderate (10-20%) and severe (20-30%) systolic hypotension and hypertension were analysed.

Results

A total of 101 stellate ganglion blockade procedures were reviewed. The average age of the patients was 64.2 years (52-74 years), 62% were female and all patients were on beta blocker medication. All blocks were performed using the landmark technique with 12-20 ml of 0.5% laevobupivacaine; blood pressure measurements were obtained before and after the procedure, in 15 minute intervals for up to one hour. The overall incidence of severe hypotension amongst the patients with refractory angina was 2%, with no episodes of severe hypertension. There were no episodes of symptomatic cardiovascular changes, and no systolic blood pressure dropped below 100 mmHg.

Table 1.

Number of episodes of hypotension or hypertension after stellate ganglion blockade

Hypotension:	Total Number (Percentage)
Mild	3 (3)
Moderate	3 (3)
Severe	2 (2)
Hypertension:
Mild	4 (4)
Moderate	2 (2)
Severe	0 (0)

Conclusion

Although the number of patients included is small, this study shows that refractory angina is a risk factor for severe hypotension after stellate ganglion blockade, with an incidence of 2% compared to 0.59%. This may be secondary to the volume of local anaesthetic used and the concurrent use of maximal anti-anginal medication. However there were no episodes of symptomatic cardiovascular changes and this study therefore adds to the safety profile of stellate ganglion blockade in patients with refractory angina.

References

1. Chester M, Hammond C, Leach A. Long-term benefits of stellate ganglion block in severe chronic refractory angina. Pain (2000); 87 (1): 103-5

2. Yokota S, Taneyama C, Goto H. Gender Difference in Incidence of Severe Hypotension and Hypertension after Stellate Ganglion Block. American Society of Anesthesiologists 2011 (Abstract)

3. Chierchia S, Muiesan L, Davies A, Balasubramian V, Gerosa S, Raftery EB. Role of the sympathetic nervous system in the pathogenesis of chronic stable angina. Implications for the mechanism of action of beta-blockers. Circulation (1990); 82: 1171-81

4. Boden W, Korr K, Bough E. Nifedipine-induced hypotension and myocardial ischemia in refractory angina pectoris. JAMA 1985; 258: 1131-1135

077

To sedate is human(e): sedation use for interventional pain procedures

Category: Interventional Pain Management

Kim Carter¹, Krishna Bakhshi¹, Bhamini Ramaswamy¹, Neil Evans^1,2, John Edwin¹, Hans Mathews^1,2, Mary Miller^1,2, Lorraine Bayford¹, Deborah Garside¹

¹Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK, ²High Wycombe Hospital, High Wycombe, Buckinghamshire, UK

Background

Sedation is mentioned in most articles discussing how chronic pain interventions (CPI) are carried out. ISIS guidelines suggest that sedation is unnecessary for these procedures but this is not born out in practice. A poll of ISIS instructors found the vast majority use sedation and many use “heavy sedation” with propofol; their patients deemed it “barbaric” to not do so. Our objective was to establish if there is a need for sedation for our CPI and to ensure safe practice. There are few publications relating specifically to sedation for CPI & no guidelines. Safe sedation practice (RCA 2001) states…” (propofol) cannot be considered safe for use by the operator-sedationist”, with reference to endoscopy and their guidance for sedation in ERPC (2011) recommends propofol sedation is used by anaesthetists only. Nowhere is the situation of the anaesthetist as the operator-sedationist discussed & the need for a separate sedationist requires clarification.

Methods

The pain and recovery nurses were asked to complete an audit form for 3 months, from May - September 2011. The patient details, the procedure carried out, the sedation given, if any and the dose were all recorded. In addition any untoward events relating to sedation use were recorded. The data was then analysed to ascertain, the percentage of our patients being sedated, the drugs & doses used, the procedures where sedation was most commonly given and to check safe use of sedative drugs. There are currently no specific guidelines on sedation for CPI, so we could not assess accordance with them but we wanted to ensure safe practice based on RCA safe sedation practice guidelines (2001).

Results

Over the audit period, a total of 268 cases were recorded, of which 58% had sedation. Sedation was used in 70% cases when ≥1 procedure was performed. Woman required sedation more than men (64% vs 46% respectively) and there were certain procedures where sedation was more commonly used; 80% of patients undergoing denervation procedures were sedated, but only approximately 60% required sedation for pulsed radiofrequency, facet joint injection, nerve root blocks or joint injections. Only 36% having epidurals had sedation. Midazolam was the commonest sedative agent (71% cases), with a modal average dose of 2mg (range 1-10mg). Propofol was used in 34% of cases, with a wide total dose range (10-400mg). There was only one report of sedation related side effects, relating to hypotension, which responded to iv fluids. No airway problems were encountered and verbal contact was maintained with all patients throughout the procedures.

Conclusion

• Conscious sedation is used in 2/3 of our patients, usually with midazolam and is safe

• Propofol use is increasing due to easier titration & quicker recovery, with less hangover effect, so potentially quicker discharge of patients

• During our CPI, there is always ≥1 anaesthetist present & an ODP, who monitors patient observations

• Changes needing implementation: written records of observations, ETCO2 monitoring

• There are no guidelines specific for sedation in CPI and we raise the issue of whether a separate anaesthetist is required for CPI if use propofol is used.

078

A survey of patient satisfaction with the experience of day case pain procedures at Ashford and St Peter’s NHS Trust

Category: Interventional Pain Management

Guy Sanders, Saad Anis

Ashford and St Peter’s NHS Trust, Chertsey, Surrey, UK

Background

The concept of patient satisfaction within the NHS was pushed to the forefront by the Department of Health 2010-2015 five year strategic review encouraging a people-centred service. It directed the expansion of the measurement of patient satisfaction and experience, and explained how a significant proportion of provider income will be linked to satisfaction scores. At Ashford and St Peter’s NHS Trust one of the four core values is ‘patients first’ and therefore the aim of this survey was to assess how a key component of the pain services - day case procedures - faired in terms of patient experience. It is common place to audit efficacy of interventions, but efficacy and satisfaction do not necessarily correlate and therefore this survey sought to determine current performance and establish what elements of the overall experience could be improved to enhance satisfaction.

Methods

A voluntary anonymous written survey was given to patients to complete who had undergone a day case pain procedure without sedation at Ashford and St Peter’s NHS Trust over a six week period. The survey was distributed by the doctor performing the procedure and there were no patient exclusion criteria. The survey requested limited demographic details before focusing on patient satisfaction with various aspects of the procedure. These included the consent process, staff courtesy, post-procedure information, and pain scores before, during and after the procedure on a 0 to 10 scale. The survey was completed within the first 30 minutes after the procedure and then collected by the day surgery nursing staff to protect anonymity before being collated by the responsible clinician.

Results

60 patients completed the survey, 40 females and 20 males with a mean age of 63.7. 100% of patients felt the procedure and consent was adequately explained and 100% felt staff treated them courteously. 73% were ‘very satisfied’ with their procedure with a further 25% ‘satisfied’. One patient was ‘very dissatisfied’ but this most likely represented a mistake in form filling as they offered no reason in the free text box and this was out of keeping with their other responses. 93% of patients felt post-procedure instructions were clear. Mean pain score before the procedure was 7.22, during the procedure 3.97, and after the procedure 3.53. The mean difference in pain score before and after the procedure was 3.68 (95% CI 2.91-4.46); this represents a statistically significant difference p<0.0001 (paired t-test).

Conclusion

Our results demonstrate a high level of patient satisfaction with day case pain procedures at Ashford and St Peter’s Trust. 98% of patients were either ‘very satisfied’ or ‘satisfied’ with the overall experience and 100% felt courteously treated. In addition reassuringly 100% of patients felt the procedure and consent was adequately explained.

There was a statistically and clinically significant reduction in patient pain scores reported in the first 30 minutes after the procedure compared with scores reported before the procedure.

079

A community pain service solution focused pain management programme: preliminary outcome data

Category: Interventional Pain Management

Joanne Iddon, Rebecca Simm, Christopher Barker, Deanne Barrow, Kate Maguire

Southport and Ormskirk Hospital NHS Trust, Merseyside, UK

Background

As a CPS, we have a sophisticated “Expert to Expert” ethos between patients and clinicians, in line with the national DoH Expert Patient agenda (2001) proposing that “knowledge and experience held by patients has been for too long an untapped resource ”. Using a solution-focused (de Shazer et al., 1986) patient-centred approach (based on evidence that autonomous goal setting, the promotion of self-efficacy and tailored resilience-building interventions are effective, Presseau et al., 2010; Lorig, 2000; Karoly, 2006) we tap into the “untapped resource”.

Along with our community setting, and sustainability ethos, using a solution focused approach is just one of the aspects that makes our service different from other pain services. Here we present preliminary effectiveness findings from our community-based group pain management programme (PMP). The programme runs for 3 sessions a week over 8 weeks, comprising of community based exercise and solution focused facilitation of pain management topics.

Methods

Outcome measures are selected in close conjunction with our expert patient support group, Pain Clinic Plus, including standardised quantitative measures and qualitative questionnaires, and are reviewed on a regular basis. Self-report data was collected from patients at five different time points including pre and post PMP, 10-week, 6-month and 12-month follow-ups. An objective physical measure (Sit-to-stand) was also carried out in order to capture any improvements in physical health and functionality status during the different time-points.

At present, due to changes in the standardised measures administered, power calculations have revealed insufficient data for statistical analysis of follow-up data, although the general pattern of means indicates that improvements are maintained. Due to the on-going nature of the PMP, up to 20 data sets are available every 10 weeks (including post-PMP and follow-up data). Our evidence database is ever-growing and analysis is regularly carried out and disseminated back to the multi-disciplinary team.

Results

Power calculations have identified sufficient sample sizes to undertake statistical analysis on the standardised measures. Two-tailed T-tests have demonstrated statistically significant differences between pre and post PMP outcome data for the following measures: Pain Self-Efficacy Questionnaire, Satisfaction with Life Scale, Warwick-Edinburgh Mental Wellbeing Scale, EuroQol Visual Analogue Scale, Positive Affect Scale and the physical Sit-to-Stand measure. Qualitative rating sheets are also used to capture the extent to which patients feel the PMP has been useful, generating very positive feedback.

Clinical significance was also explored to establish what quantitative improvements represent in terms of the impact on patients’ lives. We have observed clinical significance alongside statistical significance as outlined by standardised measure user guides, population samples and demographics. For example, the mean response on the WEMWBS increased from ‘very poor’ to ‘fair’ demonstrating that patients considered their self-perceived health status to have improved by two categories following completion of the PMP.

Conclusion

Traditionally, pain management programmes are hospital based, provide short term intervention in people’s lives and perhaps arguably aim to apply models of pain management to people whilst missing an opportunity to explore patients’ own views and expertise. Our community setting and approach enables patients to make lasting changes in their lives and enhances their self-management of chronic pain. We have preliminary statistically significant outcome data, which importantly seems also to be of clinical significance. Individuals consider themselves to be in a better health-state and evidence suggests that this may lead to potential reductions in healthcare utilisation and cost-savings (Simpson, 2001).

080

High frequency spinal cord stimulation in the management of chronic low back pain

Category: Interventional Pain Management

Adnan Al-Kaisy¹, David Pang¹, Stafano Palmisani¹, Tom Smith¹, Jean-Pierre Van Buyten², Iris Smet²

¹Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK, ²AZ Nikolaas Hospital, Sint-Niklass, Belgium

Background

Spinal cord stimulation (SCS) is a well established, NICE approved, treatment for failed back surgery syndrome. It often provides remarkable pain relief and improves functional status.

Challenges remain in optimising SCS therapy. With conventional SCS, using frequencies of 40 to 60 Hz, it easier to alleviate neuropathic radicular leg pain than axial lumbar back pain. Paraesthesias produced in conventional SCS can be unpleasant for some patients.

High frequency (HF) (up to 10,000 Hz) SCS is a promising novel therapy which may provide an alternative to conventional SCS avoiding parasthesias. We report on a prospective, multicentre, industry sponsored open label study aimed to evaluate the efficacy and safety of HF-SCS in patients with severe refractory low back pain - most of whom had FBSS.

Methods

With Ethics Committee Approval and fully informed consent, patients with severe chronic low back pain refractory to other treatments and with no contraindications to SCS underwent a one to four week Nevro^TM High Frequency (10kHz) SCS-trial with percutaneous placement of two 8-contact leads in the epidural space at the anatomical midline covering levels T8 to T10. 50% or more reduction in pain from baseline was regarded as a successful trial. Patients with a successful trial had permanent leads sited as above and tunnelled subcutaneously to an implanted rechargeable implanted pulse generator sited in the anterior abdominal wall or buttock. Patients were evaluated at 3, 6 and 12 monthly intervals after implantation with a visual analogue pain score(VAS), Oswestry Disability Index (ODI), sleep disturbance, medication use and adverse effects recorded.

Results

82 patients from 83 recruited patients completed a trial of HF-SCS and 72 proceeded to full implantation. Average age was 50 years with 58% of recruits female. 80% of patients had “Failed Back Surgery Syndrome”, 20% had no history of spinal surgery. Axial back pain predominated over leg pain in 87%. VAS mean back pain score was 8.4 and mean leg pain score was 5.4 at baseline. The axial back pain scores at 3, 6 and 12* month follow up was 2.4, 2.7 and 2.8 respectively. Leg pain scores were 1.3, 1.4 and 2.1 respectively. Baseline ODI was 55. At 3, 6 and 12 months it fell to 37, 38 and 38 respectively. The use of opioids reduced from 86% to 51% at 6 months. Seven cases required revision-four for IPG site pain, one for infection and one for lead migration.

*data at 12 months available for 59 patients

Conclusion

HF-SCS using the Nevro^TM system at 10kHZ alleviated axial back pain and radicular leg pain in patients with chronic refractory low back pain. Effects were maintained at 12 months.

Marked pain relief was seen in patients with “Failed Back Surgery Syndrome” and in patients with no history of back surgery.

Marked improvements in function (Oswestry score) and sleep were seen.

Marked reduction in pain medication was seen

HF-SCS appears to be safe and well tolerated.

Avoidance of paraesthesia and intraoperative testing (required in conventional SCS) are further favourable factors - improving patient tolerability and operating time.

081

Case report: Conversion of a patient with Loin Pain Haematuria Syndrome from short-acting fentanyl to methadone through interdisciplinary working and planned in-patient admission

Category: Interventional Pain Management

Abdul Lalkhen, Hannah Twiddy, Andrew Heck

Salford Royal Foundation Trust, Salford, Manchester, UK

Background

We present a single case study of a successful multi-disciplinary approach to the planned in-patient conversion of short-acting fentanyl to methadone in a patient with Loin Pain Haematuria Syndrome (LPHS).

LPHS is a rare disorder characterised by flank and loin pain associated with haematuria. It is often intractable and causes considerable psychosocial distress and disability. Management is difficult with various therapies having been proposed including systemic opiates, autologous renal transplantation and neuromodulation techniques.

A 36 year old woman was referred to a regional specialist pain centre following 13 years of loin pain for consideration of neuromodulation and also concern over increasing short-acting fentanyl lozenge usage and dependence on benzodiazepines. Previous therapies have included various opioids, lidocaine plasters, amitriptyline and bilateral autologous renal transplants. These had little effect.

On presentation her daily medication consisted of 18 800mcg fentanyl lozenges, gabapentin 2.8g, and carbamazepine 400mg with zopiclone and diazepam at night.

Methods

Initial medical assessment identified significant negative sequelae from the effects of short-acting opioids and a plan was formulated to convert the lozenges to methadone through an interdisciplinary approach.

Previous studies have highlighted the importance of a multi-disciplinary approach, especially the importance of appropriate psychosocial assessment and targeted therapies designed to improve functional outcome and pain expectations.

Assessment was undertaken by a Clinical Psychologist which detailed the nature and impact of the chronic pain condition, the patient’s understanding of her pain, barriers to change and anxieties. These were addressed at subsequent medical and psychological assessments including the development of cognitive behavioural therapies and a structured daily plan for the period of inpatient stay.

On admission the lozenges were stopped and converted to methadone. During her in-patient stay two more sessions were scheduled with the Clinical Psychologist to provide ongoing support. Outpatient review was at one month and at one year.

Results

The patient was admitted for a total of 7 days. The fentanyl lozenges were converted to methadone 30mg three hourly. Over five days she used an average of 180 to 210mg of methadone each 24-hour period. The dose was converted to 50mg three times a day and this regimen was monitored over two days. No breakthrough medication was required and she was successfully discharged on this dose. Her Zopiclone dose at bedtime was increased to 15mg and the Diazepam was decreased and later discontinued.

On review at one month she reported improved quality of life and reduced depression and anxiety. Review appointment at one year in a joint Medical and Psychologist clinic demonstrated sustained improvement and no escalation of medication requirements. Further plans were made to progress to a Pain Management Programme to improve functionality.

Conclusion

This Case Report has demonstrated several aspects in the management of LPHS. The literature already supports a better outcome from conservative strategies undertaken with a multi-disciplinary approach in these patients. The role of structured, focused input from a Psychologist can provide the supporting strategy for successful conversion from high dose short-acting opioid. Furthermore a brief in-patient stay with appropriate support and preparation can facilitate the successful conversion from considerable fentanyl lozenge usage to stable methadone consumption. Lastly the harmful effects of short-acting opioids can be mitigated by conversion to longer-acting alternative regimen with agreed ceiling thresholds.

082

Quantitative effects of spinal cord stimulation on surface hyperalgesia

Category: Interventional Pain Management

Lisa Bentley¹, Elizabeth Sparkes^1,2, Rui Duarte¹, Robert Ashford¹, Paul Furlong³, Jon Raphael^1,4

¹Faculty of Health, Birmingham City University, Birmingham, UK, ²Faculty of Health and Life Sciences, Coventry University, Coventry, UK, ³Aston Brain Centre, Aston University, Birmingham, UK, ⁴Department of Pain Management, Russells Hall Hospital, Dudley, UK

Background

Chronic pain is extremely difficult to manage as the manifestation of conditions and effectiveness of treatments vary greatly between patients. One symptom which can present itself in clinical pain disorders is surface hyperalgesia, where patients have abnormally heightened sensitivity to pressure on the skin, causing them discomfort and pain. When other, less invasive treatments for clinical pain are unsuccessful, spinal cord stimulation (SCS) is demonstrating positive results as an intervention. The present investigation explores the effects of SCS on patients’ experiences of pain and the symptom of surface hyperalgesia. In addition to this, the present research examines whether there is a relationship between the effects on the patients’ overall pain and their surface hyperalgesia.

Methods

Fifty patients with implanted SCS were included in this study. The patients attended a scheduled review clinic with their SCS devices switched off twenty-four hours prior to their visit, to be switched back on during the session. Patients’ pain ratings were measured using the Visual Analog Scale (VAS) before and after SCS activation. Additionally, the pain threshold for the patients’ area of maximum surface hyperalgesia was measured using Quantitative Sensory Testing (QST) with an electronic Von Frey Aesthesiometer before and after stimulation was activated. This measurement tool applies a force ranging from 0-800 grams and three readings were taken with the patients’ eyes closed in both conditions in order to calculate each patient’s average surface pain threshold.

Results

Participants, male (n=19), female (n=31). Mean duration of time in pain before SCS, 9.9 ± 7.9 years (range 2-40). Diagnoses, Complex Regional Pain Syndrome (n=21), Failed Back Surgery Syndrome (n=14), Neuropathy (n=15). Mean percentage of cover over pain area, 79.6 ± 22% (range 20-100). For all patients, VAS scores were significantly higher with SCS off (Mdn = 7) than on (Mdn = 2.8), z = -6.156, p < .001, r = -.62. The QST threshold was significantly lower for all patients with SCS off (Mdn = 185) than on (Mdn = 605), z = -5.906, p < .001, r = -.59. Similarly to the aforementioned results, there were also significant differences with the stimulator off and on within each diagnosis group, p<.001. In addition to these findings there was also a significant relationship between VAS and QST difference before and after SCS is activated, r = .426, p < .01.

Conclusion

The findings generated from this study support the effectiveness of SCS for patients suffering from Complex Regional Pain Syndrome, Failed Back Surgery Syndrome and Neuropathy. These results also suggest that measurement of effect on surface hyperalgesia may provide a more reliable measure of pain reduction than VAS in assessing response to treatment.

083

Audit on epidural injections for the management of pain of spinal origin in adults

Category: Interventional Pain Management

Kavitha Manoharan, Salma Mohammed, Ashish Gulve

James Cook University Hospital, Middlesbrough, UK

Background

The Faculty of Pain Medicine (FPM) recently produced recommendations for the use of epidural injections in the management of pain of spinal origin¹.These recommendations apply to all pain physicians who perform these procedures and refer to single shot injections. The main aim of this audit was to observe our compliance with the FPM recommendations. The recommendations we focused on included written informed consent, use of a standard World Health Organisation (WHO) surgical safety checklist, use of a pregnancy test, intravenous access, strict aseptic technique (gown, gloves and mask), fluoroscopy guided injections, use of water soluble contrast and standard monitoring. The other aims were to record compliance with fasting guidelines, the presence of a trained assistant and any complications during the procedure.

Methods

We conducted a prospective audit at James Cook University Hospital over a 2 month period. Approval was obtained from our local audit department and data was collected using a standardised data collection sheet. Data regarding patient demography, procedure, consent, WHO checklist, pregnancy status and placement of intravenous access were recorded. In addition, fasting guidelines, aseptic precautions, fluoroscopic confirmation, use of water soluble contrast, presence of a trained assistant, monitoring and any complications were also recorded.

Results

Total of 40 patients: 15 male, 25 female, mean age 60 years.

Procedures performed:3 Cervical Epidural,2 Lumbar Epidurals,9 Caudal Epidurals,26 Selective Nerve root blocks.

Written informed consent was obtained in all 40 patients. 93% of cases had fluoroscopic confirmation of needle placement during the procedure and 80% of cases were also confirmed with the use of contrast. All procedures were done with the help of a trained assistant and the only adverse event recorded was a vasovagal attack.

None of our patients in this group were at risk of being pregnant and as a result no pregnancy testing was done.

18% of patients were not fasted and a WHO checklist was not performed in 15% of patients. Intravenous access was established in 50% of patients.63% of patients had full monitoring and 33 % had no monitoring during the procedure. Full aseptic technique was practised in 73 % of the cases.

Conclusion

We did not achieve 100% compliance with these recommendations and perhaps further education and re-auditing will lead to an improvement in practice. There is still quite a discrepancy in practice and indeed debate amongst pain physicians regarding these recommendations^2,3.

084

The effectiveness of radiofrequency neurotomy of the supra-scapular nerve in refractory shoulder pain: experience of 14 cases over an 18 month prospective period (2010-2012)

Category: Interventional Pain Management

Allen Pinto, Vinayak Kumar, Paul Mathers, Nick Plunkett

Sheffield Teaching Hospitals NHS Trust, Sheffield, South Yorkshire, UK

Background

The supra-scapular nerve, derived from the C5 and C6 spinal nerves, provides sensory innervation to approximately 70% of the glenohumeral joint. Post-operative analgesia after arthroscopic shoulder surgery, as well as longer lasting analgesia from chronic shoulder girdle pain has been achieved from blockade of the suprascapular nerve. Pulsed radiofrequency lesioning of the suprascapular nerve for chronic shoulder pain has been described.

All patients in this case series were referred by Consultant Orthopaedic Surgeons as they were either unsuitable for shoulder surgery due to significant comorbidities, or they suffered from severe progression of arthritis invalidating benefit from replacement.

Methods

Radiofrequency neurotomy was chosen over pulsed radiofrequency lesioning due to lack of sustained benefit of the latter in the main operator’s hands. Initial data recorded included VAS pain scores, symptom duration and functional impairment. All patients were consented stating risks, which included pneumothorax, long-term infraspinatus/supraspinatus muscle weakness, and worsening due to deafferentation pain. Radiofrequency neurotomy was performed under aseptic conditions using superficial local anaesthesia. The nerve was located as it winds around the lateral border of the scapular spine using the landmark technique Gauci described, combined with sensory stimulation of.

Results

Five males and nine female patients with mean age 67 years (45-89 years) with chronic shoulder pain with median duration 4.5 years (1-13 years) of median intensity 8 (mean 7.9, range 7-10) on a 11-point VAS scale (0= no pain, 10=unbearable pain) underwent the above procedure and were followed-up at median 105 days (43-281 days). Nerve location was successful in all patients. Sensory stimulation was successful down to median 0.2V (0.2-0.6V).

Twelve of fourteen patients reported a minimum of 50% reduction in their pain intensity (50% to 100%). This benefit appears to persist over a six month period. One patient reported 25% improvement, and one reported no improvement in pain intensity. All patients reported an improvement in their functional abilities pertaining to their affected limb. All patients felt improvement in the range of movement compared to baseline. No patients suffered pneumothoraces or deafferentation pain.

Conclusion

Radiofrequency ablation of the suprascapular nerve is an effective method of achieving significant pain relief and improvement in functional abilities in patients who have chronic shoulder pain that is unsuitable for surgical intervention. This benefit appears to last over a prolonged period of time.

085

Treatment of severe neuropathic pain following re-implantation of fingers by median nerve stimulation in forearm: a case report

Category: Interventional Pain Management

Ashish Shetty^2,1, David Pang², Victor Mendis³, Theodor Goroszneuik²

¹Norfolk and Norwich University Hospital, Norwich, UK, ²Guys & St Thomas Hospital, London, UK, ³Mid Essex NHS Trust, Chelmsford, UK

Background

Neuropathic pain following traumatic amputation and re-implantation of fingers is often resistant to conventional treatment and can offset the benefits of the plastic surgery.We report the successful management of one such patient with a median nerve stimulator implant. To our knowledge this is first such case report.

Methods

A 35 year old patient who suffered a traumatic amputation of his medial three fingers developed severe neuropathic pain after re-implantation. This condition was resistant to all the traditional pharmacological and interventional pain treatment. After successful percutaneous trial of median nerve stimulation in the forearm at 2Hz we proceeded to permanent neurostimulator implantation. An octrode lead was inserted percutaneously to stimulate the median nerve in the forearm. This lead was then tunnelled to an implanted battery in the forearm (St Jude’s Eon mini) close to the site of lead insertion.

Results

The pain which was resistant to conventional treatment including Intravenous globulins and stellate ganglion block responded well to peripheral neuromodulation. The patient continues to report over 80 percent pain relief following median nerve stimulator implant. The benefit is persistent and has lasted beyond six months following the implantation.

Conclusion

Nerve injuries sustained during amputation and reimplantation can result in resistant and persistent neuropathic pain. This is thought to be due to small fibre predominant mono or oligoneuropathy initiated by trauma. We describe the use of percutaneous median nerve stimulation in treating neuropathic pain caused by traumatic digit amputation and re-implantation. This technique is minimally invasive and adds to the increasing use of peripheral neuromodulation. We also describe the feasibility of implanting the neurostimulator in the limb, close to the site of pain. This might be the future of peripheral neuromodulation.

086

The successful treatment of iatrogenic neuropathic pain caused by neurostimulators with Target Field stimulation using existing neuro stimulating system

Category: Interventional Pain Management

Ashish Shetty^1,3, David Pang¹, Sam Eldabe², Theodor Goroszneuik¹

¹Guys & St Thomas Hospital, London, UK, ²James Cook University Hospital, Middlesborough, UK, ³Norfolk and Norwich University Hospital, Norwich, UK

Background

Iatrogenic pain caused by implanted neurostimulation devices present a serious problem which may lead to explantation of the system. This condition is managed with various treatment modalities, often with unsatisfactory results. We report the successful management of two such patients, with Peripheral Target-Field Neuromodulation, by adding a new stimulating lead and connecting it to the existing Implantable Pulse Generator . Explanation of the device was being seriously considered in these patients.

Methods

The first patient had developed neuropathic pain around the connection site of the spinal cord stimulator implant. The original implant was done to treat CRPS of knee.

The second patient also had developed severe neuropathic pain at the site of Implantable Pulse Generator. This was implanted for Target–Field stimulation to treat neuropathic pain after appendectomy.

In both cases the original stimulation was effective, providing patients with excellent pain control. All applied treatment modalities for iatrogenic pain were ineffective. An extra lead was targeted at the side of pain and was connected to an existing IPG.

Results

The stimulation of the painful area provided both patients with total relief from the iatrogenic pain. The procedure was relatively simple and cost effective as the already implanted IPG was used as an energy source. Explanation of the working neurostimulator was avoided in these patients.

Conclusion

The neuropathic iatrogenic pain caused by an implanted neurostimulation device is not frequent but can be very resistant to treatment. The target-field stimulation in iatrogenic post-implantation pain can offer an alternative to existing treatment modalities. This simple technique can avoid explanation of the neurostimulating devices, that cause iatrogenic pain.

087

Retrospective audit of pain relief following lumbosacral selective nerve root blocks performed in 2010

Category: Interventional Pain Management

Jacquelyn Lewin, Manohar Sharma

The Walton Centre NHS Foundation Trust, Liverpool, UK

Background

Research has supported the use of lumbar transforaminal epidural injections as a pain treatment in selected patients with significant radicular pain¹.

Lumbosacral selective nerve root blockade (SNRB) is a commonly performed interventional procedure for radicular leg pain, often caused by compression of spinal nerve roots by disc herniation.

Some authors have found that a longer duration of pre-injection pain is predictive of a less efficacious response to injection. We wanted to determine whether this was the case for our patient population and also to discover the average duration of pain relief provided by a single injection. This information would help us to improve both efficiency and efficacy, by identifying those patients most likely to benefit from the procedure.

Methods

• Retrospective audit over a one year period, ethics commitee approval obtained.

• 53 patients identified who had undergone lumbosacral SNRB.

• Data was collected from patient notes or, where information was missing, by telephone contact with the patient

• Data collected included the referring specialty, whether the injection was diagnostic or therapeutic, and whether the patient went on to have spinal surgery, duration of pain prior to injection, location of injection, indication for injection, duration of pain relief provided, complications, number of repeat procedures performed, and patient impression of the impact of the procedure.

Results

• 53 patients were identified; notes available for 45.

• 3 patients had incomplete follow up data, thus 42 patients were included.

• All injections were for leg pain; 82% SNRB were at L5 level.

• 56 SNRB were performed in the 45 patients.

• Average duration of pain pre-injection was 21.5 months.

• Patients with 12-24 months of preceding pain had the longest average post injection pain relief at 7.8 weeks; >24-60 months preceding pain gave on average 4.6 weeks

• The range of pain relief post block was from 0-6 months; 5 patients had no pain relief at all. The average pain relief was 6.3 weeks; 22 patients had between 0-4 weeks, 8 had between 5 and 8 weeks, 8 had between 9-12 weeks and 2 patients had between 13 and 24 weeks.

• 2 patients had minor complications.

• 83% of patients at 2 month follow up said having the procedure had been worthwhile.

Conclusion

• Lumbosacral SNRB is a safe, straightforward procedure in our centre.

• This is a retrospective audit with limitations. No validated questionnaires were used to assess the amount of change in pain.

• Results also suggest that long duration of pain pre-injection was predictive of a poor response.

• A prospective audit of lumbosacral SNRB is in progress to address the limitations of this, with patients completing questionnaires (EQ 5D, BPI) pre-procedure, post procedure and at 1/4/8 and 12 months( EQ 5D, BPI, GIC).

1.Buenaventura RM, Datta S, Abdi S, et al. Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician. Jan-Feb 2009;12(1):233-51.

088

Clinical outcome of sacroiliac joint injections

Category: Interventional Pain Management

John Vinu Edwin¹, Murli Thiyagarajan^1,2, Krishna Bakhshi¹, Hans Mathew¹, Neal Evans¹, Bhamini Ramaswamy¹

¹Buckinghamshire Healthcare NHS Trust, Buckinghamshire, UK, ²St George’s, University of London, London, UK

Background

Back pain affects more than 1/3 of the UK population and is associated with significant economic, societal and health impacts and the prevalence is reported to be increasing.1

Studies in the past have shown that in 13-19% of patients with chronic low back pain, the main pain generator is the sacroiliac joint (SIJ) and it is increasingly implicated as a source of chronic low back pain.2-4

Fluoroscopically guided sacroiliac joint injection with local anaesthetic is used as a gold standard for diagnostic purposes and with corticosteroid for short term therapeutic pain relief.5

SIJ injections with corticosteroid have short term pain relief and radiofrequency denervation is considered for long term pain relief.6

An audit was initiated to quantify and qualify the pain relief outcome following SIJ injections in our pain clinic.

Methods

Type of study:	Retrospective case notes data analysis
Sample:	Patients with chronic low back pain
Setting:	Pain clinic in a district general hospital
Study period:	April 2010 to April 2011
Outcome measures:	Pain relief of 50% or greater, duration of pain relief 6 weeks post injection
Inclusion criteria:	Patients with SIJ injection only
Exclusion Criteria:	Patients who received SIJ injections plus other interventional procedures simultaneously.

A telephone follow up call was performed six weeks post injection where the patient was asked what they felt the average percentage pain relief had been throughout the six week period where 0% was

no pain relief and 100% was complete pain relief.

Results

A total of 44 patients’ records were analysed. Male to Female ratio was 1: 1.9. Age of patients ranged from 33-90 with an average age of 62 years. Of the 44 patients, the mean percentage pain relief was 48%.

16 records were excluded from further analysis due to incomplete data of pain relief at 6 weeks post injection follow up.

Out of the 28 completed records, 12 patients (43%) had a pain relief of 50% or more at 6 weeks post injection and the overall mean duration of pain relief was 1-4 weeks.

Pain relief scores ranged from worse to 100% relief.

Patients between ages 50-70 had the lowest pain relief (32%) and the lowest pain relief duration (1-7 days).

Conclusion

Our findings seem to corroborate previous studies.

We find this useful to isolate patients with predominant sacroiliac joint pain.

This group of patients will be considered for more prolonged pain relief with radiofrequency denervation.

089

Retrospective audit of medial branch neurotomy for lumbar facet joint pain

Category: Interventional Pain Management

Saad Anis

Ashford and St Peters Hospital, Chertsey, UK

Background

Lower back pain is a common disorder in the UK, affecting one third of the UK adult population each year (Maniadakis & Gray 2000). Facet joints are thought to be a factor in 15-45% of back pains (Manejias et al. 2008).

Radiofrequency (RF) denervation of the medial branch of the primary dorsal rami (MBPDR) of the spinal nerves has been shown to be an effective and relatively less invasive management option for this pain (Dreyfuss et al. 2000).

Diagnosis of facet joint pain is difficult and can only be diagnosed by local anaesthetic blocks of MBPDR. It is recommends two blocks be carried out before denervation to reduce false positives rate.

Recent controversy in UK due to NICE lower back guidelines(2009) which recommended no room for RF denervation for treatment of lower back pain.

Retrospective audit to look at long term pain benefit for patients undergoing denervation.

Methods

Retrospective audit of RF denervations carried out by two consultants. Patients of each consultant who had undergone lumbar RF denervation in the previous three years chosen at random. As long as there was at least a year between the denervation procedure and the audit date to allow for analysis of duration of pain relief.

We assessed the following factors to evaluate success of denervation.

Quality of pain relief- We looked for minimum 50% reduction in pain score to assess for successful denervation

Duration of pain relief- Expected at least nine months to one year pain relief to be considered a successful denervation.

The number of local anaesthetic nerve block performed for diagnosis and whether it made a difference to success rate of denervation procedure.

Results

Consultant one: 30 patients in total. 53% of the patients were male and 47% female. Mean age was 46. Most common levels denervated were L3-S1. This consultant would perform two local anaesthetic blocks for diagnosis.

RF results were 56% of patients had good quality pain relief (reduction of 50% in pain score)

40 % of patients had pain relief for over 9 months, 16% had six months pain relief and 40% had no pain relief at all.

Consultant two: 25 patients in total. 68% female and 32% male. Mean age was 57. Most common levels denervated were L3-S1. This consultant would perform one local anaesthetic block for diagnosis.

RF results showed 48% of patients had good quality pain relief (50% reduction)

48% of patients had pain relief for over 9 months, 4% had three months pain relief and 48% had no pain relief at all.

Conclusion

Results were in general quite encouraging. A 50% reduction in pain scores in at least 50% of patients. Most patients who had a successful denervation process had at least nine to twelve months pain relief. This compares reasonably with other audits performed in the literature.

Interestingly there was a difference between the two consultants in the number of patients who had a positive result in terms of pain relief (56% vs. 48%). This may well be due to the first consultant performing two diagnostic blocks compared to one which has reduced his false positive rate.

090

Lumbar facet joint injections - Is this problem behind us?

Category: Interventional Pain Management

Peter Gregory¹, Karin Cannons², Gerard Sinovich¹, Mohammed Nejad¹, Anne Fish²

¹St. Georges Healthcare NHS Trust, London, UK, ²Frimley Park Hospital NHS Foundation Trust, Camberley, UK

Background

Our local Primary Care Trust (PCT) has questioned the benefits of lumbar facet joint injection (LFJI) therapy for chronic low back pain. Consequently review of the service is on-going despite a reduction in LFJIs by 8% since April 2011 despite an increase of 43% of GP referrals during this same period. The aim of this study was to establish whether LFJIs provide benefit in terms of reduced disability to those patients receiving them and to provide information to aid policy making at PCT level.

Methods

This is a longitudinal patient survey using the Revised Oswestry Disability Index (RODI)¹ to quantitatively assess changes in disability score following radiologically guided LFJI of local anaesthetic +/- steroid. All recruited patients had presented to Day Surgery for LFJI either in isolation or as a combination treatment. No distinction was made between diagnostic versus therapeutic LFJI or between numbers of LFJIs given. Each patient had suffered with lower back pain for more than 1 year and had been managed according to the ‘Pain Management Pathway for Chronic Facetal Pain’ algorithm² employed by the Trust. An initial RODI was completed by the patient immediately prior to the procedure and subsequent questionnaires were sent by post 1 month and 3 months later. The disability scores from the post procedure RODI’s were compared with the initial score and with each other and non-parametric statistical analysis performed using GraphPad InStat 3 software.

Results

76 patients were included comprising 28 men and 48 women with a mean age of 56. The initial RODI gave a median disability score (MDS) = 29 (IQR=10). At 1 month, n=43 (MDS=23 (IQR=11), p=0.0181, Wilcoxon matched-pairs signed-ranks test (WMPSR)). At 3 months, n=32 (MDS=27 (IQR=11), p=0.6065, WMPSR). Friedman’s Test was performed where all 3 completed RODI’s had been returned, n=23; (p=0.0434 for Initial vs. 1 month, p>0.05 for Initial vs. 3 months and p>0.05 1 month vs. 3 months). Stratification of data by procedure demonstrated a reduced disability score at 1 month compared with pre-procedure for LFJI as a lone procedure; n=17 (MDS=24 (IQR=11), p=0.0181, WMPSR), and for LFJI plus Sacroiliac Joint Injection (SIJI), n=13 (MDS=22 ( IQR=14), p=0.0210, WMPSR)). However, at 3 months the null hypothesis could not be rejected; FJI alone (MDS=27.5 (IQR=14), p=0.4877, WMPSR) and FJI plus SIJI (MDS=26 (IQR=15), p=0.8203, WMPSR).

Conclusion

LFJIs as a sole procedure or as combination treatment significantly reduced disability scores in these patients. This is clearly seen at 1 month post procedure where the MDS was reduced by 21% (p=0.0181) correlating with 42% decrease in disability¹. At 3 months this benefit is less clear. This may be due to the loss to follow-up of patients resulting in a smaller sample size. Alternatively, LFJI’s may need to be administered at shorter intervals to maintain their effect although this may have financial implications. This study does not include the possible accumulative effects of repeated injections. Further studies are needed.

091

An audit of the analgesic effect of intrathecal diamorphine and its side effect profile in lower segment caesarean section

Category: Interventional Pain Management

Ben Wetherell¹

¹Leeds Medical School, Leeds, UK, ²Bradford Royal Infirmary, Bradford, UK

Background

Currently in the UK 20-25% of babies are born by lower segment caesarean section (LSCS). This operation is ideally performed under spinal block, as this has fewer risks and allows immediate contact between the baby and mother. Intrathecal diamorphine is used to provide post-operative analgesia at the Bradford Royal Infirmary. This audit aims to establish whether good practice is occurring by investigating the analgesic efficacy and side effects of intrathecal diamorphine following a LSCS.

Wang et al. were the first to report the analgesic effects of an intrathecal opioid (morphine) in 1979. Spinal opioids are now well established in improving intra-operative comfort and preventing post-operative pain. Currently, in the UK, diamorphine is the spinal opioid of choice, even though it is not licensed for intrathecal use. Regardless, its safety and effectiveness has been widely investigated, and it is used commonly in obstetric practice.

Methods

Seventy five ASA I and II women who had had either an emergency or elective LSCS were recruited into the audit. All classes (1-4) of emergency LSCS were included, as were women who had had a previous LSCS. All women received intrathecal diamorphine (0.3 mg) prior to LSCS for post-operative analgesia. All women were supposed to be reviewed at 24 hours post LSCS to document pain scores and side effects.

It was thought that there may be inaccuracy recording side effects (nausea, vomiting and pruritus) and pain scores. Therefore, forty eight women were interviewed to see if they had any side effects and to assess their pain score. The other twenty seven patients just had their notes reviewed. Pain scores were documented on rest and movement using the trust’s pain score system (0-3).

Results

Of the women audited (n=75), 49.3% (n=37) had an elective LSCS and 50.7% (n=38) had an emergency LSCS. Post-operatively 64% (n=48) required additional oral opioids to control their pain. The length of time from intrathecal diamorphine administration until first post-operative opioid analgesia peaked between 10 and 14 hours, with 70.8% (n=34) receiving them >10 hours post-operatively.

Overall, pain and side effects were documented poorly. The variation between patient reported vomiting and pruritus, and that documented was statistically significant (p=0.045 and p=<0.001, respectively). At 12 and 24 hours there was a significant difference (p=0.016) between the patients with documented (n=3) and reported (n=19) pain (a pain score of 1, 2 or 3).

Treatment of side effects was poor. Post-operative antiemetics were only received in 10.7% (n=8) of the patient’s audited, despite 25.3% (n=19) having nausea and/or vomiting. Pruritus treatment was received in 2.7% (n=2), despite a prevalence of 34.7% (n=26).

Conclusion

The post-operative analgesic effects of intrathecal diamorphine appear effective for up to 10 hours. The side-effect profile seems acceptable and is tolerated reasonably well by most patients. However, women need monitoring at 10-14 hours post-operatively because pain often commences then.

Improvements in documentation of pain and side-effects need to be implemented. The poor recording will undoubtedly affect the patient’s post-operative care. For example, the patients’ reported pain scores remained as high at 24 hours as they were at 12 hours. Improvements in documentation would allow improvements in the patients’ post-operative well-being and care.

092

Interventions for facet joint pain: a UK survey

Category: Interventional Pain Management

Catherine Stack, Anup Bagade, Mohannad Daood, Kevin Fai, Jon Norman

Maidstone and Tunbridge Wells NHS Trust, Kent, UK

Background

The Royal College of Anaesthetists and the British Pain Society (BPS) first issued guidance on the use of epidural for pain of spinal origin 10 years ago. With increasing scrutiny on pain services we wondered whether the BPS should consider guidelines on other commonly performed procedures such as injections for spinal pain originating from the facet joint. Before recommending the writing of any guidelines it is important to appreciate whether there is significant variation in current practice.

Methods

We received the permission and support of the BPS for this survey. In March 2011 a questionnaire was either posted or emailed to all pain practitioners registered with the British Pain Society who are happy to receive such surveys. We contacted clinicians regardless of whether or not they were members of the interventional SIG in an attempt to gain as broad a view as possible. The questions asked about whether and how they performed injections for facet joint pain including the use of radiofrequency (RF). One reminder was sent to those after 2 months. A total of 165 survey forms were sent out.

Results

Survey Response Rate:	97/165=59%
Spinal Regions injected:
Lumbar:	97/97=100%
Thoracic:	74/97=76%
Cervical:	72/97=74%
Routine Bilateral Blocks
For bilateral pain 66% (64/95) routinely give bilateral blocks.
Part of Joint Blocked:
Peri-articular:	26/97=27%
Intra-articular:	22/97=23%
Median branch block:	15/97=15%
Combination of all 3:	34/97=35%
Progression to RF:
67/97 practitioners actually perform RF. If pain from facet joint blockade improved for >3 months 55% (37/67) would repeat the block, 33% (22/67) would progress to RF.
Regarding the practice of RF:
Technique:
Continuous RF only:	40/67=60%
Pulsed RF only:	3/67=4%
Either technique:	24/67=36%
Median Branch Blocks Prior to RF:
Mandatory	32/67=48%
Preferable	26/67=39%
Not necessary	9/67=13%
Routine Tests Prior to RF lesioning:
Motor:	58/67=87%
Sensory	62/67=93%
Risks Consented for with RF/PRF:
Treatment failure:	49/67=73%
Flare of symptoms	51/67=76%
Bleeding/bruising:	25/67=37%
Nerve injury:	39/67=58%
Numbness:	13/67=19%
Allergic reaction:	2/67=3%

Conclusion

There is a considerable variation in the practice of facet joint intervention amongst members of the BPS. The authors feel that a more consistent approach would improve consent and governance issues. Furthermore this will aid comparability between future audits and studies thus aiding the evidence base for intervention. Better evidence will increase the likelihood of the inclusion of these interventions in future national guidelines. To initiate this process the authors feel that a procedure guideline for facet intervention should be considered, ideally under the auspices of the BPS.

093

Can sympathetic block predict the success of neuromodulation for chronic abdominal visceral pain?

Category: Interventional Pain Management

Karthikeyan Dhandapani, Ganesan Baranidaran

Leeds Teaching Hospitals, Leeds, UK

Background

Electrical spinal cord stimulation (SCS) has been used in the management of chronic neuropathic pain. The effectiveness of SCS in abdominal pain has been demonstrated in case reports and case series. Leads for SCS have been placed both anteriorly and posteriorly in the epidural space for the management of visceral abdominal pain. We have trialled and inserted SCS successfully for the management of abdominal viscera pain since 2004. The aim of the project was to assess the ability of sympathetic blocks in predicting the success of SCS in abdominal visceral pain and also to assess the difference in the electrical current required for anteriorly and posteriorly placed leads for SCS for abdominal visceral pain.

Methods

Patients who had SCS implanted for the management of abdominal visceral pain from 2004 to 2011 were followed up. This did not require ethics committee approval as it was part of follow up after SCS insertion. A face to face interview was conducted at the follow up clinic to obtain the data by a clinician not involved in the actual insertion process.

Results

25 patients were followed up. Data was available from 17 patients. Eight patients had anteriorly placed electrodes and 9 patients had posteriorly placed electrodes. Data on the response to sympathetic block before the insertion of SCS were available for 7 patients. Patients who had good response to sympathetic block had reduction of VAS ≥ 5 with SCS. Those who had some or no benefit had reduction of VAS ≤ 3 with SCS for abdominal pain. In addition, we also found that lowest amplitude of current required for anterior (2.0 mA) electrodes were lower when compared to posterior electrodes (9.4 mA) for SCS

Conclusion

Based on the outcomes, the initial response to sympathetic blocks can predict the success of SCS in patients with chronic abdominal pain. Patients who had more than 50% pain relief from sympathetic blocks were more likely to benefit from SCS in the management of visceral abdominal pain. ¹ The current required for anteriorly placed electrodes were significantly less when compared to posterior leads. This suggests that the battery would last for longer needing less frequent replacement and thereby reducing the complications including infections associated with replacement.

094

Efficacy of Botulinum Toxin Type A in the treatment of chronic migraine headache in an NHS Pain Centre

Category: Interventional Pain Management

Karthikeyan Ponnusamy¹, Norman Kufakwaro¹, Thomas Smith^1,2, M.S Chong²

¹Guy’s and St.Thomas Hospital NHS Trust, London, UK, ²King’s College Hospital, London, UK

Background

Chronic migraine headache is defined by the International Headache Society (IHS) as the occurrence of headaches on 15 days or more per month for at least 3 months and the attacks fulfill criteria for migraine without aura on at least 8 days per month during the 3 months. The prevalence of chronic migraine is estimated to be 1.2 -2.2%

Following recent multicentre, double-blinded, placebo controlled clinical trials (PREEMPT trials), Botulinum Toxin A (Botox ®) has been licensed by the MHRA as a therapy for chronic migraine. NICE is performing a health technology appraisal for Botulinum toxin type A, with results expected by the end of the year. Our Pain Centre and allied neurologists have elected to offer Botulinum toxin A treatment to patients with refractory chronic migraine, and to audit results.

Methods

Patients included in the audit fulfil IHS criteria for chronic migraine. Their migraines have proven refractory to control with prescription analgesics, at least three prophylactic therapies (anticonvulsants, calcium channel blockers, beta-blockers, pizotifen) and triptans. The possibility of medication overuse headache has not been considered an exclusion criteria. Botoxin Type A is injected in Silbersteins pattern as per the PREEMPT trials. Total dose is 155 - 175 units of Botox with 5U at each injection point. Audit outcome measures of severity and frequency of headaches and quality of life are assessed by HIT-6 and MIDAS scores covering 3 months pre and post treatment. Medication use and adverse effects have been sought.

We also administer a phone questionnaire at 6 weeks post treatment to record patients global pain scores, medication usage and side-effects. The patients will be followed over 12 months during which most are expected to have 4 treatments.

Results

Preliminary results are presented in this abstract.

81%(13 of 16) of the patients reported 50% or more global pain relief after one to three treatments. 2 patients reported complete relief. All these patients with benefit decreased medication usage. The mean number of days per month with headache decreased from 18 to 11. When patients did have headache, the severity decreased from 7.4 to 6 on a 11 point scale. Some patients who did not have benefit after the first set reported benefit after repeat procedure. The HIT questionnaire assesses the impact of headache on quality of life. At baseline all patients had scores > 60 (severe impact). Post treatment 56% of patients had score < 60. Three patients had scores < 49(little or no impact). There have been no serious adverse events. The main side effects reported are tenderness over injection sites (n=4) and slight drooping of eyelids(n=3).

Conclusion

This is an ongoing audit. Results show a decrease in frequency and severity of the headaches consistent with the the published PREEMPT results. More than 50% of patients reported that the impact of migraine on their life has reduced from severe to manageable level. There have been no serious adverse events.

095

Gadolinium can be used for Trigeminal ganglion balloon compression in patients allergic to iodinated radiocontrast

Category: Interventional Pain Management

Vinod Sanem Ramulu, Peter Toomey, Peter Hall

York Teaching Hospital, York, UK

Background

Trigeminal balloon compression is a method used for treating patients with Trigeminal Neuralgia (ref 1). A 4 French gauge Fogarty catheter is passed through a 14 gauge needle inserted through the foramen ovale. The catheter balloon is inflated under fluoroscopic control, using non-ionic iodinated radiocontrast medium to compress the trigeminal ganglion. Radiocontrast dye is used to confirm the correct placement and filling of the catheter balloon. Anaphylactic reactions to non-ionic iodinated radiocontrast media occur in about 0.5% patients exposed to them. There is a lower incidence of anaphylaxis to radiocontrast containing Gadolinium (0.07%).

We report the use of Gadolinium as an alternative radiocontrast medium for Trigeminal balloon compression in a patient allergic to iodinated contrast.

Methods

Case description:

A 60-year-old lady with Trigeminal Neuralgia was assessed in the pain management clinic. Brain MRI was normal. Medical management was unsuccessful. It was therefore decided to perform Trigeminal ganglion balloon compression. The patient had had a documented episode of an anaphylactic reaction to iodine containing contrast medium Iopromide (Ultravist). After discussion with the radiologists it was decided to perform the procedure with a Gadolinium based radiocontrast medium gadobutrol (Gadavist). The Trigeminal ganglion balloon compression was performed successfully under general anaesthesia using Gadolinium radiocontrast. The procedure was performed under fluoroscopy with satisfactory images of the inflated balloon obtained (fig 1).

Results

Discussion:

Gadolinium is a radiocontrast used to enhance MRI studies because of the magnetic properties that it exhibits in the MRI field. It has been used as an alternative to iodinated radiocontrast in performing myelograms and nerve root injections (ref 2). There are no previous reports of Gadolinium being used in Trigeminal ganglion balloon compression.

Compared to iodinated contrast, Gadolinium is less opaque under fluoroscopy hence it can be difficult to visualise when there is interference from adjacent structures. In this case, when we compared the fluoroscopy pictures using Gadolinium with other trigeminal balloon compressions done with iodinated contrast (fig. 2), Gadolinium was less opaque but still we were able to clearly visualise the catheter balloon during compression without any problems.

Conclusion

Gadolinium is a safe alternative to iodinated contrast in performing Trigeminal ganglion balloon compression in patients allergic to iodinated contrast. The chance of contrast coming into contact with the patient is negligible while doing trigeminal balloon compression. But there is always a risk of balloon rupture during the procedure, hence it is safer to avoid iodinated contrast in patients who are allergic to iodinated contrast. As far as we are aware this is the first reported case where Gadolinium has been used for Trigeminal ganglion balloon compression.

096

Patient satisfaction audit for repeat chronic spinal pain interventions in a tertiary pain centre

Category: Interventional Pain Management

Ganesan Baranidharan^1,2, Nor Abu Baker^1,2, Rachael Almond^1,2, Samia Aqeel^1,2, Navdeep Singh Sekhon^1,2

¹University of Leeds, Leeds, UK, ²Sea Croft Hospital, Leeds, UK

Background

Chronic back pain is a debilitating condition and a prevalent problem in the UK. It is difficult to treat; as patient responses to treatment can lie between complete relief of pain, partial relief, no relief, to exacerbating present pain. This audit looked at repeat interventions ranging from steroid facet joint injections, epidurals in lumbar/caudal regions and radiofrequency. These interventions are costly, painful and may not be beneficial to all patients. It is essential to monitor patient satisfaction with the intervention they are receiving, and to investigate their reasons for returning for repeat intervention. In current literature there is no questionnaire which measures patient satisfaction for repeat interventions in chronic back pain. This service evaluation audit aimed to measure changes in different aspects in quality of life and find the most influential reason for patients return.

Methods

A questionnaire was designed adapted from widely used validated questionnaires for chronic back pain; Ostwestry Low Back Pain Questionnaire, Copenhagen Neck Disability Scale, and RAND 36-item Short Form Health Survey. The questionnaire comprised of 36 questions from the validated questionnaires and 3 additional questions to assess reasons for returning for repeat interventions. The questions focused on measuring improvement in pain, mobility, work ability, daily living and social activities, sleep and mood. The self-designed questionnaire needs to be validated for future use.

71 patients from Seacroft Hospital Pain Clinic receiving at least 2 repeat interventions (steroid facet joint injections, epidural injections into the lumbar or caudal region and radiofrequency) within 6 months in 2009-2010 were found and included in the study.

Data was collected through a standardised telephone interview. Data was analysed using Microsoft excel and statistical tools to assess the significance of this study.

Results

54 patients responded to the telephone interview. Pain relief was found to be the most influential factor for 43 respondents to return for repeated intervention.

From the questionnaire, patients’ total scores were calculated. The minimum score obtainable is -36 and the maximum score is 72. The mean score is 22.22. Scores ranged from -32 to 65. These scores did not correlate with patients’ likelihood to repeat the intervention.

85% of patients had overall improvement. 88% found some degree of improvement in pain, 83% found some improvement in their mobility, 78% found some improvement in mood, 70% found some improvement in daily living and activities, 63% found some improvement in sleep and 51% found some improvement in work ability.

The original questionnaire was abbreviated using questions deemed most significant for each factor measuring quality of life. A similar frequency distribution was obtained from the abbreviated questionnaire compared to the original questionnaire.

Conclusion

Pain relief was the most important factor in returning for repeat intervention. No significant correlation was found between overall improvement and likelihood to return for repeat interventions, suggesting that patients who do not respond to the intervention will still continue to have the treatment.

The abbreviated questionnaire shows a similar frequency distribution to the original, but is of an appropriate length to be used effectively in clinics. We recommend further studies to validate our findings.

Methodology

097

Can a crowd sourcing app for those with chronic conditions lead to innovative design solutions?

Category: Methodology

Lisa Austin, Sarah Rook, Christopher Eccleston

The University of Bath Centre for Pain Research, Bath, UK

Background

Given the rise of long term conditions[1] including chronic pain, and focus on living independently in the community, we launched a crowd sourcing community app called ‘ifOnly’ to encourage people with disabilities to share the problems they encounter everyday. People record, upload, and share video and audio that demonstrates problems they are facing in the home.

Videos will be shared with designers who are asked to come up with innovative design solutions via a competition hosted by the Bath Centre for Pain. The designs will be considered by a panel of stakeholders; with representatives from the NHS, social care, creative industry, the third sector and members of the public. The goal is to bring together emerging designers and users, and offer a challenge to design students and innovators everywhere to make things better.

[1] Christensen, K., G. Doblhammer, et al. (2009). “Ageing populations: the challenges ahead.” Lancet 374(9696): 1196-1208.

Methods

After consultation with users, version 1 of ‘ifOnly’ was produced and tested by a patient panel consisting of 10 carers of those with chronic conditions; all new to smart phone technology. The consensus was that the video function was easy to use but the upload time was unsatisfactory and connectivity problematic, when relying on 3G rather than Wi-Fi. The high costs of iPhones were also highlighted by the panel. Accordingly version 2 was developed, overcoming the technical and usability problems and released in apple and android stores. In response to feedback that smart phones were not accessible to all, a BCPR Research Assistant co-ordinates events to meet local people, and conducts home visits with University phones, to make filming open to all.

Results

Community of interests are being developed with users and films are currently being supplied by the public and uploaded onto the app. A webpage is also being developed with a twitter account to connect with the new and emerging innovators and designers with an interest in improving everyday things.

Conclusion

The app aims to inspire innovative design solutions from the information it gathers. We will present the findings and an award at an inclusive design competition winner’s event in May 2013.

098

Concordance between study aims, therapy, measures and results within randomised controlled studies of chronic pain in children

Category: Methodology

Emma Fisher, Christopher Eccleston

The University of Bath Centre for Pain Research, Bath, UK

Background

There is often a publication bias when reporting the effects of psychological interventions in psychology journals. Journals are biased towards publishing significant results and shy away from reporting non-significant results. This sways authors to report only significant results despite measuring other outcomes. This bias can also make the authors change, omit or introduce a new primary outcome between design and publication (Chan et al, 2004) in order to get work published and recognised. This can lead to a ‘file drawer problem’ where non-significant results sit in file drawers having not been reported. Other issues surrounding such trials can mean that the aims do not match treatment content or the outcome measures of a study. This poses a dilemma for systematic or meta-analytic reviewers. The purpose of this poster was to investigate whether studies included in a systematic review had concordance between aim, therapy content, primary outcome measures and reported results.

Methods

Data was extracted from 34 studies that met the inclusion criteria for a Cochrane Review on psychological therapies for parents of children with a chronic illness. The stated primary aim or first hypothesis, content of treatment, primary measurement/s and reported results were extracted from each study. Judgement was then used to determine whether there was concordance between the stated primary aim and treatment content, primary aim and outcome measures, and finally the outcome measures and reported results for each study. The rating system was as follows; 2=full concordance, 1=partial concordance, 0=no concordance.

Results

Two studies were excluded as they were published in a foreign language. As demonstrated by table 1 below, a large proportion of the remaining 32 studies had full concordance between aims and treatment content, aims and measures and measures and reported results. However, half (n=16) of the studies did not have full concordance between the three variables.

Table 1.

Concordance between aspects of Studies from a Cochrane Review

Concordance between. . .
Primary Aims and Treatment Content
Primary Aims and Primary Outcome Measures
Primary Outcome Measures and Reported Results
2 (Full Concordance
20
26
26
1 (Partial Concordance)
8
4
4
0
(No Concordance)
4
2
2

Conclusion

Sixteen studies did not have full concordance between aims, treatment, primary measures and reported results showing reporting bias. A degree of caution must also be used when interpreting the results from the studies that scored full marks on concordance as they may also only report selective outcomes and therefore be biased too. Authors of trials in psychology are given a degree of trust to present unbiased findings. Although fabrication is rare, more transparency is needed and there should be more weight given to ‘what does not work for whom?’ rather than full emphasis on ‘what does work for whom?’

099

How do we know which qualitative research study is good enough to contribute to a meta-ethnography (evidence-synthesis) of chronic musculoskeletal pain?

Category: Methodology

Francine Toye¹, Kate Seers², Nick Allcock³, Michelle Briggs⁴, Eloise Carr⁵, JoyAnn Andrews¹, Karen Barker¹

¹Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford Universities NHS Trust, Oxford, UK, ²School of Health and Social Studies, The University of Warwick, Coventry, UK, ³Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK, ⁴School of Health Care, University of Leeds, Leeds, UK, ⁵Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada

Background

Qualitative research helps us to make sense of the complex processes involved in health care decisions and can contribute to substantial improvements in health care. There is a large body of qualitative research exploring patients’ experience of chronic non-malignant musculoskeletal pain, but no attempt to systematically search, appraise and integrate the findings of this research. It can be difficult to judge the quality of qualitative research, and there is no consensus on how to do this, or indeed if quality assessment is important in qualitative reviews. Although there are a growing number of checklists, some argue that these should not be used to judge the quality of qualitative research. This report presents findings from quality appraisal of research for inclusion into a meta-ethnography exploring patient’s perceptions of chronic musculoskeletal pain.

Methods

We used 3 methods to assist appraisal; (a) categorisation as: ‘key paper’ (KP), satisfactory paper (SAT), irrelevant (IRR) or fatally flawed (FF); (b) the Joanna Briggs Institute Qualitative Assessment and Review Instrument (QARI); (c) Critical Appraisal Skills Programme (CASP) checklist. Although CASP was not designed as a numerical score, we wanted to explore its capacity to assist quality appraisal. We scored each of the 10 CASP questions to indicate whether it had (1) not been addressed, (2) been addressed partially or (3) been extensively addressed (score range 10-30). JA and FT appraised all papers. If they did not agree on inclusion, the paper was appraised by 2 other team members for a final decision.

Results

From the 329 qualitative papers identified to date, 255 were rejected as they did not meet the scope (e.g. - time line not explicit, mixed sample, not patient views, not musculoskeletal, not relevant to synthesis). Following quality appraisal, JA and FT agreed 48 studies for inclusion. Papers meeting the scope that they did not agree on (n=26) were appraised by the team and a further 15 included. This gave a total of 63 studies (25 back pain, 24 fibromyalgia, 14 other musculoskeletal pain). The range of CASP scores for these 63 papers was 14-28 (FT) and 17-27 (JA). Differences in CASP scores ranged from -5 to 10. JA and FT agreed on four key papers, but identified a further 10 papers where only one person rated it as a key paper.

Conclusion

This supports the suggestion that checklists do not produce consistent judgements. However, the appraisal tools were a useful focus for discussion. Although CASP was not designed as a numerical score we tended to agree that studies with a CASP score over 20 were ‘good enough’ in terms of method. However, as method is only one mark of quality, we are investigating whether higher scoring papers will make a more meaningful conceptual contribution to the meta-ethnography. Our findings suggest there are challenges in assessing the quality of qualitative research in pain management, and a checklist approach to quality appraisal has limitations.

HS&DR Funding Acknowledgement:

This project was funded by the NIHR Health Services and Delivery Research programme (project number 09/2000/09).

Department of Health Disclaimer:

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR HS&DR programme, NIHR, NHS or the Department of Health.

Neuropathic Pain

0100

Efficacy of the Versatis® lignocaine patch in patients with non-postherpetic neuropathic pain

Category: Neuropathic Pain

Kay Davies, Saravanakumar Kanakarajan

NHS Grampian, Aberdeen, UK

Background

The use of the 5% lignocaine medicated patch, Versatis®, is restricted to treatment of postherpetic neuralgia in NHS Scotland. Potentially patients with other causes of neuropathic pain may benefit from Versatis®. We aimed to review the efficacy of Versatis® in patients, with non-postherpetic neuropathic pain, attending the chronic pain service at our institution.

Methods

From February to September 2010, patients with symptoms of neuropathic pain, amenable to topical therapy, were treated with Versatis®. At their baseline visit, each patient completed a Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire and a Brief Pain Inventory (BPI). Only scores examining the effect of pain on activities of daily living (general activity, mood, walking ability, normal work, relations with others, sleep and enjoyment of life) were recorded. At 4 month follow-up, patients repeated the BPI. Patient Global Impression of Change (PGIC) and percentage pain relief were also recorded.

Results

Results of 10 patients of mean(± SD) age 64.7(±11.6) years were analysed. Median(range) S-LANSS score was 14(2-18). At 4 months follow-up, the most frequent PGIC chosen was “no change”. Median(range) percentage pain relief obtained was 10(0-80)%. Although the median(range) total BPI scores examining the effect of pain on activities of daily living fell from 48(37-63) at baseline to 41(10-54) at 4 months this was not statistically significant (p=0.13). Three patients did benefit from their patch with median(range) total BPI scores reduced from 50(46-50) to 33(12-54), pain relief of 60%,70% and 80% respectively and PGIC choice of “much improved” or “very much improved”. Two of these patients had ongoing use of the patch at 4 months. The other patient discontinued the patch after 6 weeks because it had desensitised the neuropathic pain in her foot so much, that weightbearing was now possible. Two patients developed erythema, pruritis and vesicles from the patch.

Conclusion

The use of Versatis® in our group of patients with non-postherpetic neuropathic pain showed no statistical benefit in analgesia or the effect of pain on activities of daily living. Versatis® could be trialled for patients with neuropathic pain that is non-postherpetic in origin and a 30% success rate expected.

101

Effect of motor cortex rTMS on neuropathic pain after spinal cord injury

Category: Neuropathic Pain

Fanny Jetté^2,1, Hadj B. Meziane^2,1, Isabelle Côté^3,1, Catherine Mercier^2,1

¹Université Laval, Québec, Québec, Canada, ²CIRRIS, Québec, Québec, Canada, ³IRDPQ, Québec, Québec, Canada

Background

Chronic pain is a significant problem after spinal cord injury (SCI), affecting more than 80% of patients. Pain is associated to less engagement in physical activity and a lower level of community reintegration. Several types of pain occur in these patients (musculoskeletal, visceral or neuropathic) but neuropathic pain is recognized as the most resistant to treatment.

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive method that induces changes in cortical excitability. Studies have shown that rTMS applied over the motor cortex (M1) can alleviate neuropathic pain from diverse origins (post-stroke pain, amputation, SCI, brachial avulsion, etc).

The aim of the study was to evaluate the immediate and long-term analgesics effects of a single rTMS session applied over the lower limb vs. upper limb motor region (compared to sham stimulation). The secondary aim was to document the neurophysiological changes underlying the analgesic effect of rTMS.

Methods

We recruited 16 SCI participants with chronic neuropathic pain (mean age, 50±9y). They had either paraplegia (n=12) or tetraplegia (n=4), with complete (n=8) or incomplete (n=8) motor loss. A quasi-experimental cross-over design was used, each participant being exposed to two active (hand / foot M1 area) and one sham rTMS conditions in a randomized counterbalanced order. Each condition was separated of the previous one by at least 2 weeks. The rTMS intervention duration was 20 minutes (40 5-seconds trains at 10Hz, 25 seconds inter-train intervals). A sham coil (mimicking the noise and scalp sensations) was used for sham rTMS condition.

The outcomes measures were pain intensity (immediate and long-term), heat pain detection threshold above the lesion, amplitude of motor evoked potentials and center of gravity (CoG) shift of the FDI cortical representation. Moreover, the impact of different clinical characteristics (type and location of lesion, duration, etc.) has been explored.

Results

A decrease in average pain was observed in the first 48h post-intervention for both active conditions (median change of -13% for hand area [from -51 to +24%], and of -15% [from -38% to +25%] for foot area) compared to placebo (median of +1% [range = -40 to +114%]). There was no difference between the three conditions after that 48h period. Sub-group analyses showed that, for both active conditions, patients with incomplete lesion had a better analgesic effect than patients with complete lesion. No difference was found between conditions for heat pain detection threshold. TMS motor map measurements revealed an increase in corticospinal excitability after stimulation of hand area, but not for the other two conditions. Only small nonsignificant CoG shifts in mediolateral axis were observed in response to rTMS, but interestingly they tended to be in opposite directions between the 2 actives conditions.

Conclusion

Active rTMS applied over the motor cortex decreased neuropathic pain regardless of the motor region stimulated (hand / foot area) and of the changes in cortical excitability, suggesting that the analgesic effect is not associated with local changes at the level of the motor cortex itself. Pain reduction then probably rely on distant effects such as top-down activation of brainstem periaqueductal grey matter driving descending inhibition or triggering of mechanisms resulting in the secretion of endogenous opioids. Future researches are needed to better understand the role of those mechanisms in the analgesic effect of rTMS on neuropathic pain.

102

External neuromodulation for refractory orbital pain secondary to optic neuritis

Category: Neuropathic Pain

David Pang, Joseph Azzopardi, Ash Shetty

Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK

Background

Optic neuritis manifests as visual loss, dyschromatopsia and pain in and around the affected eye. The pain is usually mild but occasionally it is severe and debilitating. Initial treatment is with high dose pulsed corticosteroids but little is documented about specific analgesic treatment modalities. We present a case of refractory pain from optic neuritis that has successfully been treated with external Neuromodulation. This is a non-invasive treatment using transcutaneous electrical stimulation with a nerve mapping device. Unlike Transcutaneous Electrical Nerve Stimulation the stimulation from EN is deeper and more localised. Thus, it is better suited to stimulate individual nerves or their plexuses and has been successful in treating pain that has not responded to TENS. This has successfully been used for treating many neuropathic pain syndromes but we describe its first use in managing pain secondary to optic neuritis.

Methods

The patient is a 22 year old female with bilateral optic neuritis on a background of childhood acute demyelinating encephalitis. Despite treatment with pulsed methylprednisolone her pain remains difficult to manage and severe. She rates the pain as 9 out of 10 bilaterally on the Numerical rating Scale and there has been poor response to both simple analgesics and anti-neuropathic pain medications. We performed external Neuromodulation using a Pajunk nerve mapping probe transcutaneously at the supra-orbital and infra-orbital nerves bilaterally. These nerves were stimulated at 2Hz with a pulse width of 1ms and amplitude adjusted until comfortable stimulation was felt, this was usually 8 milliamps. The duration of stimulation was 5 minutes each nerve and a total of 20 minutes of stimulation was performed at 2 weekly intervals.

Results

Location of the supra-orbital and infra-orbital nerves was easily performed and stimulation was comfortable throughout. The pre-treatment NRS score was 9 out of 10 bilaterally and after stimulation complete pain relief was noted with a pain NRS 0 out of 10. The duration of action was 4 days and the pain returned to its baseline. No adverse effects were reported by the patient and the stimulation did not result in any changes in visual acuity or diplopia. Treatments was repeated on a two weekly basis and she is able to self-administer external Neuromodulation. The reduction in pain scores was similar in each subsequent tow weekly interval. We intend to provide her with a machine to take home so that she can continue its use without attending hospital.

Conclusion

This is to our knowledge, the first use of external Neuromodulation to treat the ocular pain from optic neuritis. It is a safe, non-invasive and simple therapy that can be self-administered by the patient once a suitable device has been provided. It can be used in addition to high dose steroid therapy. As few specific analgesic therapies exist for optic neuritis are available this is a promising treatment modality for a difficult clinical problem. Future possible uses are in other causes of optic neuritis such as multple sclerosis.

103

An audit of 5% lidocaine patch use in chronic pain patients with allodynia

Category: Neuropathic Pain

Joanne Rugen, Robert Searle, Anna Weiss

Royal Cornwall Hospitals Trust, Cornwall, UK

Background

There are many reports but few studies of off-license 5% lidocaine patch use. The patch may be considered third line treatment for localised neuropathic pain in people where other available treatments have been used, or are unable to take oral medication because of medical conditions and/or disability (NICE)¹.

We aimed to investigate the outcomes of patients prescribed 5% lidocaine patches to treat severe allodynia from all causes (including off license use ) within the chronic pain clinic at the Royal Cornwall Hospital.

Methods

Baseline data were collected for all patients prescribed a 5% lidocaine patch from 2009 to 2011. Data incuded pain syndromes treated, the body area affected, the presence of allodynia, pain scores, activity levels and previous analgesic medications. Patients completed a telephone questionnare 3 months later. Data collected at follow up included number of plasters being used daily (if still using patch) or reasons for discontinuing patch, perceived relief obtained, follow up pain scores, impact of pain on sleep and activity and if they were able to reduce their other analgesics.

Results

73 patients were included in the audit. 71 completed the 3 month telephone questionnaire. The most frequent cause of pain was persistent postsurgical (n=14), posttraumatic (13), Scar Pain (11), Arthritis (6), CRPS (5), Other (16), Unknown (8).

Pain Scores improved by 3 points of the VAS in 10 patients (14%).

15 patients were not taking any pain medications at time of starting the patch. 15 (38%) patients out of the remaining 58 patients reduced their intake of other pain medications.

12 (16%) patients improved their activity level by 3 points of the VAS. 23 reported 0-20% pain relief, 23 reported 21-60% pain relief, 24 reported 61-100% pain relief, 3 unknown

Therapy was ceased in 30 patients (41%). This was predominantly due to the patches not helping or symptoms improving sufficiently to stop.

Conclusion

Many patients for whom lidocaine patches were prescribed appeared to derive clear benefit although in differing areas. Some patients reduced their oral analgesic intake, some had a significant reduction in their pain scores, some improved their activity levels and some noticed an improvement in sleep quality. This ‘real world’ use of patches compares well to studies in post herpetic neuralgia patients with allodynia supporting the use of the lidocaine patch in selected patients ^{2, 3, 4}

104

PainDetect®: is it suitable for screening of neuropathic components amongst patients with inferior-alveolar, and lingual nerve injuries?

Category: Neuropathic Pain

Zehra Yilmaz¹, Leigh-Ann Morgan¹, Jared Smith², Ruben Van Der Valk¹, Miriam Bouchiba¹, Tara Renton¹

¹King’s College London Dental Institute, London, UK, ²St. George’s, University of London, London, UK

Background

Chronic pain (pain of more than 6 months’ duration) can be a lasting problem for patients unlucky enough to have iatrogenic inferior-alveolar nerve injury (IANI), or lingual nerve injury (LNI). A large proportion of these patients’ pain has a neuropathic component, as indicated by their symptoms of burning pain, allodynia, tingling and paraesthesia that are uncontrollable by non-steroidal anti-inflammatory drugs. ^[1] The PainDetect® questionnaire (PD-Q) screening tool was developed with the aim to simplify the diagnosis of neuropathic pain (NeP) for clinicians namely because it does not require a clinical examination.^[2] It was originally developed and validated in German in a multicentre study of NeP patients, which specifically targeted back pain.^[3] The aims of this study were to ascertain whether the PD-Q would be a suitable screening tool for detecting NeP in patients with post traumatic trigeminal neuropathy, such as IANI or LNI.

Methods

Patients were recruited from the King’s College Hospital Oral Surgery Department, Tertiary care nerve injury clinics. A prospective cohort of patients with clinically diagnosed chronic orofacial NeP, were given the PD-Q at their clinic appointment or sent to them after their consultation. The PD-Q contained a section on the visual analogue scale (VAS) scoring system for the level of pain experienced. There were two diagrams of the body, which allowed the patient to indicate where they were experiencing the pain. They also indicated whether their pain radiated or not, and the overall course of their pain. The remaining 7 questions addressed the quality and intensity of the pain. A score of above or equal to 19/35 indicated NeP, and below/equal to 12/35 indicated no NeP. Results were analyzed using one-way analysis of variance (ANOVA), with Chi-square tests used to evaluate possible associations

between non-parametric variables.

Results

Ninety-one completed questionnaires (IANI n=58, LNI n=33) were returned to the research team and scored. Our results indicated that the PD-Q identified 21% (n=19) of patients as having NeP and 15% (n=14) of patients scored below the neuropathic cut off, suggesting that they were experiencing few or no symptoms of NeP. Importantly, in 27% of patients (n=25) the results of the questionnaire were inconclusive in confirming NeP. This may have been due to the patients not actually experiencing intense pain at the time of completing the questionnaire, as indicated by the mean Visual analogue scale (VAS) scores of 3.14 for the patients with IANI and 3.31 for those with LNI. Likewise, the mean strongest pain level reported within the previous 4 weeks was 4.73 for IANI patients and 5.22 for LNI patients, with average pain levels during this period approximately 3 for both groups of patients.

Conclusion

Although the PD-Q is highly sensitive for those with back-pain, the questionnaire will need to be modified to identify NeP amongst patients with LNI and IANI. Such modifications include changing the diagrams of the whole body to just include the facial and oral regions, as well as the slight alterations to some of the questions. This modified PD-Q should then be assessed amongst future patients attending the specialist nerve injury clinics.

105

Gabapentin for post-surgical neuropathic pain in immediate breast reconstruction: a retrospective analysis of forty patients

Category: Neuropathic Pain

Noemi Kelemen, Kamal Singh, Graham J. Offer, Sanjay K. Varma, Roger Eastley, Jonathan Tring

Leicester Royal Infirmary, Leicester, UK

Background

Post-surgical neuropathic pain (PSNP) is experienced in 25-60% of breast cancer patients. The aim of this retrospective analysis was to investigate whether Gabapentin relieves the PSNP in immediate breast reconstruction patients.

Methods

We have analyzed forty Neuropathic Pain Scale Questionnaires (National Initiative on Pain Control^TM) of female breast cancer patients (mean age 56 years) who underwent immediate breast reconstruction between 2001 and 2010.

Results

Key results with supporting statistical analysis:

Neuropathic Pain Scale

Control group (N=20)

(Mean)

Gabapentin (N=20) (Mean)

Pain intensity (1-10)

6.20

5.65

Pain sharpness (1-10)

5.35

4.35

Heat sensation (1-10)

3.90

3.85

Dullness (1-10)

2.05

3.05

Cold sensation (1-10)

1.10

0.20

Skin sensitivity (1-10)

5.45

3.70

Itchiness (1-10)

4.30

2.30

Pain unpleasant (1-10)

6.30

4.90

Deep pain (1-10)

4.50

5.80

Surface pain (1-10)

3.60

3.35

Total score (1-100)

44.1

37.1

95% of patients experienced PSNP. Statistical analysis showed (unpaired t-test/Mann-Whitney test-p-values-0.054-0.96) no significant difference between the two groups in PSNP. However the overall pain scores for the Gabapentin group were lower.

Conclusion

Our limited data suggests that the majority of immediate breast reconstruction patients do experience post-surgical neuropathic pain, but administration of postoperative Gabapentin does not significantly decrease neuropathic pain scores.

106

A study of the prevalence and severity of symptoms of patients diagnosed with burning mouth syndrome in a specialist multi-disciplinary oro-facial pain clinic

Category: Neuropathic Pain

Danyal Awal, Tim Poate

King’s College, London, UK

Background

Burning mouth syndrome (BMS) is an idiopathic burning discomfort or pain affecting people with clinically normal oral mucosa, in whom a medical or dental cause has been excluded. BMS may affect up to one third of post menopausal women and up to 15% of all adults. Possible causes involve hormonal disturbances, psychogenic factors and neuropathic mechanisms. Symptoms associated with BMS include a burning sensation in the mouth, subjective xerostomia and altered taste. BMS has a negative impact on the health-related quality of life of individuals. Management of BMS is extremely challenging. A retrospective study of 53 people with BMS (mean follow up 56 months) reported 28% people experienced a moderate improvement with or without treatment.

Methods

This was a retrospective study of the clinical notes of fifty consecutive patients diagnosed with BMS on a multi-disciplinary oro-facial pain clinic at a London teaching hospital between January 2008 and December 2011. Patients’ severity of pain was recorded using a brief pain inventory.

Results

This study has shown that in this group of fifty patients diagnosed with BMS the site most frequently reported to be affected by burning was the tongue (77%). A further 77% of patients reported burning at intra-oral sites other than the tongue with the palate (42%) being the most common. The mean score for the best description for the pain in the past week was 7/10 (range 3-10) for pain at its worst, 4.6 (range 0 - 10) for pain at its least and 6.4/10 (range 3-10) for pain on average. Some abnormality of saliva flow was reported in 42% of patients (hyposalivation 28%, hypersalivation 14%). Some abnormality in taste was reported in 42%, this being described as metallic in 21%, bitter in 14% and just as abnormal in 14%.

Conclusion

This study demonstrates the tongue to be the most frequently affected site of burning in patients with BMS, in agreement with previous studies. It also demonstrates that other intra-oral sites are frequently affected by burning sensations in patients with BMS. Also demonstrated is the high severity of the pain documented by these patients and the frequency of other symptoms such as abnormalities in saliva flow and taste disturbance. This study demonstrates the need for improvements in the management of this condition.

107

Presentation of outcome data for all patients treated to date with a Qutenza™ transdermal patch at University Hospitals of South Manchester NHS Foundation Trust (UHSM)

Category: Neuropathic Pain

Joanne Hutt¹, Dympna Sherry¹, Ben Probyn^2,1, Sue Barnes¹, Ilan Lieberman¹

¹University Hospitals of South Manchester NHS Trust, Manchester, UK, ²Manchester Medical School, Manchester, UK

Background

Qutenza™ is an 8% formulation of capsaicin, applied as a patch for transdermal application, to treat local peripheral neuropathic pain (PHN, HIV neuropathy and other peripheral neuropathic pains). The active ingredient of Qutenza™ is capsaicin, a TRPV1 channel agonist. A single application of Qutenza™ should provide relief for around 3 months. Qutenza™ was licensed in the UK in May 2009. UHSM was one the of the first units in the UK to use Qutenza™ patches to treat local peripheral neuropathic pain and began using the patches in the Summer of 2010. We feel that as an early adopter of the patches it is incumbent on us to publish our experience to date with their use.

Methods

The initial use of Qutenza™ was first approved through discussion with the hospital pharmacy as well as the drug & therapeutics committee. All patients treated with the Qutenza™ were referred after thorough assessment through our multidisciplinary secondary care based pain management service. All patients referred for patch application had been treated according to the units local neuropathic algorythm, which is based on using the best evidenced and least invasive treatments first and introduces more complex medications and less evidence based (riskier) treatments later, dependant on risk benefit. Thus all patients referred for treatment had already been tried with lidoderm plasters, capsaicin creams, oral neuropathic medications and opioid medication.

Results

We intend to submit data from all patients treated up to two weeks prior to the meeting. At the time of abstract submission we have treated 28 patients with Qutenza™. Most of these patients have had multiple applications. 40% of all patients initially treated with Qutenza™ have continued to respond to treatment. Of the responders 60% have experienced greater than 40% pain relief. The poster will include detailed data on the subgroups of responders and the variety of neuropathic pain types treated. The poster also describes the adverse events that this group have experienced (75%) and how we have managed these events.

Conclusion

UHSM was an early adopter. We have been involved in the education and training of clinical staff on a national basis, in the use of Qutenza™. As an early adopter of a novel treatment we feel that it is important to discuss our experience of the product to date. We have used the patch in a difficult patient group as a 3rd/4th line treatment. In this context we feel that the results we have observed have been better than we expected. We feel that Qutenza™ has an ongoing if limited role in the management of refractory peripheral neuropathic pain.

108

Nociceptive and neuropathic features of pain before and after inguinal hernia repair

Category: Neuropathic Pain

Catherine Warnaby, Stacey Davie, Karl Ward, Nicola Brooks, Irene Tracey, Jane Quinlan

Pain Imaging Neuroscience Group, Nuffield Department Clinical Neurosciences, University of Oxford, Oxford, UK

Background

Chronic post-surgical pain (CPSP), persisting for more than 3 months, is well recognized after all types of surgery. In particular, previous studies have found the incidence of CPSP after inguinal hernia repair to range between 11-45%. The Oxford Persisting Post-Operative Pain Study (OxPPOPS) is a prospective, longitudinal study to investigate the incidence of CPSP up to one year after surgery and identify predictive factors for its development. Among the factors under investigation are pre-operative psychology, surgical and anaesthetic techniques, acute post-operative pain, analgesic management and sleep. As part of the protocol we used the painDETECT questionnaire (PD-Q), a neuropathic pain screening tool, to characterize the hernia-related pain both pre- and post-operatively. Using the PD-Q, it is possible to identify sensory abnormalities and discriminate neuropathic and nociceptive elements of the reported pain. Categorization of the pain is important for understanding the mechanisms involved in the development of CPSP.

Methods

The PD-Q total score is generated from the reported severity of 7 neuropathic pain symptoms (i.e. burning sensations, dysthesia, allodynia, numbness, paroxysmal pain, thermal and pressure sensitivity) as well as the time-course and any radiations of the pain. Total PD-Q scores of >18 indicate a neuropathic pain component is >90% likely but for scores less than 13 it is unlikely (<15%). Scores from 13-18 form an ambiguous region where a neuropathic component is possible. The PD-Q additionally has three numerical ratings to assess pain severity now, on average and at its strongest in the past 4 weeks.

22 patients (20M:2F, aged 23-69 years) from OxPPOPS completed the PD-Q before inguinal hernia repair and at 4 months after surgery. Pain ratings, total PD-Q scores and the reported severity of the neuropathic pain symptoms were compared for significant differences pre- and post-operatively using non-parametric Wilcoxon signed rank tests.

Results

Pre-operatively, all patients reported hernia-related pain in the previous 4 weeks: median (inter-quartile range) for strongest pain = 5.5(6) and average pain = 3(2). The pain time-course was most frequently characterized (68%) as “pain attacks without pain between them” and accompanied by sensitivity to pressure (73%) and burning sensations (45%) in the affected area. Total PD-Q scores ranged from 0-26 with 6 patients scoring >12.

Post-operatively, pain was significantly reduced with median (IQR) for strongest pain = 2(3) and average pain = 0.5(2) (both paired-t: p<0.001). Of the 14 patients experiencing pain, 11 reported the same time-course as pre-operatively. Numbness was the most frequently reported post-operative sensation (59%) and significantly increased following surgery (p=0.016). The reported severity of all other neuropathic pain descriptors was not significantly different after surgery. Post-operative PD-Q total scores were all <12. No significant difference was found between the PD-Q total scores pre- and post-operatively.

Conclusion

In this pilot study, all patients presented with some degree of pre-operative pain reflecting the current criteria for surgery. Use of the PD-Q identified potential neuropathic pain in 4/22 patients, with one individual showing distinct neuropathic symptoms. The numerical ratings demonstrated that surgery provided amelioration of pain in most individuals. However 64% of patients had CPSP at four months, with PD-Q scores indicative of nociceptive rather than neuropathic pain. One individual had increased pain scores after surgery and may be vulnerable to long-term CPSP. This study highlights that CPSP is not always of neuropathic origin resulting from intra-operative nerve damage.

109

Safe prescribing of ketamine in chronic pain patients

Category: Neuropathic Pain

Sabita Sreevalsan, Michael Sidery, Mark Sanders

Norfolk and Norwich University Hospital, Norwich, UK

Background

Ketamine has known analgesic, anti-nociceptive and anti-hyperalgesic effects, based primarily on its NMDA receptor antagonism. Ketamine, especially given orally, gives higher serum levels of norketamine and is effective in neuropathic pain of various origins i.e. CRPS, phantom limb pain, post-herpetic neuralgia, cancer pain and oro-facial pain. However problems include possible long term side effects and potential for abuse. Ketamine remains a “niche” medication which most primary care physicians have little experience of; hence primary care is an inappropriate place for its use.We have used oral ketamine within the context of a large university hospital pain management unit for several years, with prescriptions being managed by the hospital pharmacy. We have maintained a database of these patients, clinical indications, dosage, review arrangements and our local prescribing practice.

An analysis of our database and the results of a telephonic patient survey of the results of our experience with ketamine are presented.

Methods

Our database records names and demographics of patients regularly taking ketamine, indications, other medications, dosage of ketamine, change in dosages, dates medication was dispensed, time and place of collection and any new treatment instituted. A questionnaire based survey was conducted telephonically by a chronic pain clinician over a 2 week period from 03/01/12 to17/01/12. Patient responses regarding indications for which they were prescribed ketamine, their dose range, duration of medication, impact on pain, side-effects if any, effect on sleep and whether they had any problems procuring ketamine, were collected and analysed.

Results

The database contains 46 patients. All had trialled ketamine for neuropathic pain unresponsive to standard anti-neuropathic agents. Indications included CRPS, chronic pancreatitis, trigeminal neuralgia and phantom limb pain. 2 patients could not be contacted. Of those surveyed, 3 patients stopped taking ketamine due to inefficacy and 1 patient had intolerable side effects.

The most commonly prescribed dose was 60 mg daily (range 15 - 20 mg daily). 40 patients were taking other analgesic agents in addition to ketamine. The mean percentage improvement in pain reported was 45% (0-70 %). All of those reporting improved pain wished to continue ketamine use. 30 patients reported mild side effects such as dizziness. 9 patients reported increased urinary frequency and one patient reported frequent urinary infections. Sleep was generally unimpaired.

Prescriptions are automatically dispensed to the patient via GP, clinic, post or for collection. This worked well, with few breaks in provision.

Conclusion

Analysis of our database of patients taking ketamine suggests that it is an efficacious drug with tolerable long-term side effects. Our survey findings correlate with those from other surveys and studies.

We therefore recommend its routine use in a particular sub-set of chronic pain patients. But we have to remember the potential for psychomimetic and other adverse effects. From that perspective, oral ketamine should not be used in the primary care setting but be restricted to pain management units as an add-on therapy in complex chronic pain patients when other therapeutic options have failed.

110

Management of neuropathic pain in Sickle Cell Crisis (SCC): old treatment, new possibilities

Category: Neuropathic Pain

Sumit Gulati, Brigitta Brandner

University College London Hospitals, London, UK

Background

Acute severe pain of Sickle Cell Crisis presents a unique challenge in pain management. The principles of pain control are based on a nociceptive model and intravenous opiates and NSAIDs remain the mainstay along with hydration, oxygen and warmth. With recurrent vasoocclusive episodes, a complex mechanism evolves in these patients involving nociceptive, neuropathic and visceral mechanisms.

We postulate that neuropathic pain is an important mechanism in a majority of these patients and fresh evidence is accumulating. However treatment modalities for neuropathic pain in SCC are as yet unreported in the literature. A recent Cochrane review has produced formidable evidence in favour of intravenous Lidocaine for use in neuropathic pain. We decided to trial it in selected sickle cell patients with neuropathic pain descriptors. We present a preliminary case report from our ongoing series to highlight the treatment of neuropathic pain in sickle cell crisis with intravenous Lidocaine.

Methods

A successful trial of intravenous Lidocaine was performed in a male patient with SCC reporting neuropathic pain descriptors. After this initial success, we actively sought patients with a neuropathic pain in their Sickle cell crisis.

A 25 year old Carribean woman presented with widespread generalized severe pain, burning sensation in legs and headaches. A 0-10 point numerical rating scale (NRS) was used for intensity and a LANSS scale (Leeds Assessment of Neuropathic Signs and symptoms) for neuropathic pan. She was started on Morphine PCA, Paracetamol, Ibuprofen and Gabapentin and was followed up twice a week. After failure to achieve adequate relief from escalation of morphine, Lidocaine infusion was given at 3mg/kg over two hours. Her pain was reassessed after two days and after a dramatic decrease in severity of her neuropathic pain, she was gradually weaned off her morphine and discharged on oral Morphine, Gabapentin and Ibuprofen.

Results

Out of the three patients who have had iv lidocaine so far, the first patient reported a good early response while another was lost in follow up when his clinical condition deteriorated. The third patient reported site specific neuropathic descriptors in her pain history (burning legs, sensitive to touch) and scored 16/24 on a LANSS scale. She was enrolled for the active intervention after her NRS remained 10/10 inspite of escalation of morphine and other adjuncts. After Lidocaine infusion she reported a clinically significant reduction in neuropathic pain of more than 30% on the NRS scale on day 3 and could only feel the underlying bone pain. This effect was sustained and enabled a better control in her generalized pains, which were hitherto unremitting, eventually leading to her discharge in five weeks. She also reported high satisfaction levels in regards to her pain relief on discharge.

Conclusion

The pain of SCC is complex and Neuropathic pain is often an active component. Intravenous Lidocaine is a well-evidenced treatment for neuropathic pain but remains unreported in the literature for SCC. Lidocaine offers an exciting avenue with a potential Opioid-sparing effect and a more effective modulation of the hyperalgesia and tolerance to opioids, which is often reported in these patients. Although our evidence is as yet anecdotal, lidocaine in other neuropathic conditions is well documented. We are now offering SCC patients with neuropathic pain this treatment and plan to establish a clinical trial in the future to generate more evidence.

111

Patients’ experience following treatment with capsaicin 8% patch for peripheral nerve pain – an audit from 3 NHS Pain Clinics

Category: Neuropathic Pain

Roy Carganillo¹, Jo Smart¹, Tamzin Bunton³, Nick Williamson², Thomas Smith¹

¹Guy’s and St Thomas’ NHS Foundation Trust, London, UK, ²Kings College Hospital NHS Trust, London, UK, ³University Hospital Lewisham, London, UK

Background

The 8% capsaicin patch, marketed as Qutenza,™ was licenced in the UK in July 2010 for the treatment of peripheral neuropathic pain in non-diabetic adults. Capsaicin binds the Transient Receptor potential Vanilloid 1 (TRPV1) receptors found in cutaneous nocicepter fibres. After initial excitation producing pain and erythema, prolonged nociceptor desensitisation follows. Randomised, double blind, controlled trials of Qutenza in Post Herpetic Neuralgia and HIV Associated Neuropathy demonstrated pain reduction after a single application that was significant from one week to 12 weeks post application.

This is an audit of the initial experience following the introduction of Qutenza treatment to 3 NHS London Pain Clinics.

Methods

All patients treated with the Qutenza patch at Guy’ and St Thomas’ Hospitals, King’s College Hospital, and University Hospital Lewisham from September 2011 were included. Pain scores, global impression of change, and Brief Pain Inventory (BPI) were taken at baseline. The patch was applied as recommended- following topical anaesthetic, 30 minute application to feet, 60 minute application for the rest of the body. Analgesia and cooling packs were provided when required to treat pain associated with the application.

Patients were supplied with diaries with BPI, EQ5D, and Global impression of change. Patients recorded data weekly for the first 4 weeks, then at 8 weeks and 12 weeks. Patients could repeat treatment after 12 weeks. Telephone follow ups were also done to check for adverse events, changes in medications etc

Some patients were examined closely for neurological findings such as allodynia at baseline and each subsequent visit for reapplication.

Results

Updated results will be presented on th BPS poster. At the time of abstract 26 patients had been treated with the capsaicin patch, 16 at Guy’s and St Thomas’, 5 at Kings and 5 at Lewisham. Indiacations were PHN, Peripheral Nerve Injury and HIV- associated neuropathy. 14 patients reported a good and maintained reduction in their pain, 9 had nor reduction in pain, and 3 had initial reduction in pain that was not repeated with subsequent application. There appeared to be a return of pain from 8 to 12 weeks after application. In those who had good pain reduction, the BPI showed an average reduction from 6.08 to 3.51 at 3 weeks and was still reduced at 4.3 at 12 weeks. EQ5D showed a similar improvement but a return to baseline by 12 weeks. 5 of the 14 patients who reported good pain relief reduced their pain medications.

Conclusion

This audit confirms that the capsaicin 8% patch is an effective treatment option for non-diabetic patients sufering painful peripheral neuropathy in an NHS pain clinic setting. Our early results suggest that up to 50% of patients may show a worthwhile reduction in pain in the short term. We also observed reduction in the measured areas of pain and allodynia. Further data needs to be gathered to elaborate the longer term response to treatment.

Non-Pharmacological Pain Management

112

Orthopaedic patients’ views and experiences of the use of music as a pain management tool

Category: Non-Pharmacological Pain Management

Alison Jeffery, Vikki Wylde, Ashley Blom, Jeremy Horwood

University of Bristol, Bristol, UK

Background

Total joint replacement surgery can result in severe acute pain in the immediate post-operative period. It is important to trial interventions to reduce acute post-operative pain because such pain is predictive of long-term pain after surgery. In other surgical populations, playing patients a Hemi-Sync® audio-file entitled ‘Surgical Support’, intra-operatively, has been associated with significantly reduced anaesthetic and analgesic requirement and significantly lower post-operative pain scores (Kliempt et al 1999; Lewis et al 2004; Dabu-Bondoc et al 2010). Hemi-sync® consists of binaural beats - two tones of similar frequency played simultaneously, one to each ear - combined with music, sounds from nature and positive statements. However, the acceptability to orthopaedic patients of using Hemi-Sync® intra-operatively and their experiences and perceptions of music for pain relief is unknown and therefore needs to be explored.

Methods

Focus groups were conducted with patients who had undergone or were waiting for primary total hip and knee replacement. Purposeful sampling obtained groups from a range of socio-economic situations, ages and both genders and groups were stratified according to patients being pre or post operative. Semi-structured, researcher-facilitated discussions covered views and experiences of music for pain relief and attitudes towards using Hemi-Sync® intra-operatively. Focus groups were audio-recorded, anonymised, transcribed and thematically analysed using NVivo8.

Results

A total of 20 participants (7 men, 13 women, 31-82 years) took part in five focus groups. Many participants discussed their own positive experiences of using music to help cope with pre-operative chronic pain. Music was seen as effective for relaxation and distraction from pain and participants appreciated using a non-pharmacological management tool. The use of Hemi-Sync® intra-operatively was seen as valuable, simple and non-invasive.

Conclusion

The data suggests that orthopaedic patients perceive music as an effective and easily accessible tool in pain management. The findings indicate a pilot trial of playing Hemi-Sync® sounds intra-operatively is acceptable and welcome to orthopaedic patients. A feasibility trial playing Hemi-Sync® to patients during total hip replacement surgery is now underway.

113

Audit of a pilot physiotherapy/nurse led clinic for new pain patients

Category: Non-Pharmacological Pain Management

Jillian Davis, Catherine Kelsall

Lancashire Teaching Hospitals NHS Trust, Lancashire, UK

Background

The Pain Management Team at Lancashire Teaching Hospitals NHS Trust receives over 150 referrals per month and is struggling to assess New patients (NP) within the time frame outlined by the Trust. Currently NP’s are assessed either in Consultant clinic, or Multi-Disciplinary clinic.

An audit of 100 new referrals (2010) demonstrated that 1/3 of patients could be seen in a Physiotherapy/Nurse (P/N) led pain clinic, based on a pre agreed criteria.

The Pilot clinic tests an alternative model of care to that which is currently in place. It proposes that a percentage of NP’s referred into Pain Management services are assessed by an ESP Physiotherapist and Clinical Specialist Nurse, with follow up as appropriate. This utilises expert musculoskeletal assessment skills, Non Medical Prescribing qualification, previous knowledge of proposed model, pain management, orthopaedic and spinal services.

This model is already fully operational in other clinical areas within the Trust and is proven to be successful.

Methods

11 pilot clinics were scheduled (May-July 2011). 4 NP allocated per clinic (45 minutes each). Referrals were triaged to P/N clinic using information from written referral, screening questionnaires: DRAM and British Pain Inventory (BPI) and preset criteria:

Criteria for Multi-Disciplinary Clinic

• Any pain presentation indicating Dram Score: Modified Zung >33 (Distressed Depressed).

• BPI indicating very low mood or identifiers on the referral indicating complex psychological presentation.

• Criteria for Consultant Clinic:

• Urgent referrals

• Non Musculoskeletal pain

• Scar pain

• Cancer

• Red Flags

• Complex medical presentations

• RSD

• Children

• Referral from other Pain Teams

• Criteria for Physiotherapy/Nurse Clinic:

• Musculoskeletal Pain

• Dram Score: Modified Zung <33 (Normal, At Risk distressed Somatic)

• BPI indicating reduced activity levels

Patients were jointly seen by Physiotherapist and Specialist Nurse and comprehensive subjective and physical examination undertaken. Management plan was agreed with the patient with follow up arranged as appropriate. Opinion sought from Pain Consultant as needed.

Results

39 patients were seen.

21 out of 39 patients completed triage questions (patients > 70 do not receive questionnaires as only validated up to age 70). Therefore 18 patients were seen using information based upon written referral only.

Clinical presentation: low back pain (n=29), neck pain (n=5), multiple joint pain (n=3), thoracic pain (n=1) hip pain (n=1)

Management Plan (more than one may be indicated)

3 – discharged

4 – referred to Consultant clinic

21 – received nurse follow ups for medication /tens/general review

2 – Pain management courses

2 – other opinions

14 – physiotherapy reviews

2 – injections

Clinical reasoning for referral to:

Consultant clinic (n=4): complex medical presentations

Other opinion (n=2): Upper limb team, neurology opinion

Injections (n=2): epidural and facet joint injections/denervation

All patients were asked to complete patient satisfaction surveys, 36 out of 39 were completed

Conclusion

Although 18 patients were seen without questionnaires, it was felt that the correct selection of patients had been made and did in fact fit the criteria that had been set. Pilot numbers were small due to time and resource constrains, however it demonstrated that this could be an alternative model of care to that used currently, allowing Consultant time to be utilised for more complex cases.

• Patient survey demonstrated high levels of satisfaction.

• Small numbers referred onto Consultant/injection pathway.

• Issues to be considered if model accepted

• Triage of referrals has to be Multi-disciplinary

• Comparative costs of proposed model v consultant clinics

• Consultant Support paramount

114

Changes in perceived work readiness following a high intensity chronic pain management programme (PMP) using the Stages of Change Model

Category: Non-Pharmacological Pain Management

Cara Lovell, Roxaneh Zarnegar

Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK

Background

Although the negative impact of chronic pain on employment and work performance is recognized, PMPs often do not specifically address vocational issues. Measuring vocational outcomes using dichotomous data is not sensitive for detecting changes made towards return to work (RTW) during PMPs (White 2008). The Stages of Change Model (Prochaska & DiClemente 1984) suggests that individuals go through distinct cognitive stages when modifying their behaviour. Based on this, Franche & Krause developed a model of work readiness and subsequently devised the Readiness for Return-to-Work Scale (RRTWS). To score this, each item is categorized as being indicative of one of four stages of work readiness for unemployed people (pre-contemplation, contemplation, prepared for action-evaluative, prepared for action-behavioural) or two stages (uncertain maintenance, proactive maintenance) for employed people.

Using this model we investigated work-related cognitive change after completing a PMP which includes sessions focusing on RTW or employment maintenance strategies.

Methods

After obtaining Ethics Committee approval, all patients under 65 years who entered the 3-week PMP at the Royal National Orthopaedic Hospital over a four month period were invited to participate. The primary outcome measure was the RRTWS. Secondary outcome measures were the Pain Self-Efficacy Questionnaire (PSEQ) (Nicholas 1989) and a non-standardized questionnaire used in Condition Management Programmes to detect change in confidence to RTW or manage health problems while at work (Ford & Plowright 2009). Questionnaires were completed before starting the programme and after its completion.

Sample size calculation is not possible with data currently available for the RRTWS. A sample size of 20-30 was deemed sufficient to obtain initial meaningful data. The Wilcoxon Signed Rank Test was used to investigate pre- and post- changes in scores on the RRTW Scale, PSEQ and the confidence questionnaire. Data analysis was carried out according to the intention to treat principle.

Results

Thirty four patients were approached and 28 (10 male, 18 female) agreed to participate. Twenty were unemployed at the time of participation, 2 of whom did voluntary work. Unemployed participants had significant (p<0.05) reductions in precontemplation [score mean(sd): pre-programme 2.76 (0.93), post-programme 2.35 (1.15)] and contemplation [score mean(sd): pre-programme 3.45(0.98), post-programme 3.00(0.94)] cognitions and increases in prepared for action [mean(sd): pre-programme 2.05(0.65), post-programme 2.68(0.93)] cognitions, indicating a cognitive shift towards return to work. In employed participants (n=8) there was movement in the scores from uncertain maintenance to proactive maintenance but this was not statistically significant.

In both groups there was a significant increase in the self efficacy score [PSEQ scores mean(sd): pre- 21.6 (8.5), post- 33.5 (11.1), p<0.001]. Responses to the confidence questionnaire indicated improved confidence in participants’ ability to find work and manage their condition at work. However, confidence that work would not worsen their condition did not improve.

Conclusion

This study shows that positive change in work readiness occurs after participation in a high intensity PMP with vocational elements although it is probably underpowered for some of the changes in the RRTWS to reach statistical significance. There were parallel positive changes in self efficacy and work confidence. Return to work is a dynamic cognitive-behavioural process. We have found that the Stages of Change Model provides a useful framework to understand and describe this process and that the RRTWS can be used for measuring vocational outcomes.

115

An open, prospective study of coping strategies and psychophysical health in patients attending a group cognitive-behavioural therapy programme for chronic pain management

Category: Non-Pharmacological Pain Management

Nicholas Hylands-White¹, Simon Biggs¹, Jon Raphael², Karen LeMarchand², Robert Ashford¹

¹Birmingham City University, Birmingham, UK, ²NHS Dudley Group of Hospitals, Dudley, UK

Background

Cognitive behavioural therapy (CBT) for pain management seeks to identify and correct problematic behaviour patterns that can contribute to increased pain and reduced quality of life in chronic pain patients. A typical pain management programme contains sessions which focus on increasing patients’ understanding of pain; training in behavioural and cognitive coping skills; and training in relaxation techniques. The goals of CBT are to change the way in which the patient thinks about their pain, and to equip patients with the tools to manage living with chronic pain.

Methods

Approximately 360 patients attended the pain management programme at the Guest Hospital, Dudley between Oct 1997 and May 2010. All patients were asked to complete the Coping Strategies Questionnaire (CSQ), the Hospital Anxiety Depression Scale (HADS), the Frenchay activity questionnaire and the Short-Form-36 (SF-36) at baseline (pre-course), at outcome (end-course), and at follow-up (three months). In order to be included in the analysis patients were required to have completed questionnaires at a minimum of two time points (n=204, mean age 46.2 ±10.21, range 22-68).

Results

There was a significant improvement in the use of the coping strategy ‘cognitive coping and suppression’ between baseline and outcome (p<.05). There was also a significant decrease in the maladaptive coping strategy ‘helplessness’ between baseline and outcome (p<.01), which was also significant between baseline and follow-up (p<.05). There were also significant decreases in anxiety (p<.01) and depression (p<.01); and improvements in activity (p<.01), physical function (p<.05), social function (p<.05) and mental health (p<.05) between baseline and outcome. Correlations of the changes in scores over time revealed that ‘cognitive coping and suppression’ was positively related to improvement in psychophysical health (p<.05) while ‘helplessness’ was negatively related to psychophysical health changes (p<.05).

Conclusion

The pain management programme has been instrumental in bringing about significant improvements in psychophysical health and daily activity of patients. It has also contributed to a significant change in coping strategies used by chronic pain patients, with an increase in ‘cognitive coping and suppression’ and a decrease in ‘helplessness’.

116

Evaluating a modified Pain Management Program in a primary care setting

Category: Non-Pharmacological Pain Management

Helen Taylor, L Bird, M Valer

Pain Management Solutions, Barnsley, UK

Background

A Pain Management Program (PMP) aims to help people accept their pain and improve activity and function through the application of self management skills, thereby reducing reliance on medication and other passive treatments. The essential features of a PMP are outlined in the British Pain Society (BPS) recommended guidelines for Pain Management Programs for adults (2006). These include the requirement for treatment to be delivered by a multi-disciplinary team (MDT) of health care professionals, working in an interdisciplinary way, to patients in a group setting.

A modified PMP, modelled on the Sydney ADAPT PMP was established in Nottingham Primary Care setting by a nurse consultant working with a senior physiotherapist. Clinical audit was used to evaluate outcomes, using the Royal College of Anaesthetists standards for Pain Management Programs as a benchmark.

Methods

Psychometric and functional measures were collected to evaluate outcomes pre & post program on 45 patients

• Disability Questionnaire (Roland & Morris, 1983)

• Depression, Anxiety and Stress Scale (DASS. Lovibond,1995)

• Pain Self Efficacy Questionnaire (PSEQ) (Nicholas, 1989)

• Timed six minute walk. Stevens et al (2009)

• Timed five times sit to stand. Bohannon et al (2007)

• Timed get up & go. Mathias S, et al ( 1986)

The measures were entered and analysed using Excel and Statistical data computing software

The results were measured against standards for a PMP from The Royal College of Anaesthetists (2006):-

• >33% patients should have a “clinically significant” outcome on at least one of the main domains of relevance (e.g. depression, disability)

• An improvement in functional performance tests of at least 34%.

In addition to the RCA indicators this audit looked at:

• Clinically significant change in pain self efficacy (PSEQ)

• Return to work

• Medication reduction

Results

A paired sample T test for matched data at pre program and post program indicated that;

Psychometric measures

• 33% of patients had a statistically significant change of 6 or more in disability score

• 33% of patients had a statistically significant change of 9 or more in depression score

• A total of 66% patients had a statistically significant change in at least one of the above domains

• 82 % of patients progressed towards a PSEQ of 40 or above with 51% achieving it

Functional Measures

• 60% of patients increased functional performance by more than 34% in at least one of the functional measures with many patients increasing more than one measure.

Return to Work Goals

• 35% of patients with a return to work goal achieved their goal following completion of the programme

Medication reduction

• 69% of patients achieved a reduced reliance on medication to manage their pain

Conclusion

The modified PMP has exceeded the RCA standards for a PMP with 66% of patients achieving a statistical and clinically significant improvement in the main domains of disability or/and depression as demonstrated by psychometric measures and 60% of patients improved more than 34% in functional measures. Patients who complete the PMP may return to more “normal” activity and function and so achieve work related goals. Patients who complete the PMP may reduce reliance on medication to manage pain.

117

Inclusive design and chronic pain: designing technology to support self-management

Category: Non-Pharmacological Pain Management

Geoffrey Duggan¹, Edmund Keogh¹, Richard Davies², Gail Mountain³, Paul McCullagh², Christopher Eccleston¹

¹University of Bath, Bath, UK, ²University of Ulster, Ulster, UK, ³University of Sheffield, Sheffield, UK

Background

Core to the long-term management of chronic pain is the need to empower patients to engage in home based rehabilitation and self-management. Telehealth systems that support behaviour change offer a solution to this problem by replacing, augmenting or enhancing elements traditionally provided by health care professionals. We describe the development of a personalised self-management system (SMART2) for patients with chronic pain.

An inclusive design approach was used to establish which features of behaviour change interventions are best suited to remote computer assisted delivery. This approach integrates the user within the design process to maximise both the amount of behaviour change and the proportion of users that can be supported by the system.

Another key goal for the development process was to provide a theoretical account of the self-management of chronic pain using technology. To this end we shall conduct a Realistic Evaluation (Pawson & Tilley, 1997) of the SMART2 system.

Methods

Twelve healthcare professionals involved in pain management took part in focus groups designed to identify therapeutic objectives for the system and therapeutic strategies that could be implemented within the system. Eight chronic pain patients took part in focus groups and/or home visits designed to specify technological requirements and understand the impact of chronic pain upon everyday life.

Results from the focus groups were used to develop the therapeutic components within the SMART2 system and to construct Context-Mechanism-Outcome (CMO) configurations for the Realistic Evaluation. Another separate focus group was then conducted with a separate group of six healthcare professionals involved in pain management. The SMART2 system and the CMO configurations were presented to this focus group for further feedback.

All focus groups and interviews were semi-structured and audio or video recorded.

Results

Both the SMART2 system and the CMO configurations have been developed. SMART2 consists of a touchscreen computer and mobile device and has a number of key features. 1. It is a goal based system that is flexible and allows patients to identify goals which promote independent living. 2. It is a reinforcement based system that presents accurate data on task achievements reinforcing goal related behaviour. 3. It is an expert system that gives specific advice tailored to account for barriers to change identified in individual psychological assessments. 4. It makes use of local environments by situating goals and reinforcements within the real lives of patients. 5. It makes use of technological features not normally available to therapists, in particular remote sensing, collation of multiple data sources, remote messaging. The system is designed to enable people to remove pain as a major determinant in their everyday decision making.

Conclusion

The SMART2 system has integrated the results from focus groups with healthcare professionals and chronic pain patients to target the most important and achievable therapeutic goals. A four week trial of the SMART2 system in patients’ homes is now underway. The findings from this Realistic Evaluation will inform future iterations of the SMART2 system. Within this evaluation the CMO configurations will be used to develop theory of self-management of chronic pain. This will address the questions: what works, for whom, how and in what circumstances.

118

One size fits all? An outpatient pain management programme for patients with English as a second language

Category: Non-Pharmacological Pain Management

Ajay Clare^1,2, Tamzin Bunton², Sarah MacNeil³, Stephanie Jarrett^1,2

¹Psychological Medicine Clinical Academic Group, South London & Maudsley NHS Trust, London, UK, ²Department of Anaesthetics, Lewisham Healthcare NHS Trust, London, UK, ³Department of Physiotherapy, Lewisham Healthcare NHS Trust, London, UK

Background

The UK has an ethnically diverse population, and it is estimated that nearly 1 million students speak English as a second language (ESL)1. Similarly, a significant proportion of the adult population in the UK have English as their second language, although the actual figure is unknown. Consequently, many NHS services make use of translators and bilingual clinicians to cater for ESL patients, as excluding this group would be discriminatory. However, very few Pain Management Programmes (PMPs) have specific services for ESL patients. Those that do offer an ESL service, often run a programme entirely in the language of the dominant local ethnic group. The London Borough of Lewisham has a mixed ethnic population, with no one dominant language. To tackle this, a new ESL PMP was piloted, aimed at patients from varied ethnic backgrounds.

Methods

Using a single case study design, this poster outlines the ESL PMP group and outcome for one of the participants. The ESL PMP consisted of four patients, each of whom had difficulties with either speaking, reading or writing English. It was run once a week, for 3 consecutive weeks, each session lasting 3 hours. Two follow-up sessions were also offered at 6 weeks and 12 weeks. Topics in the ESL PMP covered ‘What is Pain’, ‘Pacing’ and ‘Problem Solving’. As interpreters were involved, information had to be delivered in a clear and concise way, with time allowed for translations to take place. Patients were also given handouts that were written specifically for the ESL group.

Results

The patient described in this case study showed benefits from attending the ESL PMP. He said he had a greater understanding of his chronic pain and was able to explain his condition to other people. Additionally, he started to socialise more and showed improvements in his mood.

Conclusion

There is strong evidence that PMPs are effective but they may not always meet the needs of patients for whom English is a second language. Running a pilot group, specially adapted for ESL patients was found to be feasible and enabled patients with difficulties speaking, reading or writing English to access a PMP approach. The present case study suggests an area for future research would be to conduct a quantitative study examining outcome data for a large sample of patients completing an ESL PMP.

119

Psychometric assessment supporting the need for a local pain management programme

Category: Non-Pharmacological Pain Management

Jan Rudiger, Kevin Fai, Richard Griffiths, Jonathan Norman

Maidstone and Tunbridge Wells NHS Trust, Maidstone, Kent, UK

Background

Our primary care trust (West Kent) would support a local Pain Management Programme (PMP) if the need were demonstrated. They currently do not fund out of area referrals for PMP. A previous audit (2010) suggested over 150 suitable patients per annum for PMP attended follow up¹.

The presented audit looked at psychometric data for new referrals.

Methods

By the completion of a questionnaire on pain, function, depression and anxiety data were obtained prospectively from 117 consecutive patients attending the chronic pain clinic from 27 September until 10 November 2011.

74 (63%) were female and 43 male (37%) with an average age of 56 years.

The Brief Pain Inventory (BPI), PHQ-9 and GAD-7 were used.

Results

58 patients (50%) experienced severe pain (BPI-pain > 6/10).

In 59 patients (53%) pain was significantly interfering with life (BPI-function > 6/10).

50 patients (43%) suffered from major depression and 26 (23%) from minor depression.

26 patients (23%) had severe anxiety, 21 (18%) moderate anxiety and 26 (23%) mild anxiety.

We have shown high levels of pain interference with daily activities (more than 50%) and significant levels of anxiety and depression (both more than 40%).

Conclusion

Anxiety and depression can cause increased pain perception and vice versa².

PMPs have been shown to reduce depression^3,4 and anxiety^5,6 as well as improve function^7,8,9 with increased return to work^10,11.

PMPs also qualitatively reduce pain^9,12,13 and improve quality of life^7,14.

Reduced visits to primary and secondary care^7,15,16 and lower drug requirements^7,13,14 will offset running costs and save money in the long-term^7,15,17,18.

This audit supports the need for a local PMP.

Following these results the introduction of a local PMP is currently being assessed by our primary care trust (West Kent).

120

The Pain Management Plan: a pilot study of a cognitive behavioural self-management programme for chronic pain

Category: Non-Pharmacological Pain Management

Polly Ashworth¹, Frances Cole², Patrick Hill³, Eve Jenner³, Laura Coote^1,4, Emily Toomer^1,4, Bob Lewin⁵

¹Gloucestershire and Herefordshire Pain Management Service, Gloucestershire Hospitals NHS Foudation Trust, Gloucestershire, UK, ²Pain Rehabilitation Service, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK, ³Pain Service, Birmingham Community Healthcare NHS Trust, Birmingham, UK, ⁴Cardiff University, Cardiff, UK, ⁵Department of Health Sciences Research, University of York, York, UK

Background

Psychologically-based interventions for chronic pain delivered by a MDT are known to be effective (Eccleston et al 2009). Unfortunately such resources are limited and few of those in need take part. For some an intensive programme is not necessary, for others, group activities and regular outpatient appointments are not welcome. Similar challenges exist for cardiac rehabilitation programmes and one solution, a brief self-management programme using a manual (the Heart Manual) has been shown, in numerous RCTs, to be as effective as group outpatient programmes (Dalal et al 2010).We set out to develop a similar intervention that could increase the range of treatment options we offer and allow us to reach more patients.

Methods

The intervention consists of an initial assessment process, the use of an interactive pictorial workbook, called the Pain Management Plan, and a series of brief meetings or phone contacts delivered by a ‘facilitator’ who has knowledge of the cognitive behavioural methods employed. The workbook includes education and self-management advice on living with chronic pain, a goal setting diary, and a CD-based stress management programme. Teams of clinical staff were trained in the approach in three centres (Bradford, Birmingham, and Gloucestershire and Herefordshire) in January 2011. Data was collected regarding the number/length of sessions and staff/patient feedback. Pre and post outcome measures included the Pain Self-Efficacy Questionnaire (PSEQ: Nicholas, 2007); and the Pain Disability Questionnaire (PDQ: Anagnostis et al, 2004).

Results

88 patients took part in this pilot study; 75% completed the intervention. For 48% this was their first contact with a Pain service; 19% of participants had attended a pain programme in the past. Reasons for attrition included patients’ needs being too complex and life factors. The mean age of the sample was 47.5 years (sd=13.5) with an average pain duration of 10.8 years (sd=10.0). After assessment, those who completed the intervention (N=66) received an average of 4.5 treatment sessions (sd=1.3), a mean total duration of 2.9 contact hours. Statistically significant improvements were shown in self-efficacy (PSEQ) mean pre = 28.0, sd=12.5, mean post= 37.3, sd=13.0, t(63)=-7.0, p<0.001, and disability (PDQ) mean pre= 85.0, sd=28.4, mean post 66.2, sd=32.8, z=-4.3, p<0.001. Patient feedback data (N= 63) demonstrates an overall satisfaction level of 92%. Dropout rates were no higher those of a hospital based, outpatient, group MDT chronic pain management programme.

Conclusion

The pilot has demonstrated significant value to this approach and the Pain Management Plan can be successfully implemented by trained specialist staff. Clinical outcomes and patient feedback are encouraging and the efficiency of our pain services have been enhanced; with people receiving only the level of input they require, in the manner they prefer. We are using staff and patient feedback to make some adjustments to the printed materials, develop a description of the competencies required to facilitate the intervention and provide a one-day training programme suitable to the varying needs of the different staff groups working in this area.

121

Evaluation of acupuncture in the management of chronic pain within a pain service

Category: Non-Pharmacological Pain Management

Chris Clarke-Irons, Kate Tighe, Mark Alexander-Williams

Mid Essex NHS Trust, Chelmsford, UK

Background

Accupucture has been recommended in the NICE guidelines for the managment of low back pain. It has been used as part of our clinic practice for many years. more recently we have changed our pathway and now use an algorythm that rejects this modality in patient treatment after four sessions if insufficent benefit has been shown. This audit tests this pathway.

Methods

Patients (N =111) were referred for acupuncture by the pain consultant within the pain clinic for a range of pain conditions. A course of four acupuncture sessions at weekly intervals were administered, and each patient reviewed 6 weeks after this course. Acupuncture points were selected based on the patient’s presentation, and the needles remained in situ for a period of 10 - 20 minutes.

Clinical measurements used were the Hospital Anxiety and Depression Score (HADS), (completed before treatment and at follow-up), reduction or change in medication, and reduction in pain: a 50% pain reduction was established as clinically significant. This was also used as the criteria for offering further sessions at 6 to 8 weekly intervals. Adverse events were recorded.

Results

68% of the cohort reported a reduction in pain after 4 sessions of acupuncture. 29% of the 75 patients that reported a reduction in their pain levels had reduced their pain medication.

47% of patients continued with ‘top up’ sessions of Acupuncture after their initial 4 sessions of Acupuncture.

The mean number of weeks relief reported after 4 sessions of Acupuncture was 5 weeks. Also to note reductions in anxiety and depression scores were seen after 4 sessions of Acupuncture.

Conclusion

Acupuncture is a widely used modality in the management of chronic pain states. It appears to be as successful as any other physiological treatment modality used in our clinic. Further audits will help establish if there are subsets who respond better than others; initially we will concentrate on neck pain and headache.

NICE guidelines recommend 10 sessions of acupuncture for low back pain.¹ In our experience a failure to respond within 4 sessions indicates a significantly decreased likelihood for a positive response with further treatment, based on retrospective notes review of patients who had received 10 or more sessions before

122

Pelvic pain patients: outcomes for men and women on multidisciplinary pain management programmes

Category: Non-Pharmacological Pain Management

Sarah Edwards, Amanda C de C Williams

University College London Hospitals, London, UK

Background

Patients with pelvic pain report excluding themselves from group pain programmes, or struggling to benefit from these when they do attend, because of embarrassment and social anxiety associated with the location of their pain and related symptoms. In 2009 the Pain Management Centre at the National Hospital for Neurology and Neurosurgery (NHNN) established a pain management programme (Link) specifically for pelvic pain patients, in single-sex groups by patient preference. We are now evaluating our first eight programmes.

Methods

Patients are referred to Link by the urogenital pain team, and are assessed for suitability by a clinical psychologist and a physiotherapist. The programme is run by a multidisciplinary team, and adapted for pelvic and urogenital pain from the well-established cognitive-behavioural pain management programme at the same centre. Patients attend an initial seven days of the programme, one of which includes friends and family members, followed by one-month, five-month and 12-month follow-ups. Overall they receive about 43 hours of face-to-face treatment time. Outcome measures are completed at the beginning and end of the programme and at each follow-up session.

The present study examines the 74 patients who attended Link from 2009 to 2011. 54 women attended six programmes and 20 men attended two programmes. The data were split into two groups – male and female – for the analysis, and were compared from baseline to one-month follow-up.

Results

The mean age of participants was 45. The most common diagnoses were chronic pelvic pain, pudendal neuralgia, and endometriosis. Median duration of pain was six years. 29 participants were working, and 48 were in a current sexual relationship.

Repeated-measures ANOVA showed statistically significant differences for pain and psychology measures, with effect sizes from 0.13 to 0.27. For men, pain interference (measured by the BPI) and avoidance and fear of physical activity (FABQ) improved by 27% and 19% respectively. Pain-related self-efficacy (PSEQ) and sexual anxiety (measured by the MSQ) both improved by 29%. For women, pain-related self-efficacy improved by 22%, and catastrophising (PCS) and sexual anxiety improved by 14% and 20% respectively.

Physical assessment measures were analysed for men and women combined, and showed statistically significant improvements of 10% increase in distance for a five-minute-walk, and 33% increase in one-minute sit-to-stands.

Conclusion

The results show the effectiveness of multidisciplinary pain management programmes adapted for patients with pelvic pain, with improvements in pain-related self-efficacy, cognitions and interference, as well as in physical beliefs and functioning. Sexual anxiety is not often measured on pain management programmes, but also showed a significant reduction. Both men and women demonstrate these changes. Although it was harder to recruit men to a group programme, they engaged equally well when they attended. Future work will include analysis of longer-term outcome measures, to see if these gains are maintained at five-month and one-year follow-up.

123

A new model: delivering a hotel based pain self-management programme

Category: Non-Pharmacological Pain Management

Andrew Lucas

Royal National Orthopaedic Hospital, Stanmore, UK

Background

The Royal National Orthopaedic Hospital (RNOH) Stanmore is the largest orthopaedic hospital in the UK and regarded as a leader in the field of orthopaedics both in the UK and world-wide. The RNOH provide a comprehensive range of neuro-musculoskeletal and specialist rehabilitation for chronic pain sufferers and highly disabled patients with complex needs. This broad range of neuro-musculoskeletal services is unique within the NHS. One of these services is the Active Back Programme and patients are hotel based but transferred each day to the hospital to attend therapy sessions. Increasing demand has led to exploring new models of service delivery. A hotel based five day pain self-management programme has been designed for patients who will be resident at the hotel and this pilot initiative will explore the viability of delivering such a programme.

Methods

For over 20 years the RNOH has provided highly specialised pain self-management programmes and demonstrated effective outcomes, but this is the first time a hotel based programme will be delivered. Evaluation questionnaires utilising both fixed and open-ended items will be designed and used to collect opinions of the patients, clinical staff and the hotel staff.

Results

Patient feedback will provide service user evaluation. Therapy staff will need to report on their experience regarding the logistics of service delivery. The hotel staff will be asked to provide feedback on any difficulties they faced with accommodating the patients and in providing the rooms and audio-visual equipment for the therapy staff.

Conclusion

The results will be discussed in the light of the current model of hospital based service delivery. Concerns highlighted by the evaluation will be discussed and suggestions will be offered to improve the service.

It is hoped that this pilot initiative will demonstrate that a hotel based pain self-management programme is viable and can be an effective addition to the services delivered by the Royal National Orthopaedic Hospital.

124

Improved treadmill walking with Transcutaneous Electrical Nerve Stimulation in patients with Peripheral Arterial Disease and Intermittent Claudication

Category: Non-Pharmacological Pain Management

Chris Seenan^1,2, Steve McSwiggan³, Patricia Roche⁴, Chee-Wee Tan², Tom Mercer², Jill Belch³

¹Glasgow Caledonian University, Glasgow, UK, ²Queen Margaret University, Edinburgh, UK, ³University of Dundee, Dundee, UK, ⁴University of Aberdeen, Aberdeen, UK

Background

Transcutaneous Electrical Nerve Stimulation (TENS) is employed for painful musculoskeletal conditions but has not been tested for alleviating the pain and restricted walking performance of patients with Intermittent Claudication (IC) associated with Peripheral Arterial Disease (PAD). This pilot study aimed to describe IC pain and investigate the effects of TENS on treadmill walking distance and subjective report of IC.

Methods

Thirty-six participants with PAD and IC completed a standardised treadmill test on two separate testing occasions: (i) active TENS and (ii) placebo TENS applied on the lower limb. The following measures were compared using a within-subject design: Initial Claudication Distance (ICD), Functional Claudication Distance (FCD) and Absolute Claudication Distance (ACD). The McGill Pain Questionnaire (MPQ) vocabulary was completed retrospectively and the MPQ-Pain Rating Index (PRI) score calculated.

Results

ICD increased from a median (range) distance of 74m (22-271) to 80.5m (34-385); FCD from 156m (70-545) to 164m (79-654) and ACD from 178.5m (99-806) to 211.5m (113-762) with active TENS (all p < .05). No difference was observed between PRI scores of the 2 conditions. IC pain description was characterised by high utilisation of specific Sensory, Affective and Evaluative qualities and adjectives of the MPQ.

Conclusion

The IC pain experience is multidimensional and characterised by specific subclasses and adjectives. Active TENS applied to the lower limb of patients with PAD and IC was associated with walking further on a treadmill but not with a reduction in pain. TENS may be a useful adjunctive intervention to help increase walking performance in patients with IC.

125

‘Grin and bear it’: patients’ experiences of living with Peripheral Arterial Disease and using Transcutaneous Electrical Nerve Stimulation for Intermittent Claudication

Category: Non-Pharmacological Pain Management

Chris Seenan^1,4, Linda Orr², Steve McSwiggan², Patricia Roche³, Chee-Wee Tan⁴, Tom Mercer⁴, Jill Belch²

¹Glasgow Caledonian University, Glasgow, UK, ²University of Dundee, Dundee, UK, ³University of Aberdeen, Aberdeen, UK, ⁴Queen Margaret University, Edinburgh, UK

Background

The patient experience of living with Peripheral Arterial Disease (PAD) and Intermittent Claudication (IC) has not been fully described in the literature. A previous study of Transcutaneous Electrical Nerve Stimulation (TENS) showed increased treadmill walking performance in patients with PAD and IC, however, the experience of using TENS in daily life in this patient population has not been investigated. The objective of this study was to investigate patients’ experiences of 1) living with PAD and IC and 2) using TENS in daily life.

Methods

Six patients were recruited to the study. All participants were provided with a TENS unit, training and instructions for independent use of the unit at home for one month. A focus group discussion held at the end of the month elicited participants’ experiences of living with the disease and using TENS. The transcribed text was analysed using manifest and latent content analysis.

Results

One patient withdrew due to illness unrelated to the study. The experience of living with PAD and IC was found to be characterised by frustration and linked to a number of aspects of the disease. This was interpreted through the following themes: (i) ‘transient, yet chronic pain’; (ii) ‘lifestyle limitations’; (iii) ‘limited knowledge and understanding’ and (iv) ‘grin and bear it’. The experience of using TENS in daily life was characterised by both benefit and disappointment. This was interpreted through the following themes: (i) ‘masking, but not taking the pain away’ and (ii) ‘walking further, but not far enough’.

Conclusion

The experience of living with PAD and IC is characterised by feelings of frustration. There were mixed experiences of using TENS in daily life for PAD and IC. Expectations of effects, prior knowledge and severity of the disease appear to mediate the effects of TENS.

126

Which pain rehabilitation programme should patients with chronic back pain attend? Implementing research findings by varying duration and intensity

Category: Non-Pharmacological Pain Management

Karen Barker^1,2, Leila Heelas¹, Elaine Buchanan¹, Francine Toye¹

¹Oxford University Hospitals NHS Trust, Oxford, UK, ²Oxford University NDORMS, Oxford, UK

Background

Previous research had established the efficacy of a functional restoration programme (FRP) for patients with chronic back pain. Implementing this programme in normal clinical practice presented issues with patients being able to attend a programme due to intensity or duration; managing increased referrals and patients that did not fit FRP criteria. In addition to FRP two new programmes of shorter duration and lesser intensities were introduced - active rehabilitation programme (ARP) and short management programme (SMP), with a selection algorithm to allocate patients to each programme. It is hypothesised that the alternative programmes will have clinically & statistically significant improvements in patient outcome. This audit explores whether outcome was affected by treatment duration.

Implementing gold standard research findings may not be possible within limited resources. This research suggests how findings can be translated into standard clinical practice by adhering to key principles but varying intervention intensity and duration.

Methods

Participants: 3 consecutive cohorts each of 40 patients attending each programme. Inclusion criteria: chronic musculoskeletal pain of greater than 12 weeks duration. Exclusion critieria: severe anxiety, depression or acute mental illness that would impair subjects’ ability to benefit from rehabilitation (as determined by a psychologist); medical or surgical problems.

Patients were allocated to a programme after assessment based on physical and psychological assessments and their preference. Sessions were facilitated by a physiotherapist and cognitive-behavioural principles were used. Patients had access to a psychologist and had completed medical screening. At baseline and 6 months after completion patients completed standard outcome assessments - pain visual analogue score, pain catastrophising scale (PCS), pain self efficacy questionnaire (PSEQ), Tampa scale for kinesiophobia (TSK) and physical tests of timed sit to stand and 5 minute walk test. Analysis: Paired t tests.

Results

Patients attending the ‘gold standard’ FRP programme showed statistically and clinically significant improvements in mean change scores for PCS (21.6 to 11.8), TSK ( 42.3 to 33.2), PSEQ (28.8 to 37.7), sit to stand (13.1 to 19.6)and 5 minute walk test ( 222m to 302 m) - all p<0.001. They demonstrated a smaller decrease in VAS pain score from 5.45 to 4 (p<0.021).

For the ARP there were significant improvements in the mean change for PCS (27.6 to 16.6; p 0.000), TSK (42.1 to 34.4; p0.000), PSEQ (22.2 to 31.5; p0.001) and sit to stand (10.5 to 12.8; p0.004). Other outcomes were not statistically significant.

For the SMP there were significant improvements in the mean change for PCS (18.2 to 14.36.6; p 0.002), TSK (32.1 to 27.4; p0.001), PSEQ (35.2 to 38.5; p0.001), sit to stand (15.5 to 19.8; p0.004) and walking ( 243 to 351m; p0.000).

Conclusion

Clinically and statistically significant improvements in outcome were demonstrated in cohorts of patients undergoing programmes of lesser duration and intensity than the original validated programme. As the study sample was small and the programme allocation was not randomised the ability to draw inferences about comparative outcomes is limited. However, this change to service delivery has enabled greater numbers of patients to access pain rehabilitation programmes whilst remaining within the physical and staffing constraints available within this publically funded setting (UK NHS).

Implications: Further work is needed to further validate that this is a clinically and cost effective model.

127

Survey of patient satisfaction of an outpatient pain management programme

Category: Non-Pharmacological Pain Management

Sabita Sreevalsan¹, Alison Garner², Zoe Mason², Mike Bailey²

¹Norfolk and Norwich University Hospital, Norwich, UK, ²Ipswich Hospital, Ipswich, UK

Background

The Pain Management Programme (PMP) provided by the Pain Management Centre at Ipswich Hospital has been running for the last 12 years. It is facilitated by clinical psychologists, specialist physiotherapists and chronic pain nurse specialists.

The programme involves:

• One day session a week for eight weeks, with follow up at one and six months.

• A chance for participants to learn more about chronic pain and its management, and to recognise and overcome challenges in managing their own pain.

• Cognitive behavioural therapy orientation, using a bio-psycho-social approach.

• Use of complex group processes.

• Option to attend a post-PMP support group.

The aim of this survey is to gain insight into the experience of patients attending the Programme at our hospital, and their views on the programme. The purpose is to increase staff awareness and identify if any areas could be improved.

Methods

During August 2011, a postal questionnaire was sent to 81 patients, who had attended the programme, between May 2007 and May 2011. Anonymised, completed questionnaires were analysed and results were collated by the Clinical Audit Department.

Questions pertaining to patient’s understanding of chronic pain, expectations, lifestyle, level of function and coping strategies before and after the programme were asked and suggestions for improvement of the programme were sought.

Results

30 out of 81 (37%) questionnaires were returned.

72% of patients had suffered from pain for over five years (35% over 10 years). 62% waited over three months (41% over six months) between the first Pain Clinic consultation and starting PMP.

52% had felt unable to cope and a quarter found extreme difficulty in performing simple daily tasks, hobbies and jobs. Only half the patients entered the programme with any expectation of improvement.

All patients found the handouts easy to understand, 97% of patients found the timing of the sessions convenient and working in a group helpful, 93% felt that they were able to explore all the topics they wanted, 76% felt that they had a better understanding of chronic pain and 97% said they would recommend the programme to others.

Overall, 55% experienced improvement in their ability to perform daily activities and quality of life following the programme.

Conclusion

The PMP implements a framework for a self management approach to chronic pain which often has a complex interplay of physical, social and psychological factors.

Though the response rate (37%)was less than anticipated, our survey clearly demonstrates the beneficial effects experienced by over half the respondents in the programme, with 97% recommending the programme to others

Criticism mainly related to better seating and need for a ground floor venue for better access. Suggestions for improvement included having more follow-up sessions and discussion of experiences of past or present patients.

128

Face2Face. Can you see pain?

Category: Non-Pharmacological Pain Management

Deborah Padfield^1,2, Joanna Zakrzewska¹

¹University College London Hospitals NHS Foundation Trust, London, UK, ²Slade School of Fine Art, University College London, London, UK

Background

Facial pain is common. Up to 7% of the British public suffer from chronic facial pain at some point in their lives and in 70% of these, it has a significant impact on their quality of life. It affects many aspects of social functioning such as talking, drinking, eating, and kissing, causing patients to withdraw from social action and impacting on their communication with others.

With a focus on facial pain medicine and portraiture, the face2face research project asks whether, and if so how, images can help negotiate between the different perspectives of patient and clinician. Issues of communication, already inherent to the pain experience are exacerbated when the ‘canvas’ normally used to express it, the face, is itself in pain. Unable to convey in a manner that others can comprehend, the face can become a contested and painful place, increasing the isolation of sufferers.

Methods

Face2face builds on previous research, perceptions of pain, and is a chance to look at the communication process within consultations in more depth. It explores various ways in which aesthetic spaces can allow access to other ways of ‘knowing’ illness and disease.

1. The co-creation of images of pain by artist Deborah Padfield with facial pain sufferers at different points as they progress through pain-management.

2. The integration of a selection of these images into a pack of Pain Cards for clinical use.

3. Research into the effect of using these cards within NHS Pain Consultations

4. Art workshops for clinicians and patients to attend together delivered in association with the National Portrait Gallery (NPG)

5. The creation of a new film exploring experiences of having and treating facial pain.

The project has ethical approval and is an interdisciplinary project generating peer reviewed papers, a PhD thesis and several exhibitions.

Results

122 patients and clinicians have been involved in this three year project.

Participants in the workshops had access to the NPG’s unique collection and took part in drawing/observation exercises, and discussions. Comments from discussion transcripts and evaluation forms included: ‘pain stops people from seeing me’; ‘it becomes more difficult to express pain because your face isn’t working well’, ‘I enjoyed having permission to look’.

Many photographs were created during the individual workshops at different points in the pain-management journey and over 40 of these were exhibited alongside the film at two public galleries in London – the Menier, and UCLH.

A selection have been used to develop a pack of 54 ‘PAIN CARDS’ currently being trialled during video-recorded consultations by a range of pain experts. Preliminary findings identify circumstances in which images are particularly helpful such as where emotional elements are significant and where English is not the first language.

Conclusion

Preliminary findings provide evidence that selected photographs of pain placed between clinician and patient can help trigger a more collaborative approach to dialogue within the consulting room. They suggest that not only can medicine provide rich sources of material and inspiration for art, but art is capable of bringing new knowledge into clinical settings.

Positive reviews in the press including the Independent, BMJ and the Lancet validate further exhibitions and development.

Future research will look at ways to utilise the PAIN CARDS as an innovative communication tool in NHS Pain Clinics.

Paediatric

129

Pain management in the palliative care of children with epidermolysis bullosa (EB)- a case series

Category: Paediatric

Dilini Rajapakse, Anna Martinez, Jemima Mellerio, Finella Craig, Leslie Foster

Great Ormond Street hospital, London, UK

Background

Epidermolysis Bullosa (EB) is a rare inherited disorder of connective tissue which causes blistering of skin and mucous membranes as a result of minor frictional trauma. Children with severe forms of EB may develop complications such as infection, gastrointestinal and musculoskeletal involvement which may be life-limiting and acutely life-threatening. Management is supportive with disease-modifying and supportive care aimed at prolonging good quality life. Coordinated multidisciplinary care is important both by specialist teams at tertiary centres and community teams where the child lives. This is especially vital at end of life when palliative care services strive to provide supportive care at the child and family’s preferred place of care (home, hospice or hospital) with specific goal-directed pain and symptom management.

The aim of the study was to document the experience of managing end of life care in children with EB presenting at a single tertiary centre for EB care.

Methods

End of life pain management was recorded for all children with EB referred to a specialist palliative care team. A retrospective case review identified the practicalities and challenges of palliative care service delivery, preferred place of care and death (an important outcome measure in palliative care), pain and symptom management including types of medication required and routes of administration.

Results

Ten children (6F,4M) were referred to the palliative care service. Seven had Herlitz Junctional EB, three had severe generalised recessive dystrophic EB.

Five children had died by one year of age. Nine children died at home and one died in a children’s hospice.

The duration of specialist palliative care ranged from 6 days to 1 year and was delivered by home visits, telephone and email contact.

Pain was universally reported and opioid responsive. One child required a continuous subcutaneous infusion (CSCI) of diamorphine and one child required a CSCI of morphine sulphate due to rapidly escalating pain and reduced level of consciousness at end of life. Two were switched from oral long-acting morphine sulphate to fentanyl patches due to stable analgesia. One was switched from long-acting oral morphine sulphate to methadone due to tolerance.

Oral medications were administered by parents. Syringe driver medications were managed by the community nursing team.

Conclusion

Children with severe, life limiting EB require management of challenging pain issues as part of palliative care. In the majority, pain is responsive to opioids. However finding alternative routes of administration, managing opioid tolerance and neuropathic pain requires an innovative, empirical and rational approach. We suggest that this requires a joint approach to management by a specialist pain and palliative care team working in conjunction with a specialist EB team, to deliver end of life care in the child and family’s preferred place of care.

130

A survey of paediatric chronic pain resources and workload in the UK in 2011

Category: Paediatric

Alasdair Howie¹, Winston de Mello²

¹Alder Hey Hospital, Liverpool, UK, UK, ²University Hospital of South Manchester, Manchester, UK, UK

Background

A multidisciplinary approach to chronic pain in children would improve their function, quality of life and lessen the impact on schooling. On occasions they are referred to an adult pain service for specialised therapy. We wished to establish the current paediatric chronic pain provision in the UK plus the volume and nature of this workload.

Methods

A questionnaire was posted to the lead clinician/clinical director of 14 tertiary paediatric hospitals in the UK.

Results

There was an 85% response rate. An integrated service was offered in 4 (33%), a separate acute and chronic service in 4 (33%), just an acute pain provision in 3 (25%) and no service in one hospital (9%). Two of the three hospitals with just an acute pain service referred their chronic pain problems to the adult service. There was considerable variation in the membership of the multidisciplinary team in the 12 hospitals with only 4 (33%) having psychology input. Eight of the 12 hospitals had over 20 chronic pain referrals per annum. One unit had a separate clinic for rheumatology patients. The most common referrals were for musculoskeletal disease, complex regional pain syndrome, abdominal pain, headache, post surgical pain and pain secondary to chronic medical conditions. Eight of the 12 units had over 20 referrals per annum, but this was felt to be an underestimate.

Conclusion

There is considerable variation in paediatric chronic pain service provision in the UK. Responders expressed frustration in trying to set up a multidisciplinary service and a few were providing an unfunded service. There is a need for investing in an integrated multidisciplinary pain service in all tertiary paediatric hospitals in the UK and a seamless transfer to an adult service when appropriate. If new services are to be set up, then population density and travelling times (rather than distances) will need to be taken into consideration.

131

Ethical guidance for paediatric e-health research in the context of pain

Category: Paediatric

Ellen M. Henderson, Edmund Keogh, Christopher Eccleston

Centre for Pain Research, The University of Bath, Claverton Down, Bath, BA2 7AY, UK

Background

The internet is an increasingly popular domain for adolescent research. Approximately 80% of adolescents use the internet daily (Lenhart, Purcell, Smith, & Zickuhr, 2010), indicating that they are ideal subjects for this research platform. However, the new and expanding scope for online studies is fraught with debate around the best way to design research in an ethical and pragmatic way for adults and adolescents alike. This debate is particularly salient when taking into account the vulnerabilities of adolescents suffering from chronic pain conditions. These adolescents have lower school attendance (Logan, Simons, Stein, & Chastain, 2008), interact with health care more frequently (Sleed, Eccleston, Beecham, Knapp, & Jordan, 2005) and are the bearers of higher rates of mental health distress than their peers (Compas et al., 2006). This discussion is one of how best to ethically research paediatric samples of pained patients online.

Methods

A review of the current literature on the ethics of online research with children and young people was undertaken prior to the development of this study. A case study of an on-going research project, Let’s Chat Pain will be presented to illustrate discussions around the best mode of seeking parental consent, child assent, de-brief and protection of participants from harm. Some discussion will also be given to the issue of researcher responsibility around protection of participants when they disclose they are coming to some harm outside of the research context. Specific attention will be given to the possible vulnerabilities children and adolescents with chronic pain have which may give rise to extra ethical issues such as participants attempting to solicit medical advice for their pain condition from the researcher or presenting to other participants on the board as expert patients and giving mis-information to others.

Results

Some qualitative quotations collected from the message board discussion and some screen shots of the message board will be presented to illustrate certain themes. However, the bulk of the results will pertain to a review of the literature around the ethical best practice when carrying out ICT research on children with chronic health conditions. The main discussion will centre on researcher responsibility, best practice regarding recruitment, consent, assent and de-brief and some elements of the researcher participant relationship which may be unique to that of a pain research context.

Conclusion

The current study can be considered one example of how to carry out an online study with adolescent pain populations. This study is one which meets the guidelines from the British Psychological Society and the British Pain Society. However, some important ethical dilemmas around the responsibility of the researcher in relation to participant harm have been overlooked by these previous guidances. This study aims to present possible solutions and conclusions to these problems as well as discussion of some unique issues to that of studying adolescents with pain online.

132

An online message board discussion of pain coping behaviour amongst frequent adolescent users of online pain information: Let’s chat pain

Category: Paediatric

Ellen M. Henderson, Edmund Keogh, Christopher Eccleston

Centre for Pain Research, The University of Bath, Claverton Down, Bath, BA2 7AY, UK

Background

Previous research has indicated that online information on pain available to adolescents who may seek it out is of a poor quality, hard to read and of questionable reliability (Henderson, Rosser, Keogh, & Eccleston, in press). Yet, despite its containing poor quality information the internet is still a frequently accessed source of information on health for some adolescents. The current study was designed to recruit those frequent contributors to online health information, particularly pain information, to an online message board discussion. The discussion contained questions about the offline coping and support seeking of the frequent information seekers as well as their attitudes to reliability and quality of online information.

Methods

Participants were recruited to the board by engaging active teenage health message boards to our message board. A message board discussion called Let’s Chat Pain was developed and hosted on the University of Bath servers using Flux BB 6.0. The discussion board required participants to create a log in and nominate a parent to consent to their participation. An automatically generated e-mail was sent to parents informing them about the study and their child’s intention to participate and giving them the option to withdraw their child from the study. Before participation the adolescent participants were asked for their age, level of pain and if they had a chronic pain condition. Those who indicated that they were over the age of 18 were excluded. Participants were then asked to log into each discussion which centred on their coping behaviours and attitudes to online health and pain information.

Results

The study is on-going. Expected themes will centre on information and support for participants in their offline world. It is hypothesised that one factor encouraging the use of the internet for health information is a lack of alternative sources of information or support offline. It is also hypothesised that participants will be unaware of the shortfalls of their primary online sources in relation to quality and reliability. Rather they will assume that what they read online and the information given to them is not subject to inaccuracies. As a result of this we also hypothesise that participants will be unaware of how to verify the information they find online and will be unaware of any corroborative measures they could take to ensure that the advice that they take from the internet is of and sound merit and safe for use in coping with their pain.

Conclusion

Those adolescents who frequently use the internet for advice and support for health complaints, especially pain, are unaware of the unreliable and unqualified nature of the information and support they are receiving. Adolescents are also uninformed as to how to establish a quality and reliability rating of the websites they interact with. Rather they rely on these websites due to a lack of support and advice from qualified people offline and assume that what they find online is of a sound worth. Future work should assess how best to safeguard our youth against pain information inaccuracies online.

133

A focus group discussion of the factors inhibiting online information seeking around pain in a group of healthy adolescents

Category: Paediatric

Ellen M. Henderson, Edmund Keogh, Christopher Eccleston

Centre for Pain Research, The University of Bath, Claverton Down, Bath, BA2 7AY, UK

Background

Adolescents are considered digital natives (Palfrey & Gasser, 2008), 80% report daily internet use (Lenhart, Purcell, Smith, & Zickuhr, 2010) and this figure is growing with advances in broadband availability, smartphones and accessibility of mobile technologies. Research has indicated that adolescents use the internet to search for health information, particularly information which may be considered embarrassing or difficult to discuss with a health professional, parent or peer (Coulson & Greenwood, 2011; Sharkey et al., 2011; Suzuki & Calzo, 2004). Parallels may be draw between these illnesses and the embarrassing gastrointestinal features of abdominal pain, or the isolation of a child with chronic pain. Yet, previous research by our group found that adolescents are loath to look online for pain information. The current study was designed to explore why adolescents don’t utilise the internet to look for pain information despite a wealth of resources available to those who choose to look.

Methods

Three focus groups, containing eight adolescents recruited from schools in the South-West of England were convened by two female researchers. Participants were asked about their pain coping, what levels of social support were available to them when in pain and their perceptions of the availability and reliability of health information online. All groups were voice and video recorded. Recordings were transcribed into word documents and imported into NVIVO 9 for thematic analysis by the lead researcher. An unlimited set of themes were generated by the lead researcher and refined through repeated consultation with the raw data until saturation could be said to have been reached. These were then validated as representative of the original data by the second and third authors and further refined until a manageable set of themes were generated. This method of analysis is taken from a previous study by Henderson, Rosser, Keogh & Eccleston (in press).

Results

Themes pertaining to the applicability and availability of information online regarding teenage health concerns will be discussed. It is hypothesised that adolescents will generally be well supported in their pain coping. This support will come from parents mostly, but also from peers and their schools. These support networks will be sources of pain information, such that the internet is not required as a source of pain information. When participants do require the internet as a source of information they find it difficult to navigate, difficult to find what they are looking for and difficult to understand and process once they do find information and are generally mistrusting of the information they find online. Some discussion will be given to the specific aspects of health websites that teens consult in making quality judgements about those sites.

Conclusion

This research consisted of a series of focus groups during which healthy adolescents discussed disinhibiting factors of using the internet as a pain information source. Few participants consulted the internet for pain information, preferring instead to use their social support networks, of which there were many, for information. This research indicates that initiatives aimed at providing pain information online to healthy adolescents may be misguided as they don’t seek this information. Adolescents perceive information to be of poor quality and they don’t feel further information to be required by them as an adjunct to existing pain coping strategies.

Primary Care

134

Alexander Technique for the management of chronic pain: an audit cycle in a community pain service

Category: Primary Care

Karen French, Heather Hawksley, Louise Hemphrey, Claudia Benson

Kent Community Health NHS Trust, Kent, UK

Background

This audit assessed the benefit of Alexander Technique lessons in the management of persistent pain to establish best practice and was repeated to see if standards were sustained following changes made to the process. The first audit was a baseline audit and gathered data from January to December 2010. A re-audit gathered data January to December 2011.

In the community chronic pain service patients experiencing persistent pain may be referred for Alexander Technique lessons following assessment with one of the clinicians. During their course of lessons, patients are taught to become more aware of their habitual ways of using themselves and their response to stimuli, for example how they respond to their pain. They will also learn how their habitual patterns can interfere with their overall way of functioning. If appropriate the patient is offered a course of lessons, the number of which was initially determined by the teacher.

Methods

Both audits involved retrospective data collected from 50 patients (100 in total) referred to Community Chronic Pain across the 6 sites where Alexander Technique lessons are provided. This represented 52% of referrals.

Patients were asked to complete an audit feedback form consisting of 12 questions and rate any improvement at the end of their course of Alexander Technique lessons. They were asked to complete the form in the waiting room, place the completed form in a sealed envelope and hand in to the receptionist.

Alexander Technique is popular with patients and clinicians and matching capacity with demand is important. The baseline audit led to the service implementing changes to the process and repeating the audit a year later from January to December 2011 and a patient telephone survey was included 6 months following completion of lessons.

Results

The baseline audit found a high proportion of patients (93%) receiving Alexander Technique lessons rated gaining ‘moderate’ to ‘very much benefit’ from this approach.

An even higher proportion (98%) scored ‘moderate’ to very much benefit gained from Alexander Technique in areas that related specifically to the management of their pain.

Patients who received between 13-20 lessons scored more highly on questions rated to pain management with 87% scoring the benefits of Alexander Techniques as ‘quite a lot’ or ‘very much’. A slightly lower number of patients (73%) receiving between 3-12 lesson felt this approach provided ‘quite a lot’ or ‘very much’ benefit in the management of their pain.

Results from 2011 are currently being analysed and will be added.

Conclusion

The baseline audit suggests Alexander Technique helps in the re-education of patients who are experiencing persistent pain by developing self awareness and self management which in turn contributes to improved use and functioning of themselves. It showed the majority of patients selected gained benefits, implying patients are identified appropriately.

The baseline audit suggested gains may have a relationship with the number of lessons offered and helped the service identify the number of lessons to offer patients in order to balance demand with capacity. A re audit in 2011 monitored whether standards were maintained.

Conclusion from 2011 audit and comparison with 2010 will be added to poster

135

I hurt… Help me! Improving pain management for people with Learning Disabilities. Results of a training programme using Disability Distress Assessment Tool (DISDAT)

Category: Primary Care

Val Conway, Ian Robert Taylor

Kent Community Health NHS Service, KENT, UK

Background

Carer support for people with Learning Disabilities (LD) is often given by young people with minimal experience and English is often not their first language. There are no national standards for pain assessment and treatment for people with Learning Disabilities and clinical governance varies. Residential homes are privately run with non NHS employees. No training on pain and its management is given and many staff are unaware of basic treatment options.

In 2011 Conway & Taylor carried out an audit within a range of Learning Disability Care Homes in East Kent looking at Pain Recognition and Management. Staff, carers and managers were interviewed. Three measurement tools were piloted; Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC), ABBEY Pain Scale and the Disability Distress Assessment Tool (DISDAT). The results of the audit were discussed and a training package was devised using DISDAT.

Methods

East Kent is divided into 6 Districts. Shepway has the most residential care homes (69) for people with Learning Disabilities (L/D) and was chosen as the initial locality for training. A hotel venue was chosen which was central, had easy access and able to accommodate up to 25 carers for each session. Flyers were sent out to all Shepway L/D care homes and followed up by telephone calls and visits to encourage recruitment. A charge of £20 per attendee was made to cover costs of venue and refreshments.

Each training session was followed up four to six weeks later, by a visit to individual attendees’ residential home, in order to support implementation of the DISDAT Tool. Further follow up visits were arranged where needed.

Results

Half day training sessions have been delivered for 183 carers, working within 54 residential homes and providing care for more than 250 residents. Pre- and Post- Training Questionnaires show that carers’ pain management skills and awareness has gone from low to high. Challenging behaviour has reduced for some residents, communication and handover between staff team members has improved, allowing individualised intervention. Standard of recording has improved and health action plans are now becoming commonplace with detailed descriptors of individual residents- allowing a baseline to work from, enabling faster and more effective care for people with Learning Disabilities.

Outcomes from initial training session and follow up visits have been collated and show an overall improvement in carers’ pain management awareness and residents’ treatment.

Conclusion

DISDAT is a successful measuring tool for people with Learning Disability, cared for in residential homes by people with a range of skills and experience.

The interactive training package allowed carers to discuss and identify their own strengths and weaknesses. The DISDAT tool was sometimes difficult to implement initially in the care homes, as carers needed extra support from Conway and Taylor to get started.

Once implemented, carers and managers found DISDAT and the information gleaned at the training session invaluable in managing their residents’ pain and supporting them in their day to day lives.

136

Identifying patients with chronic musculoskeletal pain in primary care databases (an example of using ambiguous data for secondary work)

Category: Primary Care

Jens Foell, Dawn Carnes, Stephanie Taylor, Kate Homer

Queen Mary University of London, London, UK

Background

A huge part of the workload in primary care is dedicated to chronic pain. Musculoskeletal pain is a dominant feature of chronic pain conditions. Despite the high prevalence of chronic pain there is no code based on the IASP definition in the Read-Code classification system. Chronic pain is coded in various ways. There are no single search criteria in the primary care information infrastructure. Psychoeducational work including education for effective self-management strategies is often delivered in group-settings. Identifying the appropriate people to participate in these treatment strategies is challenging. Group-searches in GP databases to identify the target population are complex searches. If pain treatment is delivered in different ways than responding to need-states in acute situations criteria to categorise the target population need to be developed. Searches to identify the target population in absence of a single code are complex searches.

Methods

We used an exploratory, iterative approach. The first phase involved consultations with IT specialists, practice managers and GPs to gain an understanding about the processes and issues of electronic coding. We used convenience-sample and purposeful selected samples of people interacting with the information infrastructure to develop our search strategy. In the second and third phase we determined the most appropriate search terms and strategies. We tested different search terms and search strategies, such as block-searches and layered searches. In the final phase we tested, modified and re-tested the search strategy until it appeared appropriate under the given circumstances.

Results

Our initial snowballing strategy established that practitioners orientate themselves in a variety of ways. Some information is searchable; other information relates to the pattern of entries and is technically not searchable. We identified three main search ‘domains’: prescribing, electronic coding and attendance. We found the most useful identifier for chronic pain was the use of repeat medication. Wide variations in coding terms were seen between practices and individuals. Understanding coding cultures is necessary to inform electronic searches. In the case of chronic pain, searching on repeat medication for analgesia, low dose antidepressants and carefully selected coding terms captured most relevant patients.

Conclusion

We generated a search strategy which served the purpose of identifying patients with chronic pain in order to reach a selected target population to recruit into a pain management trial in the community. The process made us aware of the ethical dimensions of coding and the complex dynamics influencing the information infrastructure. Using data for other purposes than the initial task carries the risk of using inadequate information. Knowledge of the context in which the information has been generated is essential. These circumstances include IT factors, organisational factors and individual factors

137

Experiences of primary care consultations of patients with chronic low back pain

Category: Primary Care

Francine Toye, Karen Barker

Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK

Background

Chronic back pain accounts for a considerable amount of the daily workload of the primary care doctor. In primary care, doctors need to maintain a good relationship with their patient and also follow guidelines for best practice. Although the National Institute for Health and Clinical Excellence recommends that decisions about care and treatment of chronic back pain should be made in partnership between the patient and their clinician, this partnership can pose a challenge. Qualitative research can help clinicians to understand patients’ expectations and perceptions of the process of care and this can help to facilitate the best possible outcome. This paper presents a conceptual analysis of patients’ experience of primary care in relation to their chronic low back pain.

Methods

We conducted in-depth interviews with 20 patients with chronic back pain who were waiting to attend a chronic pain management program. All patients had suffered with back pain that had lasted from between 3 and 23 years, and had tried various treatments prior to attending the pain management programme. We conducted semi-structured interviews at three stages: before attending, immediately following the programme and at one year after attending, yielding a total of 60 interviews. We used the methods of constructivist grounded theory to analysis the data. This was appropriate as we aimed to present a conceptual analysis, grounded in the data, which could be transferable beyond the specific sample.

Results

We conceptualised the findings into two main themes. Firstly, being fobbed off by the doctor. This theme incorporated several findings: being told that you should ‘just take the tablets’ and prepare yourself for worst; not getting a ‘thorough examination’; being told ‘I see buckets of people like you’. Importantly, being fobbed off meant that patients felt they were not heard by the doctor, meaning that the doctor did not understand the impact of their pain on them as a person. Secondly, patients constructed narratives of ignorance, perceiving the primary care doctor as ‘just a general practitioner’ who does not know about back pain. Patients adhered to a medical model whereby advice from a specialist was vital, and were prepared to fight to get a referral to see one.

Conclusion

An important paradox is played out in primary care. Although it is important to be heard and understood as an individual, at the same time disease is constructed as an objective biomedical category diagnosed by a specialist. This paradox is made more complex because of the associated cultural polarity between reality (e.g. body, medical), and unreality (e.g. mind, psychosocial). Patients construct their primary care doctor as ‘ignorant’ rather than challenge the pervading biomedical model. Clinicians should be aware of the tensions experienced by a person with chronic back pain, and aim to facilitate the resolution of these tensions.

138

Content of Chronic Pain referrals: time to implement national guidelines?

Category: Primary Care

Maria Koutra, Tamilselvan Rajamanickam, Meera Tewani

South Warwickshire NHS Foundation Trust, Warwick, UK

Background

It is estimated that the number of chronic pain sufferers is gradually increasing. Documents such as the NICE guidelines for management of acute lower back pain and the NaPP resource pack have been produced in an effort to provide guidance for General Practitioners referring patients to pain services. Although most GP referral letters to pain clinics meet the appropriate criteria, the content of the referrals often lacks essential clinical information. Some trusts have published ‘referral proformas’ to overcome this problem, but there is a lack of guidelines at the national level.

Methods

Hundred consecutive GP referral letters for new patient appointments to the South Warwickshire NHS trust Pain Services were audited for the period January 2010 to January 2012. The following data were recorded: Patient demographics and documentation on the referral letter with the following information: diagnosis of underlying condition, history of pain, relevant investigations and results, details of treatment for pain received by the patient before referral to the pain clinic, past medical history, psychosocial history and current medications.

Results

The patients were sixty seven females, thirty three males (mean age years 59.23 years, SD 14.97years). Clinical diagnosis was recorded in 53% of cases. Detailed history of pain was included in 31% of referrals. Details about relevant investigations were included in 49% of referrals. Accurate information about medical treatment for pain received by the patient prior to their referral to pain clinic was included in 64% of letters. Past medical history was recorded in 79% of cases and current medications were recorded in 75%. Psychosocial history relevant to chronic pain was documented in 29% of cases.

Conclusion

There is often lack of essential clinical information on the Community referrals to Chronic Pain services. This does reduce the efficiency of Pain services and delays appropriate treatment for patients. Some Trusts have published “referral proformas” for primary care at local level, in an effort to overcome this problem. There is a lack of national consensus on the content of chronic pain referrals. Implementation of national guidelines would improve the efficiency of Chronic Pain Services.

139

A General Practitioner’s mind-map to the interface between Primary and Secondary Care services for pain

Category: Primary Care

Joao Calinas Correia

The Corner Surgery, Lambeth, London, UK

Background

The IASP defines pain as damage, threat, or something described in such terms (Merskey 1986). This concept of pain has been instrumental in organising the secondary care pain services we currently enjoy, and the conceptual framework where the pain specialist operates. Presently there is a drive for the development of the primary care ability to care for chronic pain. However, GPs caring for chronic pain are not a new specialty defining itself around some new concepts. Rather than calling GPs to rally around the concepts operating in specialist secondary care, a more delicate matching of the conceptual framework already operating in General Practice to the diverse concepts of pain is required. The question to answer is precisely how to make best use of what a GP already is, in caring for chronic pain patients. We start with a reflection on the chronic pain population to be cared for.

Methods

We considered several conceptualisations of pain, namely Wall’s characterisation of pain as a need-state (Wall 1976), Seery’s work on resilience and pain (Seery 2010) and the diathesis-stress model (Flor and Hermann 2004). This diversity provides insights into the reality of pain more akin to a Generalist’s approach.

We drew heavily on our experience and knowledge of primary care services for Chronic Pain, from the dedicated MDT based models in operation to the Health Trainer models being developed, as well as our experience of secondary care specialist services. Also considered were non-pain services in primary care, like the current inter-practice for Gynaecology and Dermatology; and the focus on complexity in organising primary care services for the elderly and multipathology/polypharmacy patients.

We aim to tease out what has a GP, while a GP, to offer to the chronic pain patient, adopting a mind-map approach to explore and connect the issues arising.

Results

The vast hidden need has been confirmed by a systematic review of the prevalence of chronic pain (Ospina and Harstall 2002), finding an average prevalence of 35% among the general population. It is plain the need for chronic pain care is vast and overwhelming.

The clarification of the space lying between the average competence in Pain management of the average GP on one side, and the population targeted by specialist services on the other. Two groups are readily identified here: one that exceeds the ability of the average GP but does not meet the criteria for secondary care intervention; and another group who had met the criteria but has exhausted the resources of secondary care and does not benefit from continued specialist care.

Conclusion

A first step in mapping the diverse possible approaches to caring for chronic pain in primary care is the reflection on the impact, advantages and disadvantages each brings to the core problem being addressed. We produced a visual presentation of this reflection, from which we can proceed to a discussion of the mix of methods to be incorporated in the design of a primary care service for chronic pain.

Psychology

140

The influence of ‘significant others’ on persistent back pain and work participation: a qualitative study of illness perceptions

Category: Psychology

Serena McCluskey, Joanna Brooks, Nigel King, Kim Burton

University of Huddersfield, Huddersfield, West Yorkshire, UK

Background

Individual illness perceptions have been shown to be important influences on clinical outcomes for low back pain, and the influence that others have on pain outcomes and disability are well documented, yet significant others’ illness perceptions are rarely explored, particularly in relation to work participation. The aim of this research was to initiative qualitative research in this area in order to reveal how significant others and wider social circumstances might contribute both to the propensity of persistent back pain and to its consequences.

Methods

Semi-structured interviews based on the Illness Perceptions Questionnaire were conducted with two samples of non-working chronic back pain participants, along with their significant others (n=18). Participants were recruited from both a Condition Management Programme or a hospital-based chronic pain clinic in the north of England. Data were analysed using template analysis.

Results

Significant others further reinforced and validated claimants’ negative beliefs/illness perceptions, including fear of pain/re-injury associated with certain types of work, perceived job inflexibility and/or lack of support from employers. Keen in their desire to be viewed as a ‘good’ spouse/partner/close family member, significant others acted as a ‘witness to pain’, supporting claimants’ self-limiting behaviour and statements of incapacity, often responding with assistance and empathy. In some cases, significant others were more pessimistic about the likelihood of claimants returning to work, and more resigned to the permanence of the claimant’s condition. Interestingly, many of the significant others also experienced chronic illness, some being disability benefit claimants themselves, thus participants’ lives were often intertwined and defined by illness.

Conclusion

This research reveals novel and interesting insights about the illness beliefs and behaviours of significant others in relation to persistent back pain, and findings may usefully inform the design of future intervention programmes aimed at work participation. Further investigation of the influence of significant others on persistent back pain and return to work appears to be a promising area of research.

141

Psychological interventions for parents of children with chronic illness

Category: Psychology

Emma Fisher¹, Emily Law², Tonya Palermo^2,3, Christopher Eccleston¹

¹The University of Bath Centre for Pain Research, Bath, UK, ²Seattle Children’s Research Institute, Seattle, USA, ³University of Washington School of Medicine, Seattle, USA

Background

Chronic illnesses affect a growing proportion of children around the world every year (Halfon 2010; Van cleave 2010). Parents play an important role in their child’s illness and have been found to influence the child’s pain levels and disability. However, a parent is also negatively affected by the child’s illness which has been found to increase anxiety, depression (Eccleston 2004).

Psychological interventions that target parents to improve their mental health and behaviour have a positive effect on the child symptoms and family functioning (Laffel, 2003). Individually, these therapies have had success with particular populations of chronically ill children including diabetes, recurrent abdominal pain and cancer and can be delivered through various methods. However, the overall effectiveness of such interventions has not yet been analysed.

The aim of this systematic review was to investigate the effectiveness of psychological interventions aimed at parents of children with chronic illness.

Methods

An inclusion criterion outlined fourteen chronic illnesses including headache, recurrent abdominal pain, back pain, idiopathic pain conditions, complex regional pain syndrome, rheumatological conditions, cancer, diabetes mellitus, asthma, traumatic brain injury, inflammatory bowel diseases, sickle cell disease, skin diseases and gynaecological disorders. MEDLINE, EMBASE, PsychINFO and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for studies that used a psychological therapy involving parents of children who endured a chronic illness. Of the 6149 studies, 106 were extracted for further analysis and a final sample of 34 studies met the inclusion criteria. These included twelve pain studies, nine diabetes studies, six cancer studies, three asthma studies, three traumatic brain injury studies and one eczema study. The psychological therapies used within these studies were categorised into the following groups; cognitive behavioural therapy (18 studies), problem-solving therapy (7 studies), family therapy (5 studies) and multisystemic therapy (2 studies).

Results

Data analysis will be centred about four main themes. First, the effectiveness of all psychological therapies will be analysed within each condition. Second, each psychological therapy will be analysed individually across all condition. Third, the interaction between the effectiveness of each psychological therapy and condition will be investigated and finally, parental content and duration will be analysed.

Conclusion

The data is currently being analysed and our results will be presented. We will present results regarding which intervention is most effective for parents of children with a chronic illness.

142

Does cognitive load moderate the interruptive effect of pain on attention?

Category: Psychology

David Moore, Christopher Eccleston, Edmund Keogh

The University of Bath, Bath, UK

Background

There is a growing consensus surrounding the importance of attentional processes in pain. We have shown that tasks that place particular demands on attention are susceptible to the interfering effect of pain (Moore et al., 2012). This has been investigated using different tasks that are assumed to vary in cognitive demands. The present study aimed to examine task demand within the same set of tasks. We achieved this by modifying our original battery to measure performance under low and high load.

Methods

Three experiments were conducted with 20 participants. A similar protocol was followed, with the only difference being the attentional task used. Experiment 1 used an n-back task (attention span), Experiment 2 an attentional switching task (attentional control) and Experiment 3 a divided attention task. Two versions of each task were designed, one with a low cognitive load and one with a higher load. For example, for attention span a 2-back (low load) and 3-back (high load) task were used. Participants completed both the high and low load task under two counterbalanced conditions: once in pain and once without pain. In the pain condition, heat was applied to their right ankle using a Medoc ATS system. This involved presenting a heat sensation that oscillated 1⁰C above and 1⁰C below participant’s pain threshold. This occurred for 10 oscillations before returning to a 32⁰C baseline. This cycle was repeated throughout the task.

Results

There was a significant interaction between pain and cognitive load on n-back performance. When compared to the control condition, pain resulted in was worse performance on the high load n-back task. There was no effect of pain on the low load version of this task. For the attentional switching task and the divided attention tasks performance was poorer in the high load compared to the low load condition. However, there was no main or interactive effect of the pain manipulation on these two tasks.

Conclusion

These findings partially support our previous findings that pain has an interruptive effect on attentional performance. It also suggests that while cognitive load may be an important factor in the relationship between pain and attention, it may depend on the task concerned. Further work is needed to examine what aspects of load related to pain processing as well as to examine in more detail how pain interrupt attentional performance.

143

Qualitative study of the patient experience of spinal cord stimulation

Category: Psychology

Stacey Mann¹, Elizabeth Sparkes^1,3, Robert Ashford¹, Jon H Raphael^1,2

¹Faculty of Health, Birmingham City University, Birmingham, UK, ²Department of Pain Management, Russells Hall Hospital, Dudley, UK, ³Faculty of Health & Life Sciences, Coventry University, Coventry, UK

Background

Spinal Cord Stimulation (SCS) is effective at decreasing pain intensity in patients with chronic pain¹, however, efficacy has been found to be reduced over time.² This could be due to physiological, technical or psychological reasons. Though the impact of psychological factors upon the efficacy of SCS has been investigated using quantitative methods, these have failed to produce confident predictors.

Qualitative interviews allow for the collection of alternative unexpected data, therefore highlighting additional factors which questionnaires alone may fail to uncover. The current research aimed to investigate the experience of SCS 12 months after therapy using a qualitative approach.

Methods

Semi structured interviews were carried out 12 months post SCS implantation. The semi-structured interview schedule was derived from literature depicting topics suggested to be important when assessing patients with chronic pain for treatments, including SCS.The sample included thirteen chronic non-cancer pain participants trialled for SCS, recruited via a pain management clinic (6 male, 7 female). The majority had gone on to permanent implantation. Eight patients reported ≥50% pain relief and five reported <50% pain relief. Interviews were audio-taped and transcribed verbatim and thematic analysis was carried out by two independent researchers.

Results

Two core themes emerged around expectations: “Failure to Fulfil Expectations” and “Unexpected Experiences”. Failure to fulfil expectations included expecting doctors to adequately reduce pain, and then losing faith in doctors when this anticipated pain relief was not achieved. Participants often displayed frustration towards doctors, for not fulfilling their expectations and not ‘curing’ their pain. Participants also described the desire to speak with an expert patient before the trial and described feeling disappointed when they did not get this opportunity. Unexpected experiences included participants feeling unprepared for the SCS experience, not expecting the trial to be so painful and concerns over body image from the implanted SCS system.

Conclusion

The current findings need further investigation regarding whether if incorporated into the preparation for SCS, they improve would long term outcomes. Information giving via expert patients to reduce unexpected experiences alongside enhanced management of patient expectation via health professionals may improve SCS outcome.

144

Suicidal ideation in chronic pain patients- assessment and management

Category: Psychology

Karthikeyan Thanigaimani, Norma Waite, Jane Hazelgrove

University Hospital Southampton NHS Foundation Trust, Southampton, UK

Background

Suicidal ideation is more common in chronic pain patients when compared to the general population. Previous studies have shown that the prevalence of suicidal ideation in chronic pain patients is between 20% and 50% and the lifetime prevalence of suicide attempts between 5% and 14%. Several risk factors for suicide are commonly found in chronic pain patients. These include: history of mental disorders especially depression, history of alcohol and substance abuse, and loss of work and social roles. Fishbain et all have recommended that in all chronic pain patients exhibiting suicidal behavior, a careful assessment of associated suicide risk factors should be done. We decided to conduct a retrospective observational study of our patients to identify prevalence of suicidal ideation and to assess whether a detailed history of suicidal risk factors is obtained in order to risk stratify these patients and ensure appropriate management.

Methods

Institutional approval for this service evaluation was obtained. One hundred consecutive patients attending their first multidisciplinary assessment in the Southampton Chronic Pain outpatient clinic from July to September 2011 were included. Patients are routinely sent a pain assessment questionnaire along with a Becks Depression Inventory-II (BDI-II) to be filled in before coming to the clinic. Data were collected from these questionnaires and from the clinicians’ documentations. Details such as past psychiatric illness, drug or alcohol abuse, BDI-II score and response to question 2 and 9 on the BDI-II scale relating to pessimism and suicidal ideation were collected. The suicide question, question 9 (Q9) in the BDI-II was used as the screening tool and the documentation of other risk factors and protective factors for suicide was assessed. Patients scoring greater than 19 on the BDI-II scale are considered to be moderately to severely depressed.

Results

The prevalence of depression (BMI score >19) and suicidal ideation (score 1-3 for Q9) on the BDI-II scale was 48% and 28% respectively. Among the patients with suicidal ideation the prevalence of past psychiatric disorders was 67.8% compared to 34.2% among other patients. Other risk factors such as social abuse and past history of self harm or suicide were not clearly documented.

Twenty eight patients were identified to have suicidal ideation. Twenty four patients scored 1 for Q9 (I have thoughts of killing myself, but would not carry them out) but only 10 (42%) of these had a clear assessment and documentation of suicide risk. One patient scoring 2 (I would like to kill myself) and 2 patients scoring 3 (I would kill myself if I had a chance) on Q9 were referred to mental health services. One patient scoring 2 on Q9 did not have clear documentation.

Conclusion

Assessment of risk factors was not done on all patients with suicidal ideation. Patients who have been identified to have suicidal ideation using a screening tool (BDI-II) should have a more detailed assessment of their suicide risk either by a structured interview or using scales such as Becks Scale for Suicidal Ideation to ensure that appropriate management either by the GP, a chronic pain psychologist or the mental health team is delivered. Therefore we recommend that health professionals involved in the treatment of chronic pain patients need increased awareness and education about risk factors for suicide in this patient group.

145

The interrelationship of psychological distress, multidimensional fatigue and chronic pain duration among chronic pain patients

Category: Psychology

A Taiwo, A Soni, T Kinsella

Trafford Healthcare NHS Trust, Manchester, UK

Background

It is a well established fact that patients with chronic pain commonly present with a range of inter-related problems far beyond the pain itself. There is a growing body of evidence that psychological distress, fatigue and some socio-demographic factors are part of these inter-related problems and play significant roles in the exacerbation of chronic pain experience. This study assessed the subjective psychological distress and multidimensional fatigue, as well as age, gender, duration of pain, and work status of the Chronic Pain Patients attending pain management clinics at Trafford Health Care Trust. The purpose of the study is to examine the relationship of these factors to the patient’s chronic pain experience. The information will be useful in making informed decision regarding the provision of multidisciplinary treatment approach for these patients.

Methods

The study was a prospective survey and adopted a co-relational design. Participants were volunteers drawn from the patients attending the pain management clinic between February and May, 2011. The criterion for inclusion were clinically diagnosed chronic pain patient consented to participate in the filling of the questionnaire. The questionnaire was divided into sections A, B, and C. Section A obtained socio-demographic information; section B contained the 12-items General Health questionnaire (GHQ-12) to measure their subjective psychological well being and establish the presence of psychological distress; while section C was a Short form 20-items Multidimensional Fatigue Inventory(MFI). The MFI has five subscales including general Fatigue, physical fatigue, reduced activity, reduced motivation and mental fatigue. Sections A and B are psychometrically sound scales and has been widely used in research. The authors of GHQ-12 suggested a criterion score of 4 as basis for further psychological investigation among patients with medical problems.

Results

The total numbers during this period were 51, with a mean age of 58.3 years. In section B (GHQ-12), 61% of the patients scored above the criteria of 4 adopted in this study. In section C, 90%, 94%, 86%, 78% and 60% of the participants scored above average on subscales of general fatigue, physical fatigue, reduced activities, reduced motivation and mental fatigue respectively. A significant positive relationship exists between psychological distress and fatigue of all dimensions. Also, younger patients are more likely to report more psychological distress and mental fatigue than older patients. The mean duration of pain was 6.96 years. There was no significant relationship between duration of pain and other observed variables.

Conclusion

There is a strong presence of psychological distress and multidimensional fatigue among the participated chronic pain patients. The fact that the majority of the participants reported physical fatigue found support from previous studies. The need for more extensive psychological assessment is implied. A combination of cognitive behavioural (CBT) and insight therapy that will teach skills to enhance activities, increase motivation, how to pace to combat physical fatigue and also dig out hidden factors causing psychological distress is implicated.

146

Developing a new set of pain scenarios for experimental research purposes

Category: Psychology

Edmund Keogh, Hayley Wimpenny

University of Bath, Bath, UK

Background

Social-contextual factors are increasingly being viewed as important in understanding why there is variability in pain behaviours. One method used to explore contextual effects has been to use written scenarios, which vary in terms of core features e.g., emotional reactions. As there are no standardized scenario sets that include pain alongside other emotions, we sought to develop a new stimulus set that could be used for research purposes.

Methods

We developed 36 different written scenarios, which were of similar length (4-5 sentences), and written to reflect one of three core emotions (pain, anger, happiness) experienced by the main character to a specific event. Anger and happiness were chosen as they reflect core negative and positive emotions, respectively, and were considered to be useful comparison groups to pain. Following ethical committee approval, 30 adults (15 males; 15 females) were recruited to rate one of three scenarios sets, with each set containing a selection the three core emotions. Scenarios were rated on Likert scales for intensity of core emotions (happy, sad, anger, pain, surprise, fearful, disgust), as well as more general levels of arousal and emotional valence.

Results

The rating data was collated by target emotion, and mean intensity scores used to remove scenarios that did not show a clear dominant emotion. Inclusion was based on the retention of scenarios where there was a relatively high target emotion rating, and low non-target emotion rating. This produced a final stimulus set of 24 scenarios, with 8 examples of each emotional response. ANOVAs confirmed that each emotion set received a significantly higher target emotion intensity rating than their non-target comparisons. Expected differences were also found in terms of valence and arousal i.e., happy scenarios were rated as more positive and relaxed.

Conclusion

We have created a new set of short scenarios that describe a persons’ emotional response to a specific event, which includes pain. We believe that these scenarios could be utilized within experimental pain research, and further validation and reliability testing will strengthen their efficacy. We are currently utilizing these scenarios in a series of studies that examine the role of context on pain detection. Although each of the scenarios involved a gender-neutral character, they could be easily modified to see whether gender affects ratings.

147

Auditory priming in the recognition of facial expressions of pain: are there sex differences?

Category: Psychology

Joseph Walsh, Edmund Keogh

University of Bath, Bath, UK

Background

Pain does not occur in isolation. Rather it is a perceptual experience which is influenced by a range of biopsychosocial cues, including social-contextual factors. Research also shows that males and females differ in pain experience, and in their ability to recognise emotions in others. However, little research has considered the extent to which males and females differ in pain recognition, and whether context plays a role. The present research aims to rectify this omission by investigating sex differences and the effect of contextual cues on facial pain perception.

Methods

Following ethical committee approval, 36 (17 male and 19 female) participants were recruited from the University of Bath. Participants completed a computer based priming task. Two stimuli were presented. The first, a prime stimulus, was presented in the form of an emotional vocalisation (pain or sadness). This was followed by a target stimulus, which was an emotive face (pain or sadness). Both primes and targets were either male or female. Trials were, therefore, defined according to two types of prime-target congruence: emotion congruence (where the same or a different emotion prime was presented before the target stimuli) and sex congruence (where the emotion prime was either the same or different sex as the target). Participants were required to identify the emotion presented in the target facial stimulus using a forced choice paradigm.

Results

ANOVAs were used to analyse the accuracy and reaction time (RT) data. For accuracy data, no sex difference was present in accuracy of recognition. However, emotion incongruent primes significantly reduced pain identification accuracy. Prime congruence had no significant effect on sadness recognition accuracy. For the RT data, there was evidence that females’ reaction times were significantly influenced by contextual cues compared to males. Women were faster at correctly identifying female pain face targets when they had been preceded by an emotionally congruent prime. Conversely, emotion incongruent cues slowed reaction times to female pain faces. Gender congruence of primes had no significant effect on RTs. Males showed no effect of priming on reaction times.

Conclusion

Emotionally congruent contextual cues help improve the accuracy of pain expression identification. The current study also indicates that contextual emotional cues may speed correct recognition of pain facial expressions, although this may occur in a sex-specific way. These findings suggest that the speed by which women recognize another female’s pain may be affected by context. If the recognition of pain expressions is context dependent, then this has implications for our understanding of pain as a prototypical emotion. Avenues for further research are considered.

148

Beyond catastrophizing: mental defeat and stress in chronic pain

Category: Psychology

Denise Hrouda, Katherine Finlay

Buckingham University, Buckingham, UK

Background

Mental defeat is a cognitive construct that conceptualises the negative impact of pain on self and identity. In chronic pain patients, it has been found to be a stronger predictor of pain interference, depression and psychosocial disability than catastrophizing (Tang et al, 2010). Significantly higher levels of mental defeat have also been observed in chronic pain patients (those seeking treatment in a pain clinic) relative to non-patients (those with chronic pain not seeking specialist treatment) or those with acute pain (Tang et al, 2007). Yet mental defeat has not been investigated longitudinally or in relation to stress. This study examined longitudinally the relationship between mental defeat, stress and pain interference/disability in a population of discharged chronic pain patients.

Methods

A longitudinal within-subjects, cross-sectional design was used. 31 chronic pain sufferers (24 female and 7 male) were recruited from 2 regional support groups. All had chronic pain for a duration of 6 months or longer. Most participants had previously attended a pain clinic at their local hospital and been discharged following completion of a pain management programme. Participants completed 6 questionnaires measuring mental defeat in relation to pain interference, functional psychosocial disability, pain intensity, pain catastrophizing and perceived stress. Questionnaires were completed at baseline, 1 week, 1 month and 3 months.

Results

Mental defeat displayed a trait-like profile, remaing stable across all time points. Stress levels also remained constant over time. Mental defeat was moderately-to-strongly positively correlated with functional and psychosocial disability and both pain and sleep interference (p<0.05). Relative to participants with lower levels of mental defeat, those with higher mental defeat reported significantly greater levels of disability and pain interference. However, although mental defeat was the strongest predictor of functional disability at baseline, pain intensity, not mental defeat, was the largest predictor of disability overall. Perceived stress was a significant predictor of sleep interference at 3 months. Strong correlations were observed between mental defeat and pain catstrophizing and when partial correlation analyses were performed between mental defeat and disability, controlling for catastrophizing, correlations remained significant (p<0.05).

Conclusion

Results confirm previous findings of elevated levels of mental defeat in chronic pain patients and positive correlations between mental defeat and disability (Tang et al, 2010). In contrast with previous research, pain intensity, not mental defeat was the strongest predictor of disability in this population of patients. Mental defeat is a stable personality trait rather than a transient emotional state and therefore a target for treatment and prediction of outcomes in a pain management programme. Mental defeat may explain individual differences in functional disability, but should not be managed in isolation and should be considered alongside pain intensity and perceived stress.

149

Evaluation of a pilot Cognitive Behaviour Therapy (CBT) programme for people with insomnia secondary to chronic pain

Category: Psychology

Sue Peacock, Susan Ferrara, Rebecca Daniels, Belledeep Tanday, Harbinder Sandhu

Pain Clinic, Milton Keynes Hospital NHS Foundation Trust, UK

Background

Chronic pain is experienced by 7.8 million people in the UK, two thirds of these suffer from disturbed sleep (CMO Report, 2008). Usually secondary insomnia is addressed by focusing treatment on the condition assumed to initiate the sleep disturbance as opposed to treating the insomnia itself (Ashworth, Davidson & Espie, 2010). Those that experience insomnia secondary to chronic pain have higher levels of dysfunctional beliefs regarding their sleep than insomnia sufferers without chronic pain (Ashworth, Davidson & Espie, 2010). It is important to address thoughts and beliefs as initial research suggests that quantity and quality of sleep is improved in those with chronic pain and insomnia when treated with CBT, yet despite these findings CBT interventions targeting this group remain underused (Currie et al, 2000). This pilot study aimed to develop a CBT programme to improve the quality and quantity of sleep in chronic pain patients with secondary insomnia.

Methods

Participants (n= 20) were patients that attended the chronic pain clinic, who reported sleep disturbance and opted into the programme. The programme involved attending 6 two hour weekly group sessions in which CBT methods were discussed with them for managing their sleep. The Pittsburgh Sleep Inventory was completed at the beginning and end of the programme to measure quality and quantity of sleep. Throughout the programme participants kept sleep diaries to monitor their progress. The sessions focused on measuring and understanding sleep and insomnia, sleep hygiene, dealing with a racing mind, relaxation techniques and scheduling a new sleep pattern. Participants were followed up by telephone one month after the programme had ended, and asked to share their views of the programme, and if attending the programme had impacted at all on their sleep.

Results

Results from the Pittsburgh Sleep Inventory show the majority of the participants (n=19) found that the programme had started to positively influence the amount of actual sleep they obtained, with all but one reporting that they were obtaining more sleep. This sleep programme had a positive effect on most participants (n=15) with regard to various aspects of their sleep routines and daily lives. All participants expressed having less trouble getting to sleep after completing the programme, and a majority (n=19) felt that the quality of their sleep had improved. 14 participants completely stopped relying on sleep medication and experienced less difficulty in staying awake during the day. Themes identified from telephone discussions focused around the benefits of group support, they felt that the programme and sleep diary were informative and useful, their change in thoughts and behaviour, and the challenge implementing new sleep patterns.

Conclusion

Overall results from this small pilot programme indicate that CBT treatment for secondary insomnia caused by chronic pain improves sleep quality, sleep patterns and thoughts and beliefs regarding sleep. Patients benefitted from the group setting, being able to share experiences and support each other. Should this programme become more widely available to patients, it could act as an effective and empowering treatment for secondary insomnia that alleviates patients’ dependence on pharmaceuticals as well as the debilitating effects of their chronic pain.

Funding: Initial funding was providing by South Central Health Authority Innovations Fund

Reviews

150

Searching for and reviewing self help material-a lay perspective.

Category: Reviews

Carrie Stewart¹, Patricia Schofield¹, Ron March¹, Richard Gard¹, Michael Morrison¹, Sheena Fowler¹, Blair Smith³, Geraldine Anthony¹, Amanda Clarke²

¹Aberdeen University, Aberdeen Scotland, UK, ²Northumbria University, Northumbria, UK, ³University of Dundee, Dundee Scotland, UK, ⁴Greenwich, London, UK

Background

Pain is common: the one month population prevalence of pain, in persons aged 18-65 years in the UK, has shown to range from around 8% in the abdomen in the abdomen to 28% in the low back pain area ¹. In older persons, the occurrence of pain especially disabling pain and /or pain at multiple sites- is a particularly important problem since it threatens independent functioning & functional self -efficacy ². There is a plethora of self help materials available from a range of sources accessible to the general public. The difficulty is and in what format they be offered. This project was developed to compliment the systematic reviews carried our as part of the EOPIC study.

Aim- The overall laim was to identify and agree usefulness of self help material or ‘grey’ literature.

Methods

Reviews were were drawn from lay participants within phase1 &2 1 of the EOPIC programme along with volunteers from the advisory group and contacts of older adults recruited into earlier studies within Aberdeen who also, expressed interest in maintaining continued involvement in research. One of the PHD students linked to the study and the members of the group which included developing internet and literature searching skills and support in accessing self help material. A scoring system was developed by the group which was based upon service user preferences for self help materials and included ten items such as font size and colour. Literature was identified and reviewed. Any resources scoring above 5 on the scale were retained. Sources searched included chemists; library; GP surgeries; Arthritis Research Council; International Pain Societies including American, Australian, British; CKS NHS; INTUTE; Scirus; SIGN; NICE; Patient UK; Concern; Books and periodicals.

Results

Over fifty-seven recourses from over twenty-eight sources were identified. Thirty-two items were identified as meeting the key criteria for inclusion. Others were rejected as they did not meet the criteria for updates, support networks or identified finding body. None of the recourses that were identified were for older adult specifically. The material was organised into five categories: books/eBooks; internet; periodicals; leaflets and tapes.

Conclusion

Overall leaflets seem to be the preferred format. There are few good internet sites and some useful books. The general rule is that a range of formats is probably the best option. A range of books, internet sites and leaflets were found to be useful. But usefulness of these may vary in use according to personal choice.

151

From presentation to journal publication: the journey of British Pain Society- Annual Scientific Meeting abstracts

Category: Reviews

Neeraj Saxena^1,2, Shefali Kadambande¹, Sharmila Khot^2,1

¹Cardiff University, Cardiff, UK, ²University Hospital of Wales, Cardiff, UK

Background

Presentation of abstracts at scientific meetings provides an opportunity for clinicians and researchers to showcase their work and gain informal feedback and critique. It also allows the audience to gain useful, timely knowledge and information, potentially long before it is published. Since conference abstracts undergo a less rigorous review process for acceptance as compared to scientific journals, this allows presentation of preliminary research work, research methodology protocols and non-research work such as clinical audits, service evaluations and case reports. However, following this informal peer- review at society meetings, all abstracts do not progress on to full- text publications in scientific journals. This, ‘presentation to full-text publication conversion rate’ maybe considered as a quality benchmark of these scientific meetings.

The aim of this study was to determine what proportion of abstracts presented at a British Pain Society -Annual Scientific Meeting (BPS-ASM) subsequently results in full-text publications in peer reviewed journals.

Methods

All abstracts presented at the BPS-ASM in 2005 (chosen to allow a 6 year follow up period) were considered. Ovid Online was used to search various databases including, EMBASE, MEDLINE, OLDMEDLINE, PsycINFO, CINAHL and AMED databases. Database searches were done using the first author’s name, with a period limit (2005 till 2011). If numerous citations appeared, search was further narrowed down using the last author’s name. The resulting titles were searched through for a matching title and the abstracts read to compare with the conference abstracts. If a definite match was not found, further searches were done using other authors’ names and keywords from the abstract titles. Finally, Google Scholar was also used to search using the titles and authors’ names. Following this search strategy, if no citations were found, it was considered that the abstracts had not led to a full publication.

Results

There were a total of 97 abstracts accepted (but 1 withdrawn) for presentation at the BPS- ASM in 2005. Thirty eight abstracts (39.6%) resulted in a full text article publication in a peer-reviewed journal with no change or some change from the original abstracts. At least 5 other abstracts appeared on internet searches on author’s or their institution’s websites either as abstracts or titles in their lists of presentations. The other 53 abstracts (55.2%) could not be accessed in any format on the web. All the full-text publications were achieved within 5 years following the presentations, with the most being published within the first 3 years after presentation.

Conclusion

Only about 40% of the abstracts presented at the BPS-ASM in 2005 were published as full-text peer-reviewed journal articles. Over half of the abstracts do not appear in the public/ scientific domain after their initial presentation.

All scientific work, involves valuable resources including time, effort and money. Failure to disseminate their hard-earned data to other interested clinicians/ researchers restricts its full application to patient care. Steps should be taken by presenters to publish their work through peer-reviewed journals and by BPS to publish their abstracts through their regular publications or on their website and made accessible to all.

152

A systematic review of the prevalence of neuropathic pain in the general population worldwide: initial findings

Category: Reviews

Raga Elzahaf^1,2, Osama Tashani^1,2, Mark Johnson^1,2

¹Leeds Metropolitan University, Leeds, UK, ²Leeds Pallium Research Group, Leeds, UK

Background

Neuropathic pain arises as a direct consequence of a lesion or disease of the somatosensory system. Studies suggest that prevalence is high although there has not been a systematic review of published studies. The aim of this systematic review was to analyse surveys of the neuropathic pain in the general adult population worldwide.

Methods

Computerised databases (Medline, Embase, CINAHL, SportDiscus, Sciencedirect, CAS ILLUMINA, Academic search complete, PsycINFO) were searched and screened for inclusion by 2 reviewers. Studies were included for review if they: i) were cross-sectional surveys of adults from the general population using randomised sampling techniques e.g. telephone, postal or primary care service lists; ii) identified neuropathic pain using a validated screening tool or clinical investigation; iii) estimated the prevalence of neuropathic pain. Study data was extracted by 2 reviewers and overall prevalence calculated as a weighted mean after an outlier analysis was conducted.

Results

67 of 624 studies identified were potentially relevant. Five studies (59157 respondents) met the inclusion criteria. Telephone, postal and internet based survey techniques were employed in the studies and DN4, LANSS or S-LANSS was used to identify neuropathic pain. Estimates of the prevalence of neuropathic pain were 3.3% in Austria (Gustorff, et al.2008, n=7707), 3.3% in Spain (Perez et al., 2009, n=23529), 6.9% in France (Bouhassira et al., 2008, n=23712), 8.2% in the UK (Torrance et al., 2006, n=3002), and 17.9% in Canada (Toth et al., 2009, n=1207). The small sample size and low response rate (42%) may have inflated the estimate in Canada, although the study was not rejected following outlier analysis. Weighted mean prevalence for the 5 studies was 5.29% (95% CI=5.1% to 5.48%) with women being more likely to be identified as having neuropathic pain than men (Odds Ratio = 1.27, 95% CI=1.06, 1.52).

Conclusion

Our initial estimate of the prevalence of neuropathic pain of 5.29% of the general adult population was based on data from 5 countries each with a Human Development Index (HDI) >0.9 (i.e. developed countries). Therefore, it may not be a true reflection of prevalence worldwide because of the lack of studies from countries with HDIs <0.9 (i.e. developing countries).

153

Evaluation of post operative pain relief - “closing the loop” through education

Category: Reviews

James Wright, Radhika Bhishma

North Manchester General Hospital, Manchester, UK

Background

Effective postoperative pain management can improve morbidity, decrease duration of hospital stay and provide the best quality of care for the patient.¹ Preventive analgesia can positively effect postoperative pain and therefore help to reduce the risk of uncontrolled pain and escalating problems.² Uncontrolled pain is defined as ‘A pain score of 4 or more on a visual analogue scoring system.’² The Royal College of Anaesthetists (RCoA) audit standard states:’100% of surgical patients should have a pain score of less than 4/10 at waking and thirty minutes later.’ However a search through literature shows that severe pain following surgery occurs in 11% of cases.³

We therefore initiated an audit on post operative pain relief to evaluate the standards as set by RCoA and planned to implement the recommendations from the results through education and training with the view to closing the audit loop by re-auditing with the same set of standards.

Methods

During February-March 2011, prospective data was collected by recovery personnel regarding post operative pain relief from all surgical cases using a proforma designed by multidisciplinary team of Anaesthetists, Pain nurses and Recovery staff. This enabled 200 case data set involving ten different surgical specialities to be recorded and evaluated.

The aim was to record:

• Pain scores at waking, thirty minutes and at discharge from recovery unit using a 0-10 visual analogue scoring system

• All intra and post operative analgesia usage

• Surgical procedure undertaken

• Delay in discharge from recovery unit and the reasons for the delay

The results were presented to members of the anaesthetic and recovery department. Recommendations on methods to improve outcome were discussed. Dissemination of information through a ‘traffic light system’ was designed and implemented through repeated emails, oral presentations and by exhibiting posters in all anaesthetic rooms.

Re-audit was undertaken after 8 months.

Results

Initial data:

• 75% of cases achieved pain scores of <4/10 on waking and hence failed to meet the RCoA standards. There was great variation amongst surgical specialities with some achieving the standards in only 40 % of cases. Laparoscopic surgery, dental extractions, drainage of abscesses and colorectal surgery attained low scores.

• Good pain control and low pain scores were recorded with multimodal approach to analgesia administration. Using more than one analgesic agent along with regional/neuroaxial blocks offered the best outcome.

• Over 25 working days, the cumulative delayed discharge due to pain was 44 hours 50 minute, an average of 108 minutes per day.

Re-audit after education:

• Overall improvement was 13%. 88% of cases scored <4/10 on waking.

• All surgical specialities achieved <4/10 pain scores in at least 80% of cases.

• Delayed discharge was reduced to an average of 31 minutes/day with inherent cost savings.

Conclusion

Poor pain management increases morbidity and delays recovery resulting in inefficiency in service provision and increased costs. Multimodal analgesia and neuroaxial blocks given in a timely manner is the most effective method of achieving good postoperative pain relief.

Our audit identified failures in meeting standards set by RCoA. Education played a key role in improving the outcomes as shown by the re-audit.

At our hospital, management of post operative pain control in recovery area has improved by 13% after the implementation of recommendations through education. The audit cycles will continue until the RCoA standards are achieved in 100% of cases.

References

1. American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. J Am Med Assoc 1995:274:1874-1880

2. Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: Evidence from published data. Br J Anaesth 2002;89(3):409-423

3. Australia and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management scientific evidence (2nd Ed). ANZCA, Australia 2005.

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Does religious identity influence chronic pain experience and expression?

Category: Reviews

S. José Closs¹, Jill Edwards¹, Chris Swift², Michelle Briggs¹

¹University of Leeds, Leeds, UK, ²Leeds Teaching Hospitals NHS Trust, Leeds, UK

Background

An issue which has untapped potential for improving pain management is the influence of religious beliefs and practices on pain. A knowledge review considered five faith groups, Christians, Jews, Muslims, Hindus and Sikhs. While research, policy, practice and other relevant papers were identified, the research literature is considered here. We aimed to identify first the relationships between religious identity and chronic pain experience and expression, and second, religious meanings attributed to pain.

Methods

The broad criteria for inclusion were:

1. Empirical research of any design was considered, plus relevant policy, organisational and good practice examples.

2. Study population was identified as Christian, Jewish or Hindu or Sikh, or Muslim, or white or South Asian.

3. The subject of the paper was pain and spirituality or religion (specific or general) or faith or culture or ethnicity.

4. Published in English.

Papers were screened for inclusion by two researchers, with arbitration by a third when necessary. Data extraction and assessment of methodological quality were also undertaken by two independent researchers.

Results

Twenty-eight studies were identified which met the inclusion and quality criteria. Most were concerned with the association between faith and pain intensity, or coping with pain, and the vast majority focused on Christianity. They were extremely heterogeneous in terms of aims, methods, measures used and findings. There was considerable inconsistency in definitions of the religious and related concepts being studied and how they could best be measured. Twenty-one different assessment instruments were used to assess faith/spirituality and findings were diverse and contradictory. There was no research identified which explored how any of the five specific faiths impacted on the experience of chronic pain or how it was expressed.

Our two research questions remain unanswered. In addition, there is a dearth of research which has considered how faiths other than Christianity (practised by 33% of the world’s population) are involved in the experience and expression of pain.

Conclusion

Consistent definitions and use of terms such as religion, religiosity and spirituality and dimensions within these concepts is needed in future research. Related to this is the need to undertake rigorous psychometric testing of the various scales which have been used to measure these concepts as well as testing of their suitability for use with a wide range of different faiths (and those with no faith). This work is an essential prerequisite for research into the relationship between faith and pain, in order to improve how pain is assessed and managed.