Acute Pain

doi:10.1177/2049463713481587

. 2013 Apr;7(2 Suppl):5–76. doi: 10.1177/2049463713481587

Acute Pain

PMCID: PMC4590087

001 A Follow-Up Pilot Study Looking at Pain Management After Discharge, Following Major Surgery

Category: ACUTE PAIN

Charlotte Halmshaw, Carsten Bantel, Stephen Ward, Tanya Carr, Sarah Thomas

Chelsea and Westminster Hospital, London, UK

Background

Background

Post-operative pain is often undertreated due to poor assessment of the pain as well as the reluctance to use strong opioids due to the misconception that this would delay discharge from the hospital due to side-effects like constipation, nausea and vomiting. Patients are often treated with weak opioids like codeine and tramadol even from day three after being on an epidural following laparotomy. This not only resulted in inadequate pain control and at higher doses patients were not only complaining of constipation and nausea, but also found that post-operative physiotherapy and mobilisation was being negatively affected. We started using Targinact (Oxycodone-Naloxone combination) that is proven to reduce the incidence of opioid-induced constipation for the management of acute post-operative pain. We are presenting the preliminary case series of patients who had undergone surgery for cancer at The Christie NHS Foundation Trust.

Methods

We looked at patients undergoing major surgery including laparotomies for colo-rectal, gynaecological and urological malignancies as well as major reconstructive surgery following mastectomy for breast cancer. Patients already on strong opioids and those with prolonged post-operative stay in the critical care unit were excluded. Data collected included pain scores (BPI) at rest, on coughing, on movement and on straining for bowel movement. Patient satisfaction scores, time of first bowel movement, drinking and eating and removal of nasogastric tube was recorded along with bowel function index. Mobilisation parameters like tolerance to physiotherapy, walking to toilet and climbing stairs were noted. Side-effects like constipation, nausea, vomiting, sedation and respiratory depression were also recorded till the day of discharge and any identifiable cause for discharge. The use of concommitant drugs like paracetamol, anti-emetics, laxatives and neuropathic pain agents were documented and patients had telephone follow-up to ascertain analgesic usage and side-effects.

Results

In the preliminary series of 45 patients, all of the patients reported significant reduction in their pain scores over days three to five as compared to the previous standard, which was Tramadol at a dose of 50-100 mg four times a day. Three of the patients had reported constipation at day 5 and six patients had symptoms of nausea and vomiting during their peri-operative period. Patients were using less of oxynorm for rescue analgesia and had better satisfaction scores. Bowel function index were favourable for ease of defecation and for completion of evacuation, but were less reliably recorded for rating of constipation as patients were finding it difficult to quantify it. Patients also recorded better satisfaction scores about their overall peri-operative experience. Patients gave varying duration of use of post-discharge analgesics. One patient died during the observation period.

Conclusion

The use of adequate dose of a strong opioid was better in controlling post-operative pain following major surgery compared to tramadol. The addition of naloxone has effectively reduced the troublesome side-effects of constipation and is an alternative to conventional opioids. The combination of oxycodone and naloxone (Targinact) has been accepted by the surgeons as it effectively addresses the issue of opioid-induced constipation that often delays discharge planning and is currently incorporated in the Enhanced Recovery Pathway as the opioid of choice for the management of post-operative pain. More randomised controlled studies are required to validate the findings of this audit.

005 Acute Neuropathic Pain: How Prevalent is it in Hospitalised Patients?

Category: ACUTE PAIN

Mae Johnson, Lenny Ng, Melissa Mellis, Jeremy Cashman

Acute Pain Service, Department of Anaesthesia, St George’s Healthcare NHS Trust, London, UK

Background

Acute neuropathic pain (ANP) is defined as “pain arising as a direct consequence of a lesion or disease affecting the somatosensory system” (1). It is a condition that is under-recognized, under-treated and can progress to chronicity and disability.

ANP has been previously reported in approximately 2% of inpatients reviewed by an acute pain service in a tertiary referral hospital in Australia (2). It is not as common as nociceptive pain in the hospital setting. The challenge is therefore to identify high-risk patients for the development of ANP. There is evidence that the risk of progression to persistent neuropathic pain is high and that early intervention may prevent this from developing (5).

The aim of this survey was to define the prevalence of neuropathic pain at St George’s Hospital, a tertiary referral and major trauma centre in the UK.

Methods

A retrospective survey of all in-patients reviewed by the Acute Pain Service (APS) at St George’s Hospital between April 2012 and October 2012 was done. Detailed information was collected via the APS patient electronic database.

Data collected included: age, gender, specialty, operation, pain assessment, number of visits, type of pain, pain scores, side effects of pain medication, medication started by the APS and patient satisfaction with their treatment.

Patients with a history of chronic pain were excluded. As this was an observational study, no formal statistical analysis was undertaken.

Results

Over the six month period, 1318 patients were reviewed by the APS. 80 patients were excluded. Consequently, 1238 patient records were analyzed.The mean age of the patients was 50 (range 5- 92) years. 52% of patients were male and 48% female.

123 out of 1238 patients were diagnosed with ANP, an overall prevalence of 11%. Out of the 123 patients with ANP, 120 were from surgical specialties and 3 from medical specialties. The percentage of ANP from surgical specialties was 10% (120/ 1222). The percentage of ANP from medical specialties was 19% (3/16).

The four highest surgical subspecialties with ANP were: vascular 24% (8/34), neurosurgery 19% (9/47), trauma and orthopaedics 16% (40/ 253) and plastics 12% (7/ 60).

Conclusion

The prevalence of ANP in this survey was 11%, a higher percentage than previously reported (2). ANP was more common in those surgical specialties with a predominant trauma case mix. The number of medical patients was small, making it difficult to draw conclusions on ANP rate. Thoracic surgery, perceived to be high risk for ANP, had a low rate of 6%.

To our knowledge, this is the first report of the prevalence of ANP in the UK.We have ascertained the high-risk groups for the development of ANP, this will help in the identification, recognition and treatment for these patients.

006 National Inpatient Pain Study -Using Real Time Data Collection to Measure the Quality of Inpatient Pain Service Techniques and Identify Variations in Practice

Category: ACUTE PAIN

Fiona Duncan¹, Ruth Day², Olga O’Neill³, Jeremy Nightingale⁴, David Counsell⁵

¹Manchester Metropolitan University, Manchester, UK, ²South Devon Healthcare NHS Foundation Trust, Torbay, UK, ³Belfast Health and Social Care Trust, Belfast, UK, ⁴Portsmouth Hospital NHS Trust, Portsmouth, UK, ⁵Betsi Cadwaladr University Health Board, Wrexham, UK

Background

Pain management for patients in hospital is a major problem. Evidence of pain service impact has been lacking, there is significant variation in care provision. Evidence is needed about the ways in which pain services are organized in order to understand whether these are linked to important differences in what happens to patients. The National Inpatient Pain Study group (NIPPS) is a voluntary collaborative venture of inpatient pain specialists working towards building a national prospective research database.

Methods

The long-term aim is to improve the quality of pain management for patients in hospital. The objectives are (1) to describe the case mix of the inpatient pain population (2) to define and monitor the quality and side-effects of different techniques and identify variations in practice.

The pilot clinical dataset is divided into six main sections and includes demographic data, surgical details if relevant, the primary technique used to control pain (e.g. epidural, intravenous Patient Controlled Analgesia, nerve block, intramuscular/subcutaneous and oral analgesia), pain scores, adverse events, and a measure of effectiveness. We use ASA physical status as a general measure of comorbidity. Routine data is collected by members of the pain team using handheld devices, and downloaded to a central site.

The pain service website is live, recording information about service provision including staffing, hours of work, and the drugs and equipment used.

Results

Results indicate that staffing varies widely from 0.5 to 8 nurses per hospital site. 12% of hospitals do not routinely collect data. The main workload is orthopaedic and general surgery based on data from 13 hospitals and 29,080 patients in 2011. 37% of patients reported a pain score of moderate to severe pain on the first assessment, and 21% reported severe pain. Nausea and vomiting was the most frequent adverse event reported. Sixty-nine major adverse events were logged, of which 64 documented respiratory depression. 29% of epidurals were reported as being stopped earlier than planned due to a variety of technical reasons.

Conclusion

We continue to develop and refine our outcome measures, and have a rapidly growing accurate and meaningful database. This is an important step towards reducing variation and improving effectiveness. Prospective longitudinal data has the potential to improve our understanding of variation in outcomes and establish future research priorities.

007 Examining the Effects of Perioperative Pain Management on Pain at First Waking in the Recovery Room

Category: ACUTE PAIN

Stephen Ward, Charlotte Halmshaw, Dushyanth Gnanappiragasam, Carsten Bantel

Imperial College, London, UK

Background

Pain outcomes immediately following surgery may be the result of standardised approaches to preemptive and preventive analgesia, risk factors associated with postoperative pain, or a combination of both.¹

However, it still remains unclear how these factors influence patients’ pain intensities in the ‘real life’ scenario of busy theatres in a major hospital and whether multimodal approaches are used sufficiently enough.

The primary aim of this study was to determine the quality of intra-operative pain management as assessed by pain-intensity scoring on first waking in recovery. Royal College guidelines were used as benchmarks.²

The second aim was to define predictors for the observed pain-scores on first waking through analysis of intra-operative management practice and determination of genuine patient factors.

Methods

After institutional approval between April 2012 and June 2012 n=100 patients’ scheduled to have elective or emergency trauma and orthopaedic surgery, or general surgery were randomly selected for service evaluation. Pain intensity was assessed with a 5-point verbal rating scale (VRS) and recorded immediately on first waking. Co-variables thought to influence this outcome were determined from analysis of anaesthetic, operation and recovery room charts including the patients’ healthcare records. Co- variables for preemptive and preventive analgesic approaches were pain scores at first waking in relation to; total morphine dose, total morphine boluses and total number of preventive analgesics administered. Co-variables for risk factors were; age, gender, previous history of pain, previous history of surgery and open versus closed surgical procedures.

To determine how the independent variables predict the outcome variable logistic regression was applied for the main analysis. A P-value of P<0.05 determined statistical significance during the analysis.

Results

27% of patients’ were found to be experiencing pain greater than mild at first waking. Pain experienced in the recovery room was more likely to be treated than not. However, 30% of patients’ remained untreated, which was carried over to the surgical wards. In general, multimodal approaches were not sufficient enough to have a significant impact on pain scores.

However, a history of previous surgery was identified as a significant predictor of pain at first waking. Patients with such a history revealed a three times increased risk of waking in greater than mild pain at rest. In contrast, age, gender, total morphine dose, number of morphine boluses, number of preventive analgesics administered, open versus closed surgery or wound infiltration were not found to predict post-operative pain scores.

Conclusion

This survey showed the management of immediate post-operative pain following surgery continues to present challenges, and was frequently inadequately treated. Overall, analysis of clinical practice of preemptive and preventive analgesia showed a trend towards artificial standardization with a shortage of individualized care.

In addition, this audit also identified a direct correlation between previous surgery and post-operative pain intensity. However, whether this correlation relates to all types of previous surgery or only to certain procedures remains to be determined. Further research also needs to be done to uncover the relationship of immediate post-operative pain with physiological mechanisms and psychological factors.

008 Efficacy of Patient Controlled Analgesia (PCA) for Post Operative Pain for Level 2/3 Critical Care Patients: Does Early Connection Make a Difference?

Category: ACUTE PAIN

Edward Todman, Amieth Yogarajah, Sian Griffiths, Tim Wigmore, Paul Farquhar-Smith

The Royal Marsden NHS Foundation Trust, London, UK

Background

Failure to provide good post operative pain relief risks increased hospital stay, impaired quality of life and the development of chronic pain, all of which have negative health economic implications. PCAs have been used extensively and there is a good evidence base to support their use. In our hospital, several anecdotal reports suggested in those patients going to level 2/3 care in CCU or overnight recovery, post operative pain was more problematic if the PCA was not connected before arrival in CCU compared to those who arrived with the PCA connected. Therefore we retrospectively examined the CCU electronic database (IntelliVue Clinical Information Portfolio (ICIP)) to examine this question.

Methods

After gaining approval from our local Clinical Audit Committee, data was collected retrospectively from ICIP on all post operative patients having an abdominal procedure (31/10/11 to 17/2/12) returning to level 2/3 critical care, who were prescribed an opioid PCA. Pain numerical rating scores (NRS) at rest and on movement on first arriving in CCU/overnight recovery were recorded and expressed as means. The next NRS documented in ICIP was recorded to assess the impact of pain management in CCU/overnight recovery. Connection (or not) of PCA prior to CCU/overnight recovery was documented. Results were also expressed as percentage of patients being ‘analgesed’ which was defined as a NRS of ≤2 at rest, and ≤4 on movement. Prior PCA connection (‘before’ group) was compared to connecting the PCA in CCU/overnight recovery (‘after’ group) for pain scores (Mann-Whitney U) and if patients were ‘analgesed’ or not (Chi squared).

Results

91 patients were identified. Of those, 45 were connected before arrival and 46 after arrival. Overall, pain scores on arriving in CCU/overnight recovery were 2.7 (rest) and 3.4 (movement). Pain scores after intervention were 1.5 and 2.4.

NRS pain scores were significantly less if the PCA was connected before arrival (‘before’ group) than if connected ‘after’, at rest (1.5 compared to 3.3, P<0.05) and on movement (2.6 c.f. 4.6, P<0.01). Significantly more patients were analgesed in the ‘before’ group compared to the ‘after’ group at rest (66% compared to 44%, P <0.05) and on movement (77% c.f. 38%, P<0.02). Nevertheless, in the ‘after’ group, the number of patients analgesed improved to 69% (rest) and 67% (movement) at the next pain score. One possible confounding factor was the higher proportion of level 2 patients in the ‘before’ group possibly having less major surgery associated with less pain.

Conclusion

These data demonstrate prior connection of a PCA is associated with improved analgesia compared to connection after arrival to a level 2/3 postoperative facility. Conceivably, prior connection minimises potential analgesic administration delay of having to connect a PCA as one of the myriad of tasks on CCU/overnight recovery arrival. This is a simple intervention with no cost implication that potentially can improve post operative analgesia. Before this audit, pain issues on arrival to CCU/overnight recovery had made connecting a PCA before transfer to level 2/3 care compulsory. A repeat audit has started now all PCAs are connected prior to arrival.

009 Pulsed Radiofrequency Electromagnetic Field Therapy for Menstrual Pain, a Double Blind, Randomized and Placebo Controlled Pilot Study

Category: ACUTE PAIN

Ian Rawe

BioElectronics Corporation, Frederick, Maryland, USA

Background

Primary Dysmenorrhea, commonly referred to as menstrual cramping, is a medical condition characterized by pain from contractions in the lower abdomen occurring at the onset of menstruation in the absence of an identifiable pelvic disease. Sharp pains in the lower abdomen begin at the start of menstruation and may continue for up to 5 days. The pain can range from mild to severe and can often interfere with many normal activities. While the majority of women who have menstrual periods experience some discomfort, an estimated 10% or more are temporarily disabled by the high level of pain they experience. A miniaturized, lightweight and battery pulsed shortwave radiofrequency electromagnetic field (PEMF) device has been developed as a wearable pain therapy. The device operates at the 27.12MHz radio frequency, 1000Hz pulse rate with a pulse width of 100 seconds. The electromagnetic field is delivered by a 12 cm loop wire antenna.

Methods

A total of ninety-one (91) women were enrolled with moderately to severe dysmenorrhea. Subjects self-reported perceived levels of pain for each day of their menstrual cycle prior to participation in the clinical trial were collected. Subjects were then randomly assigned a number coded PEMF device, either active or placebo. The energy from the functioning device can’t be felt by the recipient so subjects were unable to determine device allocation through use. The patients ranged in age from 18-34 years, with an average age of 26.2. Forty-eight (48) patients were assigned active devices while the remaining forty-three (43) received placebo devices. Subjects were asked to wear the PEMF device over the lower abdomen, from the onset of their symptoms, for 24 hrs per day for 5 days, and record their daily VAS pain scores on an 11 point scale (0 -10 scale). Subjects were not restricted in use of pain medications.

Results

On average, pain was decreased significantly on a daily basis, with the study group reporting a 31% decrease in pain compared to the placebo group on day 1, 39% day 2, 42% day 3, 48% day 4 and 63% day 5. Average VAS scores for the 5 days of the study were, day 1 control v study group 8.3 v 5.7, day 2: 7.9 v 4.8, day 3: 7.4 v 4.3, day 4: 6.5 v 3.4 and day 5 5.7 v 2.1. The result indicate that over time 5 days the percentage of decrease in pain increases, suggesting that there is a strong correlation between duration of use of the PEMF device and amount of pain reduction. Overall 77% study group subjects reported a decrease in pain compared to 14% in the control group. No significant adverse events were reported.

Conclusion

The pilot clinical study demonstrated that the PEMF menstrual pain therapy is an effective and safe non-drug method for use in the treatment of primary dysmenorrhea. The results suggest that PEMF in this form can be used as a drug-free treatment method for women suffering from moderate dysmenorrhea. In more severe cases of dysmenorrhea, it can be a possible adjuvant treatment allowing for a reduction in the amount of oral pain medications used. Further clinical study is needed to fully determine the effectiveness of this therapy for primary dysmenorrhea.

010 Do Pre-Operative Screening Questions on Pain Predict a Worse Post-Operative Pain Experience? An Exploratory Audit

Category: ACUTE PAIN

Andrea Magides¹, Sophie Carter², Ruth Day¹, Douglas Natusch¹

¹Torbay Hospital, Torquay, UK, ²Nuffield Research Placement, Devonshire, UK

Background

There is interest in predicting patients likely to have a poor post-operative pain experience. Instinctively those with chronic pain and opioid tolerance will present challenges. Identification of these would allow pre-operative formulation of pain management plans and early involvement of the inpatient acute pain service (APS). In Torbay, all elective patients undergo nurse-led pre-operative assessment and this is entered into a computer record. In the routine questionnaire we included four questions thought to be predictive of a poor pain experience. Data is collected on the Acute Pain Database (TIPPS) of all patients seen by the APS. The two databases allowed us to compare whether the post-operative pain experiences of the patients seen by the APS could have been predicted by the pre-operative questions and if so, which questions, and whether 1, 2, 3 or 4 questions were required. Data for 12 months of elective patients was retrospectively reviewed.

Methods

The records of 908 patients assessed pre-operatively were reviewed. Based on the Salford pain team questions (which were later incorporated in RADAR) the pain predicting questions were:-

Significant anxiety over post-operative pain
Previous experience of post-operative pain
Established chronic pain syndrome
On long-term opioid therapy

In patients regularly taking opioids, oral morphine dose equivalence was calculated and the patient banded into high (>150mg), medium (100-150mg) and low dose (<50mg). Patients taking anti-depressants or anti-convulsants for pain management were recorded.

The results were entered into an excel spreadsheet from the TIPPS database. Data includes number of visits from the APS, number of days under the care of the APS, pain scores at the time of the visit and for the preceding 4 hours, the nurse’s assessment of efficacy of pain management and patient satisfaction.

Results

Individual factors

30 (3%) of patients scored positively for significant anxiety over post-operative pain.

19 (2%) of patients had had a previous bad experience of post-operative pain.

138 (15%) had a chronic pain diagnosis.

64 (7%) were on long-term opioid therapy, over 20 of which had a pre-operative morphine equivalent dose of 50mg or more.

71 (8%) of patients seen by the APS were taking anti-depressant commonly used for pain relief and 39 (4%) were taking anti-convulsants

Patients received an average of 1.5 visits with a range of 0 (not seen due to insufficient time) and 33.

Further results and correlations will be presented on the poster.

Conclusion

Only a small number of patients (3% & 2% respectively) were found to volunteer significant pain anxiety or a previous bad post-operative pain experience. Only 7% were on long-term strong opioid therapy. The factor with the most significant pickup was a previous experience of chronic pain which, at 15% would reflect confidence limits for current population studies for chronic pain. Correlations of the predictive value of the questions with a need for APS input post-operatively are being undertaken and will be presented.

011 An Audit to Evaluate the Efficacy of Transversus Abdominis Plane Blocks in Total Abdominal Hysterectomy in a District General Hospital

Category: ACUTE PAIN

Melanie Shuker, Andrea Magides, Ruth Day

Torbay Hospital, Devon, UK

Background

Trials have demonstrated the efficacy of transversus abdominis plane (TAP) blocks in reducing opiate consumption for up to 48 hours postoperatively, for various abdominal procedures, including total abdominal hysterectomy (TAH). Carney et al. (2008) demonstrated that TAP blocks in patients undergoing TAH reduced the mean (+/- SD) total morphine requirements in the first 48 postoperative hours from 55 +/- 17 mg with placebo block, to 27 +/- 20 mg with ropivacaine block. Our audit aimed to evaluate if TAP blocks affected the cumulative dose of opiate received by patients in the first 48 hours post TAH in our district general hospital. It was a service evaluation of a change in practice, introduced as a result of the enhanced recovery program, which recommended TAP blocks for TAH as this was considered best practice. It was suggested by the recovery nurses who questioned the efficacy of TAP blocks.

Methods

We aimed to identify 50 patients who had undergone TAH without receiving a TAP block and 50 who had undergone TAH and did receive a TAP block. A retrospective case note review was undertaken. Data was ultimately collected for 56 patients who did receive a TAP block and 32 patients who did not receive a TAP block. Those excluded were patients with a history of opioid tolerance and who underwent laparoscopic TAH. The data collected came from patients who had had a TAH between January 2010 and January 2012.

Data collected included patient demographics, the dose of opiate drugs received in the first 48 hours post TAH and other analgesics received. Opiates received included intravenous morphine and fentanyl, oral morphine and codeine phosphate. These opiate doses were converted to intravenous morphine dose equivalents and thus cumulative opiate dose for the first 48 hours postoperatively calculated for patients in both groups.

Results

On analysis there was no difference in the variances between the 2 groups for age, weight, height or body mass index. Results showed that the mean (+/- SD) cumulative opiate dose in the first 48h post TAH was 45.8 mg (+/- 36.7) in the TAP block group versus 53.8 mg (+/- 30.5) in the no TAP block group. This is a reduction of 8 mg (IV morphine equivalent) which is approximately equivalent to a 15-20 mg dose of oral morphine. We felt this was not a clinically significant difference and indeed the difference between the two groups proved to not be statistically significant either (p=0.2959). Results also showed that patients who received a TAP block received a higher proportion of the mean cumulative opiate dose in theatres recovery than those patients who did not receive a TAP block (18.4% vs 10.5%).

Conclusion

TAP blocks for TAH did not produce a significant reduction in cumulative opiate dose in the first 48 postoperative hours. Translating results of controlled trials into clinical practice is challenging. Some disparities in the methods of delivering TAP blocks in our institution and those used by Carney et al. were identified however, prompting development of a departmental guideline to optimise the procedure. It includes adopting a posterior ultrasound approach similar to that used by Carney et al. and performing the block preoperatively. It highlighted that not performing a TAP block does not necessarily mean providing an inferior standard of care.

012 Paracetamol Dosage - Are We Prescribing Correctly? An Experience From a District General Hospital

Category: ACUTE PAIN

Ravi Kare, Kate O’Callaghan, Heather Lynes, Udi Akhigbe, Coralie Carle, Subhash Kandikattu

Anaesthetic Department, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, Cambridgeshire, UK

Background

Paracetamol is widely used as an analgesic and antipyretic. Its recommended dose is weight dependent (BNF). Following reports of accidental overdose of paracetamol the MHRA issued guidance on ‘Drug Safety Information’ in May 2010. The National Reporting and Learning System identified 206 paracetamol related incidents (44 neonates and 162 children) of them 2 had severe harm and 14 had moderate harm (NPSA Signal, Nov 2010).

These incidents were attributed to ‘lack of awareness among various healthcare professions of neonatal and paediatric drug dosage regimens’, ‘poor documentation resulting in double dosing’, ‘confusion between oral and IV Paracetamol drug doses’ and ‘calculation and prescription errors of IV Paracetamol’.

This motivated us to review the paracetamol prescribing practices within our hospital. This review involved three components: first looked at anaesthetists’ understanding of paediatric dosing; second focussed on peri-operative prescription (adults) and the third assessed the knowledge of paracetamol prescribers in the wider hospital.

Methods

With appropriate audit permission, the initial component of our review was carried out in June 2010. This involved a written questionnaire sent to all anaesthetists. We sought to establish the current practice of paracetamol prescribing in paediatric patients (dose, dosing interval, maximum daily dose, errors). The results were presented locally and the anaesthetists updated on key elements of paracetamol prescribing.

We then re-audited Peri-operative paracetamol prescribing in July 2012.The notes, drug chart and anaesthetic chart of patients passing through the post anaesthesia care unit (PACU) were reviewed. Details relating to paracetmol prescribing, including potential and actual errors, were collected on a proforma. The findings were presented locally, the medical and nursing staffs were re-educated and the audit repeated in September 2012.

The final component of our review involved a written survey establishing paracetamol prescribing practices of the hospital’s physicians, surgeons and paediatricians. This was carried out in August 2012.

Results

Our initial survey received a 70% response rate. The notable results include: children < 10kg, 50% of anaesthetists stating an incorrect treatment dose and 83% stating an incorrect maximum dose; children 10-50kg, 50% of anaesthetists stating an incorrect max dose; children >50kg, 70% of anaesthetists stating both an incorrect treatment dose and incorrect maximum dose.

The PACU audit most significant finding was that in 50% of patients there was the potential for a second IV dose to be administered within 4 hours. This error occurred in 6% of patients. Following staff education, the re-audit revealed a reduction in both actual and potential errors.

Our survey of other specialities received a 20% response rate. The notable results include: 70% doctors were not aware of the MHRA guidance; 30% made no dose alteration for adult patients under 50kg; 20% stated an incorrect paediatric dose and; 15% stated an incorrect adult dose.

Conclusion

The three components of our review highlight that errors in paracetamol prescribing for both adult and paediatric patients is widespread throughout the hospital. Despite improvements in practice following staff education, 100% compliance with BNF and MHRA guidance is not being achieved. It is important for us to be vigilant while prescribing paracetamol doses and dosage intervals. To prevent potential and actual errors we should communicate and hand over carefully during the perioperative period. We should continue the cycle of education and re-audit to help in improving our practice

013 Documentation of Pain Observations Following Implementation of the New Uhbristol Observation Chart

Category: ASSESSMENT & MEASUREMENT

Ben Welham², Steven Lindley¹, Nilesh Chauhan³

¹Royal United Hospital, Bath, UK, ²University of Bristol, Bristol, UK, ³University Hospitals Bristol, Bristol, UK

Background

In 2008, the Chief Medical Officer advised that a pain score should become part of the vital signs that are monitored routinely for all inpatients . Previously at UHBristol NHS Trust, following the introduction of the early warning observation system, pain recording did not feature on this form. A separate (Pain Observation Forms (POF) was disseminated to encourage the recording of pain. An audit in 2009 found that there was poor uptake of this form and many patients were left without adequate pain documentation. Following this audit, space for pain observations was included as part of the redesigned UHBristol Observation Chart (UOC). This form also included the Abbey Pain Scale for patients with cognitive impairment and an ‘action report’ for the recording of intervention of moderate to severe pain.

Methods

Five patients were randomly sampled using a random number generator from each ward at UH Bristol. The Emergency Department, ENT and Maxillofacial wards and the Intensive care unit were excluded as these wards used alternative charts to assess pain. Five questions were asked of the form: 1. Is the UHBristol Observation chart (UOC) used? 2. Is pain assessment filled in correctly 3? Is the patient verbally able to communicate their pain? 4. Is the Abbey Pain Scale employed? 5. Has an action report been recorded if pain is documented as moderate or severe?

Results

A total of 132 patients were sampled which was similar to the initial audit of 152 patients. Uptake of the UOC was 96%. 100% of patients with UOC documentation had pain recorded, compared to only 50% (1% patients on medical wards 64% on surgical wards) in the previous audit. 99% of patients had more than half correctly entered pain recordings, compared to less than 40% on POF. There was a very small take up of the Abbey Pain Scale with only 0.8% of patients having this employed which likely represents a fraction of patients with cognitive impairment (likely 1/3 of inpatients). 38% of patients reported moderate to severe pain at some point, of these, only 26% had ‘action reports’

Conclusion

The uptake of UOC compared well with the previous EWS observation chart. The use of the UOC for recording pain assessment was exceptional, with the quality of entries representing an improved chart. However, improvements can be made to the utilisation of the Abbey Pain Score and freetext action-reporting.

This audit has shown the importance of pain assessment documentation on the same chart as an early warning system, we have shown that by having two separate charts pain assessment is poor. With the introduction of the ‘National Early Warning Chart’, which has a minimal amount of pain assessment, this is threatened.

014 The Assessment of Chronic Pain After Knee Replacement: A Systematic Review

Category: ASSESSMENT & MEASUREMENT

Vikki Wylde¹, Julie Bruce², Andrew Beswick¹, Karen Elvers¹, Rachael Gooberman-Hill¹

¹University of Bristol, Bristol, UK, ²University of Warwick, Coventry, UK

Background

Total knee replacement (TKR) is a successful operation for relieving pain for the majority of patients. However, approximately 20% of patients experience chronic pain after TKR. Despite the prevalence of this condition, there is no agreement in the research literature about which measures should be used to assess chronic pain after TKR. For clinical trials investigating efficacy of chronic pain treatments, IMMPACT recommends that the assessment of pain should encompass measurement of pain intensity, pain medication usage, pain quality and the temporal aspects of pain. The aim of this systematic review was to determine which pain instruments and broader health-related measures incorporating pain items were used in all original epidemiological and experimental research articles published over a 10-year period. Within this literature we explored geographical and contemporaneous trends in the use of pain-related outcome measures, and compared the pain domains assessed within the measures to the recommendations from IMMPACT.

Methods

Searches identified 8,486 articles with 1,164 eligible for inclusion. MEDLINE, Embase, PsycINFO, Cochrane Library and CINAHL databases were searched for research articles published in all languages between January 2002 and November 2011. Articles were eligible for inclusion if they assessed pain at a minimum of 3 months after TKR. Studies were excluded if they were case studies, conference abstracts, PhD theses, recruited less than 10 participants or did not present original primary data. Abstracts or full text articles were screened to determine if the article met the eligibility criteria. Data extracted included study design, country, timings of assessments, and outcome measures that contained pain items. For 184 articles only accessible as abstracts, authors were contacted. Of 84 authors with contact details, 36 provided full text articles or verified data extraction.

Results

Studies used a variable number of measures that incorporated pain items (range 1-14), with 17% of studies using three or more measures. A wide variety of composite and single-item measures were used to assess chronic pain after TKR, with the American Knee Society Score being the most common. Other commonly used multi-item measures included the WOMAC, Hospital for Special Surgery Knee Score, SF-36 and Oxford Knee Score (OKS). Comparison of pain domains assessed within the measures to those recommended by IMMPACT revealed that many measures failed to capture the multi-dimensional nature of pain. Of measures commonly used, the WOMAC and OKS provided the most comprehensive assessments of pain. Geographical trends were evident, with nation-specific preferences for particular measures. Comparison of temporal trends identified recent reduction in the use of clinically-administered tools and an increase in the use of patient-reported outcome measures.

Conclusion

This systematic review found extensive variation in the outcome measures used to assess chronic pain after TKR. A key finding was that, despite a growing interest in investigating this condition, assessment has been inconsistent and predominantly orientated towards pain severity, with little consideration of other key aspects of pain, such as temporality and quality, as recommended by IMMPACT. The review also highlights the presence of nation-specific preferences and conservatism in pain assessment within orthopaedic studies. Standardisation and improvements in assessment has the potential to enhance the quality and generalisability of research and facilitate the establishment of a core outcomes set.

015 The Colour of Pain: Can Patients Use Colour to Describe Osteoarthritis Pain?

Category: ASSESSMENT & MEASUREMENT

Vikki Wylde, Victoria Wells, Sam Dixon, Rachael Gooberman-Hill

University of Bristol, Bristol, UK

Background

Pain assessment is fundamental to management of osteoarthritis (OA) pain and evaluation of the effectiveness of clinical interventions. While the subjective nature of pain means that self-report is appropriate, some people experience difficulties in completing standardised numeric or descriptive pain measurement tools. This may be because it can be challenging to define and explain pain experience through pre-defined questions and response options. In a clinical setting, patients’ ability to describe pain is a key component of successful communication between patients and clinicians. Optimal and diverse methods of pain assessment may help to facilitate communication and shared-decision making about treatment and management strategies. The aim of this qualitative study was to explore patients’ views about the acceptability and feasibility of using colour to describe OA pain, and whether they thought that colour was an appropriate means of communicating about pain in clinical settings.

Methods

Seventeen patients with knee OA took part in one of six group interviews, each comprising 2-3 participants; groups were stratified by gender. In each interview, participants were first asked to describe living with OA, experiences of pain and management strategies, and thoughts about using colour to describe pain. Next, 10 loose circles of coloured card were placed in the centre of the table. Participants were asked to describe and discuss whether they could relate the coloured circles to OA pain, and if so how those colours related to pain qualities and changes in pain intensity. Participants then used coloured pencils to depict their pain on a body diagram, and were encouraged to describe their choice of colours. Group sessions concluded with participants’ views about the potential to use colour in conversations with healthcare professionals. Anonymised transcripts were imported into NVivo© version 9 and analysed using methods of constant comparison.

Results

The group interviews revealed that while the idea of using colour was generally acceptable, it did not suit all participants as a way of describing pain. The majority of participants chose red to describe high intensity pain; reasons given were its symbolic association with inflammation, fire, anger, and its connection with a traffic light system. Colours used to describe absence of pain were those associated with positive emotional feelings, such as purity, calmness and happiness. A range of colours was chosen to represent changes in pain intensity. When describing aching pain, participants consistently identified colours such as grey or black. In comparison, sharp pain was described using a wider range of colours including yellow, white, red and purple. The majority of participants thought that they would be able to use colour to describe their pain to healthcare professionals, although issues around the interpretability and standardisation of colour were raised.

Conclusion

This study suggests that presenting patients with a range of colours and asking how they would use these colours to describe their chronic pain may be a useful communication tool. As evident from this research, this would not be appropriate for everyone, but some people may find that engagement with colour provides a comfortable way to initiate discussions around pain. Although not explored in this study, colour symbolism varies between cultures and any such tool would need to allow for diversity. Further research could establish the utility and possible impact of a colour-based communication tool in a clinical setting.

016 Is Confidence the Key to Accurate Paediatric Pain Assessment or Is There More We Need to Learn?

Category: ASSESSMENT & MEASUREMENT

Laura Angco^1,2, Mansimran Cheema^1,2, Carsten Bantel^1,2, Helen Laycock^1,2

¹Imperial College London, London, UK, ²Chelsea and Westminster Hospital, London, UK

Background

Children and infants experience pain¹. Inadequate analgesia and the experience of pain in children can lead to physical, psychological and behavioural consequences in the short and long term^2,3. Despite the importance and moral obligations of healthcare professionals to ensure a patient’s comfort, pain in hospitalised paediatric patients is often poorly managed^4,5.

Accurate pain assessment is key to pain management, both as a screening tool and also a measure of effectiveness of analgesia. Pain assessment in children should be completed with tools appropriate for age, clinical situation and the child’s ability to self-report⁶.

A previous hospital audit demonstrated over 75% children were not assessed for pain using hospital recommended tools and 50% had inaccurate pain assessments⁷. We aimed to explore, how nursing staff evaluate their practice in pain assessment and its importance, to help address the above discrepancy.

Methods

Over a two-week period, 20 paediatric nurses were approached on a general medical and surgical paediatric ward in a Central London Teaching Hospital. No prior introduction to subject matter was given and each was asked to complete a qualitative Likert scale questionnaire with additional areas for free text.

Questions were constructed to evaluate nurses’ confidence levels in assessing pain and previous training. Additionally they were asked about how to conduct pain assessments, the frequency with which they perform them and average time taken to complete an assessment on the ward. They were also asked to list their top 3 responsibilities on the ward to assess the importance of pain / pain assessment.

Results

95% responder rate, 5% refusal. 84% felt confident or very confident in their accuracy in assessing pain, with none feeling unconfident or worse.

Only 42% felt children could accurately report pain, although 84% identified ability to do so was age related. There was a wide range in average time spent assessing pain (3 seconds to 10 minutes, mean 2.6 minutes) and nurses were inconsistent in frequency of pain assessment. Most identified that frequency depends on the patient, but average frequency ranged from every 30 minutes to once daily. Hospital guidelines recommend frequency should be every 4 hours.

16% of nursing staff felt assessing pain was one of their top three responsibilities. They found patient care, supporting family, running the ward, managing staff, and keeping safe, clean environments more important. Only 53% had received training in pain assessment, with only 30% of those having received more than a one-day study course.

Conclusion

Despite previous evidence that pain assessments are inaccurate, most staff were confident in their ability to assess pain. Many felt children were unable to self report accurately and illustrated large ranges of frequency and time take to complete assessments. This suggests lack of training, which was confirmed by the questionnaire. It is likely they exist in the “unconscious incompetence” stage of the competency model of learning⁸ and a more standardised format of pain assessment training could address this issue, leading to more accurate assessments and a better standard of care.

017 Collecting Patient Reported Outcome Measures (PROM) Using Smart Phone Technology Within a Clinical Setting

Category: ASSESSMENT & MEASUREMENT

Andrew Vitiello, Dave Newell, Ahmet Ulusan, Maja Bjorn

Anglo European College of Chiropractic, Bournemouth, UK

Background

Mobile health (mHealth), and the use of mobile technology to enhance care, is an emerging debate. The model of the ‘doctor knows best’ has been questioned, whereas the involvement of the patient in their care and management, including ongoing treatment decisions and the development of a ‘partnership’ between physicians and their patients has been shown to impact outcomes and cost, particularly in chronic conditions. ^1,2

However, engaging patients in monitoring their health care and managing their condition has remained a challenge.³ With the emergence of mobile technology considerable scope for innovation^4,5 has arisen with opportunities to improve patient self management and experience of care, as well as potentially reducing unnecessary and costly health seeking behaviour.⁶

We have developed a smart phone app⁷ that provides validated PROMs on the patient’s phone together with the ability to provide these outcomes to both the patient via a secure server to the clinician.

Methods

Code was written to enable the presentation of 2 validated PROMs (Roland Morris Disability Questionnaire⁸ and Bournemouth Questionnaire⁹), in an appropriate format for smart phone screens as well as web site to display PROM data to the clinician. The apps were tested for face validity using a number of students and faculty and feedback as to the ease of use, both as a potential clinician and patient was obtained. A further pilot study was then carried out to ascertain the experience, utility and practicality of 10 non specific low back patients over the course of 7 days following the initiation of treatment. Feedback concerning the use of the app and patients experience was collected using a short questionnaire and in a smaller sample, a semi structured interview.

Results

A smart phone app able to present two validated questionnaires with daily notifications to the patients has been created along with a website to display PROM data from individual patients to their clinician. The details of the app along with the results of the face validity and pilot study will be presented at the conference.

Conclusion

The use of smart phone technology is an emerging area and has potential to impact favourably both in terms of providing valuable patient data concerning symptomatology as well as providing a platform for feedback to the patient in attempts to encourage and support self management. We have developed a patient friendly smart phone app that enables the recording of PROMs directly from the patient’s phone providing direct feedback to the patient as well as uploading this information to a secure central server for review and use by the clinician

018 Does the Start Back Tool Shortly After the Initial Visit Compared to Before Better Predict Outcomes in LBP Patients

Category: ASSESSMENT & MEASUREMENT

Dave Newell¹, Jonathan Field^1,2

¹Anglo European College of Chiropractic, Bournemouth, UK, 2Back²Health, Petersfield, UK

Background

Low back pain is common and costly ¹. Most LBP is non-specific in nature and identifying those individuals likely to respond to intervention has proved problematic. Research has attempted to identify prognostic groups² through the development of screening methods. ³

Hill et al ⁴ have developed the STarT Back, which has proved to add utility beyond physiotherapist choice alone in determining treatment for LBP patients by categorising into low, medium and high-risk groups, with low risk given advice, medium, physical therapy and high-risk physical therapy with a CBT component.

Recently⁵ we investigated whether the SBT could predict outcomes in nsLBP patients undergoing chiropractic care and found no significant association between SBT risk groups and outcomes. Previous work in this population indicates early change may be associated with favourable outcomes and we hypothesized that the SBT post the initial visit as opposed to before may provide better prognostic information.

Methods

Consecutive patients aged over 16 presenting with nsLBP to one of six chiropractic clinics in the south of England are asked to complete the SBT at baseline and within 2 days of their initial visit online, via a web page. A Patients Global Impression of Change (PGIC) was e mailed at 14, 30 and 90 days following their initial visit.

For this study, the primary outcome was the PGIC. Patients were categorised into the three SBT risk groups using the method as described by Hill et al⁴. For each of the follow up points, all outcomes were dichotomized with poor outcome defined as a score of <6 on the PGIC ⁶

Any association between the SBT groups and outcomes were investigated using univariate logistic regression where SBT categorisation was the independent variable and the dichotomised outcome (PGIC) was the dependent variable at each of follow up points.

Results

One hundred and eighty six patients with nsLBP filled out the baseline questionnaire, with 91% completing this via e-mail. Around half were attending for a new episode of LBP and had not seen that practitioner before. There were a slightly higher proportion of females with around half reporting pain for more that 30 days a year with over 2/3 of patient’s reporting the back pain as a reoccurrence. Twenty-eight and 12% reported pain in the leg above and below the knee respectively.

Analysis of the odds of the SBT risk groups associated with outcomes (Table 1) revealed that the SBT neither at baseline or post the initial visit was unable to distinguish between those that improved or did not at any of the follow up time points of 14, 30 and 90 days. The proportion of improved patients was therefore similar across the risk groups for all follow up points

Conclusion

We hypothesized that those patients not experiencing improvement might be better identified by the SBT if given immediately after the initial consultation as opposed to at baseline before the patient attends their first visit. However, this was not the case and the SBT performed as poorly as in our previous study that looked only at baseline recorded SBT.

It is likely that the population of patients attending chiropractors maybe different and the additional confounding effect of treatment may have some impact on these results. Caution however, should be used when extending this screening tool to other populations of LBP patients.

019 BAPQ: The Development of an on Line Assessment Tool for Adolescents Who Experience Chronic Pain

Category: ASSESSMENT & MEASUREMENT

Lisa Austin, Chris Bevan, Christopher Eccleston

University of Bath, Bath, UK

Background

Chronic pain causes significant problems in the lives of many adolescents, considerably affecting their physical, psychological and social functioning. The assessment of the multidimensional impact of chronic pain is therefore an essential clinical task. The Bath Adolescent Pain Questionnaire (BAPQ); is an assessment tool designed specifically for use with adolescents who experience chronic pain, developed by the Bath Centre for Pain Research. The BAPQ offers a comprehensive way to assess the widespread deleterious impact of adolescent chronic pain in both a research and clinical setting. However, it is currently only in paper version. New online technologies mean it is possible to produce an online version, which is quick and easy to access anywhere and allows for immediate access of data for a distributed or remote clinical team.

Methods

The questionnaire was replicated in full using standard web input controls (free text entry, drop-down lists etc). Efforts were made however to use each type of input mechanism appropriately in order to sensibly limit the range of possible response to minimise ambiguity wherever possible - e.g. if the range of possible answers are known, a fixed drop-down list was used. It is thought this resulted in no loss of resolution.

There was also a design decision to repeat the labels for each of the likert-scale questions on each question (as opposed to just presenting them in a table with the labels shown only once at the top. This was done to prevent the need for the user to scroll to the top to check their response (e.g. ‘1’ : never) and two, to allow for more physical space between questions (mostly to increase selection accuracy on touchscreen based devices).

Results

The online BAPQ is an HTML5 website that has been designed to be usable in multiple environments. Efforts have been made to ensure cross-browser and (more importantly in this day and age) cross-device compatibility (website automatically adjusts for mobile phone / tablet use / interface is usable on touchscreen-based devices etc). All participant data is validated and verified before submission. Data is non-personally identifiable and is stored securely on a UoB-based database.

A great advantage of the online BAPQ is that scores are calculated automatically. The clinician is provided with these results immediately, which they can then print for further discussion with their patient. In addition, subject to ethical approvals, researchers can get immediate access to the aggregate / anonymised data in a usable form (MS Excel), with the BAPQ calculations already complete.

Conclusion

The online BAPQ is currently being tested with clinicians in the Royal National Hospital for Rheumatic Diseases in Bath. If deemed useful in service settings, it will be being rolled out for wider clinician and patient feedback.

020 Service Evaluation- Adequacy of Aseptic Techniques in Pain Clinic Based Procedures

Category: ASSESSMENT & MEASUREMENT

Monica Chogle, Michael Stafford, William Campbell, David Miller

Ulster Hospital, Belfast, UK

Background

Asepsis plays an important role in any pain procedure. Operator hands can be a significant source of bacterial contamination before patient contact. In our Pain Clinic, where procedures are performed in a dedicated treatment room on an outpatient basis, the role of following strict aseptic precautions is of utmost importance. The aseptic techniques need to be at par with what are followed in an operating theatre environment.

In our Pain Clinic treatment room, we follow RCOA guidance for performing central or peripheral nerve blocks. Operators wear cap, mask, gown & gloves as a rule. Procedure site is cleaned with Chlorhexidine 0.5% in ethanol spray & draped with sterile drapes. This project was a quality assurance process to evaluate the adequacy of various aseptic techniques we routinely follow in the pain clinic treatment room and improve or modify our techniques if deficiencies were observed.

Methods

Service evaluation was approved by local research and ethics department. Microbiology department supported the project. Patients and staff were consented for sampling. All patients received standard care in the pain clinic. Staff were instructed to follow standard aseptic precautions.

There were4 areas for evaluation:

Area 1: Swabs were taken from staff hands on 3 occasions (on arrival from home, after 1^st and after 2^nd hand washing)

Area 2: Epidural injection group, where swabs were taken before, during and post procedure from patients skin)

Area 3: Ultrasound guided procedures, where swabs were taken before & after application of gel.

Area 4: Ultrasound gel (samples from sterile single use pouches and refilled bottles)

As this project only aimed at quality assurance, only 4 sets of samples were obtained from each area of interest. Microbiologic assessment was performed to identify organisms and quantify as colony forming units (CFUs)

Results

Area 1 Clinicians Hands: Two out of 4 samples from clinicians hands grew pathologic organisms on arrival to the clinic. And after 1^st Hand wash, only normal skin flora were cultured form the same hands. No flora was cultured after subsequent hand washes.

Area 2 Epidural procedure: Two out of the 4 samples collected from patients skin grew pseudomonas (opportunistic pathogens). But after cleaning with Chlorhexidine 0.5% (in 70% v/v ethanol) spray all four samples showed no growth. Spraying the back with Chlorhexidine 0.5% eliminated all organisms.

Area 3 Ultrasound Blocks: One skin sample out of 4 grew non staphylococcal gram positive cocci. No organisms were cultured after cleaning the same site with Chlorhexidine 0.5% & application of ultrasound gel from refilled bottles.

Area 4 Ultrasound gel: Both gel from sachets and gel from refillable bottles were cultured. Both did not grow organisms of any clinical significance.

Conclusion

Microbiological snapshot data showed that adequate aseptic techniques were followed in our treatment room. In view of results obtained from swabbing staff hands, importance of regular hand washing needs to be emphasized to all staff in all clinical areas. We obtained local data to show that ‘seven step hand washing’ is of utmost importance on arrival to a clinical area from home. The microbiological data also reinforced that Chlorhexidine 0.5% skin spray is an acceptable cleaning technique for a regional or central neuraxial procedure in an office based environment.

021 Rasch Analysis of the Fatigue Severity Scale and an Examination of the Relationship Between Pain and Fatigue in People With Knee Osteoarthritis

Category: ASSESSMENT & MEASUREMENT

Bryan Moreton, Maggie Wheeler, David Walsh, Nadina Lincoln

Prospective survey recruited 100 new patients over 3 months, who were requested to fill the questionnaire. The questions covered the following: The reason for consultation and their expectations from the clinic, choices include -

Someone to listen
Diagnose the problem
Further Investigations
Medication
Injections
Acupuncture
Alternative therapies (TENS)
Cure
Coping skills
Improve quality of life

They were also asked where would they like the consultation - either at the hospital or at the GP / PCT and how far they were prepared to travel for this.

The duration of the consultation and the information given were satisfactory or not.

Patient understanding of the management plan and professionalism of both the doctors and the nurses were in the questionnaire.

Finally they were requested to value their appointment by putting a number between 0 to 10; 0 being waste of time to 10 being most satisfactory. Patients were also requested to add comments regarding consultation.

Results

Out of 100, 6 refrained from valuing, 3 did not reply.

> 70% patients expected someone to listen, diagnose a problem, investigate and offer medications and injections.

Majority did not expect cure but wanted a better quality of life.

80% expect consultation at local hospital.

90% were happy with timing of referral and the length of consultation where they understood the given information, except for the leaflets. Patients rated doctors and nurses as professionals.

Value of the appointment mostly had high scores, which then plotted in Net Promoter Score (NPS) chart.

NPS is a customer loyalty model of Harvard Business School to improve services, which correlates with revenue growth. NPS seeks votes on a scale 0-10 for a service; where 0-6 detractors, 7-8 passives and 9-10 are promoters. NPS is calculated as (% promoters) - (% detractors). NPS maximum score can be 100 (everyone promoter), NPS +50 is excellent. Our survey yields NPS of 82.

Conclusion

Patients highly valued the service provided. NPS should be included as a regular feedback programme at all patient care delivery level.In reflection of this survey we concluded that the patients still want the services to be delivered at secondary care level and chronic pain consultants were most valued among the team. Long waiting time remained as a challenge. But overall pain clinic based delivery of the chronic pain management programme was highly valued by this patient endorsement survey.

025 The Intermed System: An Exploration of Changes in Case Complexity From 2008-2012 at Wirral University Hospitals NHS Trust Pain Management Clinic

Category: ASSESSMENT & MEASUREMENT

Emma Bain, Peter Williams

Wirral University Teaching Hospitals NHS Foundation Trust, Upton, Wirral, UK

Background

Background

Cancer pain remains a major public health problem affecting as many as one in two patients attending oncology outpatients departments (1,2,3).

Reports from the American and British Pain Society’s have recommended a proactive approach to pain management, including regular assessment of pain and use of evidence-based treatment protocols, integrated into routine oncological practice.

We aimed to explore whether a new ‘proactive screening and treatment system’ for pain, which incorporates these recommendations, is effective and cost effective when compared with ‘usual care’.

Methods

We screened patients routinely attending outpatients for pain using a single question. Patients scoring >4 on the BPI-NRS ‘worst pain in past 24 hours’ were approached for inclusion and randomised to intervention or ‘usual care’.

Intervention included immediate (on-the-day) access to pain treatment advice according to individualized protocol algorithms, follow up, reassessment and patient education.

The primary outcome was difference in pain scores (BPI) at one, two and three months.

Secondary outcomes included pain interference with activities (BPI), adequacy of pain management (PMI), quality of life (EQ-5D), patient satisfaction (0-6 Likert scale) and anxiety or depression (HADS).

Data was prospectively collected to evaluate healthcare costs.

Results

From January 2011-July 2012 we screened 1087 patients (2212 visits).

We recruited 156 patients, mean age (SD) 58.1 (10.6) years, 64.7% male.

The most common diagnoses were thyroid 18.6%, tongue 17.9%, tonsil 10.9%, and parotid cancer 7.1%. Average (SD) pain scores at baseline were 6.4 (1.6).

Conclusion

Final data will be available March 2012 and full results presented at this meeting.

029 Invasive Neurodestructive Procedures in Cancer Pain (INPIC): Development of a Cordotomy Registry

Category: CANCER PAIN

Nicholas Campkin¹, Matthew Makin², on behalf of INPiC pilot study group³

¹Portsmouth Hospitals Trust, Portsmouth, UK, ²The Marie Curie Palliative Care Institute, Liverpool, UK, ³INPiC pilot study group, INPiC, UK

Background

The Marie Curie Palliative Care Institute Liverpool Pain Group and NRCI Palliative Care Studies Pain Group established a working party to examine the role of Invasive Neurodestructive Procedures in Cancer Pain (INPiC). The initial focus has been on cordotomy (INPIC Pilot study) The aims and objectives of the INPiC Pilot study were:

To produce national guidelines for the use of cordotomy in mesothelioma-related pain management
To provide a benchmark for the availability of cordotomy for mesothelioma-related pain in the UK
To establish a National Registry for cordotomy
As a pilot, if successful, to be repeated in other interventional approaches in cancer pain management

Methods

Three phases to the project were identified:

Systematic Literature Review:

Is cordotomy a safe and effective treatment for mesothelioma-related pain?

Consensus Study

Service Survey/ Screening – identifying UK centres providing cordotomy

Delphi Study – measuring consensus regarding: place of cordotomy in mesothelioma-related cancer pain; benefits vs risks; evidence base; appropriate uptake and timing of referral for cordotomy; use in non-mesothelioma cancer pain.

Nominal Group Technique - developing consensus using case scenarios at Palliative Care Section, RSM October 2011 following presentation of outcomes of Systematic Review, Service Survey and Delphi Study.

Registry Study:

Meeting of INPiC group and Dendrite Clinical Systems Ltd. March 2012 to initiate registry study, agree data set by consensus and commission registry of all cordotomies in UK. Data set and site development online by clinical / IT group.

Funding for project provided by NCRI SuPaC Lung Cancer Research Grant approved June 2008

Results

Literature Study:

Evidence base for cordotomy in mesothelioma pain limited - case series

Percutaneous fluoroscopic technique most commonly used

Studies demonstrate good pain relief in most patients

Life-threatening complications rare

Minor side-effects common

Consensus study:

160 Interviewed;136 entrants into Delphi; 101 completed First Round;75 complete data sets.

Cordotomy has place in managing mesothelioma cancer pain? YES

Potential benefits of cordotomy far outweigh risks of procedure? YES

Evidence-base for use of cordotomy in mesothelioma pain is robust? UNCERTAINTY

Are patients with mesothelioma in the UK who could benefit from the procedure referred for cordotomy? NO

Are patients with mesothelioma in the UK who could benefit from cordotomy referred at appropriate time? NO

Cordotomy should only be considered for mesothelioma-related pain? NO

Registry study:

Data set agreed, pilot site tested,now live. Online UK registry includes demographics, baseline pain, medication and interference scores, procedure data, post-procedure outcome data etc.

Conclusion

Consensus methodology is useful for collating information and expert opinion where published evidence is limited for priority setting and guideline development. Our findings indicate:

Cordotomy has a place in the management of mesothelioma-related cancer pain.
The potential benefits far outweigh the risks of the procedure.
Not all patients with potential for benefit are referred.
Patients are often referred late.
Cordotomy should be considered for unilateral cancer-related pain from other causes.

A National registry has been developed with the aim of standardising and improving outcome data across the UK and ensuring safety and efficacy of cordotomy.

030 Pain Screen and Treat: The Feasibility of Regular Screening for Pain in a Busy Oncology Outpatient Department; An Update on the Ongoing Service Evaluation Study

Category: CANCER PAIN

John Williams¹, Janet Peacock², Anthony Gubbay¹, Rose Ellard¹, Julia Riley¹, Odile Sauzet³, Joy Ross^1,4

¹Royal Marsden NHS Foundation Trust, London, UK, ²King’s College London, London, UK, ³Universität Bielefeld, Bielefeld, Germany, ⁴Imperial College, London, UK

Background

Pain in the cancer patient is seen in nearly half of attendees to oncology outpatient departments [1,2,3]. Recommendations from the American and British Pain Societies outline the need for a more proactive approach to cancer pain management involving regular assessment and early, individualised treatment using evidence-based protocols [4,5].

Screening for clinical signs and symptoms such as fatigue, distress and depression in general or oncology outpatient departments is common [6,7]. However, screening for pain is less so. At the Royal Marsden Hospital, one of the largest tertiary referral cancer centres in the United Kingdom, a new proactive screening and treatment approach for pain is being explored for its effectiveness when compared to usual care with findings due to in 2013.

Part of this research involves investigating the feasibility of regularly employing this proactive screening and early treatment approach in a busy oncology department.

Methods

Patients attending the outpatient department at the Royal Marsden have been screened for pain over the last fourteen months. A screening form asking the attendee to score their BPI-NRS ‘worst pain in past 24 hours’ between 0 and 10 is handed out at the reception. Once filled in, the forms are given to their clinic nurse. If their pain score is ≥4/10 (a positive score), the nurse will offer the patient an immediate assessment by the pain team or a pain clinic appointment. The patient can also chose to remain under the supervision of an alternative clinician e.g. oncologist or GP, or can decline.

Quantitative data is collected on the number of patients attending, forms distributed and returned, pain score and treatment choice. Positive scores without documented treatment choice are also recorded. Qualitative information from the outpatient clerical and nursing staff has been collected during two focus group meetings.

Results

From October 2011 to date, over 1400 outpatients have been screened for pain from approximately 3000 attendees. Almost 70% of screening forms have been distributed to patients on arrival by clerical staff with approximately 50% returned for collection.

Of those attendees screened, 20% of patients complain of pain that scores ≥4/10. 12% of these patients requested immediate pain service attention in the form of an assessment or clinic appointment. The remainder chose for another party to manage their pain. However, over 30% of positive forms (i.e. pain that scores ≥4/10) did not have a treatment option documented.

Qualitative focus groups meetings and relevant communication with the outpatient staff and clerical staff are currently being analysed. Noted topics of discussion range from the need to screen cancer patients for pain and preferred methods of screening at the Royal Marsden.

Conclusion

This study into regularly screening outpatients for pain will be completed by early February 2013. Remaining quantitative and qualitative data will be collected, analysed and finalised and further dissemination of results will take place at that time.

031 Survey of Paediatric Chronic Pain Training in UK

Category: EDUCATION

Senthil Vijayan

Chelsea and Westminster hospital, London, UK

Background

1. To assess the delivery of paediatric chronic pain training for advanced pain trainees in UK. 2.To improve the delivery of paediatricchronic pain training for APTs.

Delivery of pain training is not uniform within United Kingdom and different deaneries have different modes of pain training delivery. The aim of this survey is to assess the delivery of paediatric chronic pain training within UK to address the issues, improve the delivery and bring uniformity in pain training [1].

Methods

Survey was conducted among all the advanced pain trainees on UK via the internet tool survey monkey.

Results

The survey was sent to all advanced pain trainees in UK. The response rate was 80%. Only 10% had attended more than 10 sessions of acute ward rounds. 100% agreed they need to have access for a module in paediatric chronic pain. 10% have attended more than 10 outpatient sessions. Only 10% managed to achieve their recommended competencies in paediatric chronic pain training.

Conclusion

The survey clearly illustrates lack of uniformity in paediatric chronic pain training and the main reason being difficulty in access to such module.

Recommendations:

Uniformity in training should be rolled out across the country.
Paediatric chronic pain training should be delivered as a continuous module rather than random clinics.

032 Using Social Media to Assess Public Perception of Fibromyalgia

Category: EDUCATION

Rajiv Malhotra, Sara Kelly

Royal Liverpool University Hospital, Liverpool, UK

Background

Fibromyalgia is a common chronic pain syndrome associated with adverse symptoms of cognitive, behavioural, and emotional dysfunction. It has a prevalence of 0.5-5%. However, public knowledge has been shown to be poor, with false perceptions regarding the medical basis of the condition being widely believed. Social media platforms have been rapidly expanding in recent years and often involve discussions on medical topics. We sought to access various social media sites to gauge current public perception of fibromyalgia.

Methods

A search of YouTube, Facebook and Twitter was performed on 27/11/12 with the terms fibromyalgia, fibromyalgia syndrome and fibrositis. The 20 most-viewed videos on YouTube were selected, with the top 10 comments for each being reviewed. The 10 most recent comments on the top 20 Facebook webpages were reviewed. The 20 most recent tweets on Twitter were also included. Each comment was graded as “sympathetic”, “neutral” or “derogatory”. Comments that questioned the validity of a diagnosis of fibromyalgia were identified.

Results

A total of 21,100 hits were obtained on YouTube, with the top 20 videos having an average 39, 887 views and 44 comments. The top 20 Facebook webpages had an average of 22 211 “likes”. The 20 most recent Tweets had an average of 4 replies.

Sympathetic responses: 72% YouTube, 92% Facebook, 82% Twitter

Neutral responses: 18% YouTube, 7% Facebook, 13% Twitter

Derogatory response: 10% YouTube, 1% Facebook, 5% Twitter

Question validity: 1% YouTube, 1% Facebook, 0% Twitter

(Displayed as a graph, not included)

Conclusion

The expansion in social media has resulted in a significant amount of public discussion regarding fibromyalgia. The majority of comments were sympathetic in tone, with only 6.6% of total comments assessed being derogatory. There is still a small percentage of the public that questions the validity of a diagnosis of fibromyalgia, in accordance with previous studies. Enhanced public education, utilizing the social media network, may improve awareness of this common condition.

033 Independent Healthcare: The Knowledge and Attitudes of Nurses Towards Pain Management

Category: EDUCATION

Katharine Wall¹

¹HCA Healthcare International, London, UK, ²The Wellington Hospital, London, UK

Background

Evidence supports continuing education to improve knowledge, attitudes and understanding towards pain management ¹.

At a large Independent Healthcare facility with 6 hospitals and an infant pain service, a corporate pain group was conceived, who devised a pain training programme using an adapted knowledge and attitudes to pain questionnaire ¹.

The content of the programme was based on local audit results² showing that only 67% of pain assessments were accurate when documented pain scores were compared with the patients’ report. Physiology and pharmacology were taught with emphasis on pain assessment and also assumed gaps in knowledge regarding addiction and opioid use ³.

Methods

The delegates (n=179 ) were asked to complete the questionnaire prior to the training session and the data was collated and analysed to examine trends in attitudes and gaps in knowledge, specifically looking at beliefs of patient ‘over-reporting’ of pain. The mean correct response rate was 71%

The questions were answered and discussed during the first 3 sessions of the study day and the amount of correct answers increased even during that short space of time with intense teaching.

The speciality of pain has been significantly highlighted over the previous 18 months with the advent of a Pain Clinical Nurse Specialist and heightened the awareness even before the formal teaching and this is evident when comparing the data to previous studies.

Results

Ambivalence was observed toward pain assessment and treatment when faced with 2 identical patients reporting severe pain; stoical patient A; patient B exhibiting behavioural manifestations of pain.

Patient B received adequate analgesia 62% of the time. This finding is an improvement in comparison ⁴ (45.1%). The stoical patient was under scored (24%) and received inadequate analgesia (53%).

94% correctly identified the patient as the most accurate judge of their pain but, 47% believe that the patients exaggerate their report of pain.

Poor opioid knowledge (31% identified respiratory depression as rare in opioid tolerant patients), and opioid addiction misconceptions (62% identified <1% of patients will become addicted when pain treated with opioids, compared with 30% ⁵), may account for the poor vignette choices. This lack of knowledge does not clarify the philosophy that patients must demonstrate visual pain behaviours before we are more likely to believe their report of severe pain.

Conclusion

Nurses’ inability to effectively titrate opioids has been identified as a central cause for the under treatment of pain ⁶. Several authors have listed the possible reasons why nurses consistently choose dosages which do not correlate with patients’ self-report of pain including: fear of overmedicating patients with opioids; personal beliefs regarding patients’ pain scores.

The majority of respondents (87%) correctly indicated that subsequent doses of opioid analgesics should be adjusted according to individual responses, however clinical application of this belief was not reflected in the patient case vignettes and the stoical patient remained poorly managed

034 Intermediate Level Pain Training - Survey of Sesa Trainees

Category: EDUCATION

Fauzia Hasnie

Guy’s & St. Thomas’ NHS Foundation Trust, 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, 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 survey details the training experiences of trainees in the South East School of Anaesthesia (SESA) and highlights areas for training improvement when compared to requirements in the Royal College of Anaesthetists (RCoA) 2010 Curriculum².

Methods

SESA trainees StR3 and above who had completed their intermediate level pain training by end of September 2012 were invited via e-mail to participate in an online survey consisting of 8 questions relating to their training experience. The 2010 RCoA Curriculum for a CCT in Anaesthesia was reviewed, specifically with regard to those competences that relate to acute pain and those that relate to chronic pain. A comparison was then made between curriculum requirements and survey findings to identify any training areas that could be improved.

Results

Of the 190 SESA Trainees StR3+ who were contacted, 42 responded (response rate 22.1%). 97.6% undertook intermediate level pain training as a dedicated block. Acute pain ward rounds were attended by 88.1% of trainees; whereas, chronic pain ward rounds were attended by 45.2%.83.3% of trainees spent less than ¼ of their time in acute pain, whilst only 4.8% of trainees spent at least 50% of their time in acute pain. 54.7% of trainees spent <50% of their time in chronic pain clinic compared to participating in theatre lists. 7% spent <25% of time assessing and managing patients in clinic during their pain module. Median confidence score in assessing and carrying out basic management of chronic pain in adults was 3/10. 60% of trainees had confidence levels of <50%. 85.7% of trainees felt that their pain module was well organised and with adequate sessions. However, the majority were not interested in furthering their pain training.

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. This survey highlights areas for improvement in training needs: (1) Pain training should be performed as a dedicated ‘block’; (2) More Acute Pain sessions including ward rounds; (3) More sessions in chronic pain clinic, rather than in theatre to allow a more balanced training experience.

035 Why Not a Career in Pain Medicine?

Category: EDUCATION

Bence Hajdu, Mohjir Baloch, Ann Hatch

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

Background

In our region, London & KSS Deanery, we have noticed consistently low numbers of trainees wishing to pursue a career in pain management, with pain training posts being undersubscribed. The aim of our survey was to find out what may be the reasons why junior specialist anaesthetic trainees (ST3/4) decide not to pursue pain training.

Methods

A pre-formatted scannable survey consisting of five questions was distributed to a group of ST3/4 level anaesthetic registrars appearing at a regional training day on “Anaesthesia for cancer surgery”. It was organised by the London and KSS Deaneries, in Guildford.

The survey consisted of two main parts. In the first we identified the exact training level & experience gained in the field of pain medicine using multiple choice questions. This was intended to identify the context for the second half of the survey where trainees were asked to give free text answers about their career choices and the reasons why they decided against pain medicine.

Results

23 out 29 (79%) participants completed the survey in. Out of the 23 responders 3 were other grades than ST3/4, 3 were ST4s and 17 ST3s. 13% had finished the intermediate pain training already, and 61% had started intermediate pain training since August 2012. The range of exposure to the domains of training were3-5 pain clinic sessions, 2-4 acute pain round sessions, 2-10 theatre block lists.

100% of ST4s (3) and 24% of ST3s (7) have already made a decision on their career. 4 trainees chose ICM, 2 Obstetric anaesthesia, 2 Pain medicine, 1 Regional anaesthesia, 1 Paediatric anaesthesia.

Reason for not choosing pain medicine were:

interested in something else (10)
not interested pain medicine, but no other preference(5)
clinics are difficult(4)
not enough exposure to pain medicine as yet (3)
doesn’t feel trained in managing personality/psychological issues (1)

Conclusion

This small survey of ST3 & 4 trainees shows that the ST3 trainees come to a decision by the end of the academic year, hence their exposure in this year could be crucial in their decision. Exposure seemed to be the factor driving these decisions and the experience gained in clinics seem to be a major determinant in deterring trainees from seeking a career in pain medicine. A larger scale survey would be necessary to be able to generalise these findings.

036 But How Do You Feel About Morphine Doctor?

Category: EDUCATION

Helen Laycock^1,2, Emma Casely¹, Carsten Bantel^1,2

¹Chelsea and Westminster Hospital, London, UK, ²Imperial College, London, UK

Background

Pain in hospitals continues to be managed insufficiently (Hefand 2009). Causes are multifactorial, but include doctors prescribing habits. The process of prescribing is influenced by the patient, traditions, guidelines and cost (Ljungberg 2007), but may also involve highly sophisticated learning and memory schemas, which generate certain concepts or values about specific therapies (Higgins 2005).

Moderate and severe acute pain is commonly treated with opioids. Barriers leading to ineffective opioid prescribing include safety concerns and “fear” of addiction or abuse (Murnion 2010). However terminology used to describe these barriers appears to be similar to those associated with value judgments. Therefore are value judgments a barrier in opioid prescribing and can they be modified?

This study aims to evaluate if a dedicated teaching session on opioid use in acute pain improves newly qualified doctors’ confidence and reduces perceived difficulty in dealing with acute pain, whilst also altering individual value judgements regarding morphine.

Methods

Newly qualified doctors completed questionnaires before and after a teaching session.

The teaching session was Consultant led and focused on intravenous morphine use in severe acute pain. It included a video based clinical scenario, tips on opioid use, complications, side effects and time for questions.

The questionnaire included a written case describing a patient in severe acute pain requiring immediate management. Doctors then evaluated confidence and case difficulty by marking on 100mm visual analogue scales (VAS) anchored with easy / difficult and unconfident / confident. A further two pages were headed with either “30mg mophine” or “1g paracetamol”, with ten 100mm VAS lines underneath. Each VAS was anchored with value judgment words with opposite meanings. Five word pairs came from a junior doctor generated word database describing morphine and paracetamol. The remaining five word pairs were synonyms of the original pairs included to ensure inter-individual scoring validity.

Results

100% responder rate (n=18).

Mean difficulty VAS scores changed by 20mm towards the “easy” anchor and the range of individual scores reduced by 30mm following teaching. All doctors scored the case easier to manage following teaching.

Mean confidence VAS scores improved by 17mm following teaching and 94% of doctors had improved confidence following teaching irrespective of original confidence.

Two VAS were removed from the value judgment section due to lack of scoring consistency. The remainings mean VAS scores prior to teaching showed morphine scores trended towards potent, apprehensive, excessive and dangerous anchor words, whereas paracetamol scores trended towards weak, unconcerned, inadequate and safe. All mean VAS scores following teaching were within a few millimetres of the pre teaching scores, except paracetamol, which scored as increased risk following teaching.

Conclusion

Newly qualified doctors reported increased confidence and ease in dealing with an acute pain scenario, following a dedicated teaching session on opioid use in acute pain. This session focused on improving knowledge but this single educational intervention did not alter individual value judgments regarding morphine, these remained unchanged. This may indicate that value judgments are not influenced by improved technical knowledge. Therefore if value judgments are important in influencing junior doctor prescribing of opioids, teaching needs to be focused on altering these aspects in addition to improving knowledge.

037 Does Attendance at a Pain Special Study Unit Significantly Improve Medical Students’ Knowledge of Pain at Peninsula Medical School?

Category: EDUCATION

Anand Mehta^{0, 2}, Mark Taylor¹, Suzanne Blowey¹, Roy Powell^{0, 2}

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 post-operative pain management ^[1]. At the Peninsula Medical School (PMS), in South West England, medicine is taught in a patient-centred approach. Students are in contact with patients throughout the five years of their undergraduate studies. Medical students 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 the various forms of pain, can adequately assess patients who are experiencing pain and understand how such patients should be managed. At PMS, medical students can choose from various optional special study units (SSU) to enhance their understanding of various subjects. We wanted to know if a ‘Pain SSU’ significantly improves pain knowledge among medical students.

Methods

To determine if 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 the Study of Pain (IASP) ^[3]. Our questions tested medical students’ knowledge of the definition, assessment, physiology and pharmacology of pain plus pain management in various clinical scenarios. Questionnaires were given to 1^st - 5^th year undergraduate medical students at PMS. One of the questions asked participants to reveal if they had attended a pain special study unit - an optional course available to medical students. A statistician analysed the data utilising non-parametric (Kruskal-Wallis and Mann Whitney U) tests and SPSS. Statistical analysis was undertaken to establish if there was a significant difference in the number of correct answers from students who had undertaken a ‘Pain SSU’, compared to students who had not undertaken a ‘Pain SSU’.

Results

Analysis of student scores from completed questionnaires showed the percentage of questions answered correctly improved sequentially between 1^st - 5^th year PMS students. 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 students’ understanding of pain improved as they progressed through medical school. However, there are clear discrepancies between what they should know ^[2-3], compared to what they actually do know.

15,057 papers were identified through the electronic search. Following application of inclusion and exclusion criteria, six papers were selected. All were assessed to be of good methodological quality. An association between widespread pain and all-cause mortality was reported in three studies. Five papers reported an association with cause – specific mortality, particularly from diseases with links to lifestyle factors (e.g. cancer and cardiovascular disease).

The meta-analysis indicated a trend toward an increased risk of all-cause mortality in people with widespread pain although not statistically significant (MRR and SMR combined = 1.11; 95% CI 0.91 to 1.35, p=0.305, MRR only = 1.12; 95% CI 0.87 to 1.45, p=0.375). There was evidence of statistically significant high heterogeneity (MRR and SMR combined I² =73.4%, χ²=18.80, p=0.002, MRR only I² =82.4%, χ² =17.01, p=0.001). No significant results for cause-specific mortality were found although an increased risk of cardiovascular disease and cancer mortality was indicated.

Conclusion

This study identified that mortality from diseases with links to lifestyle factors are associated with widespread pain. However, in the meta-analysis there was no confirmation of a significant pooled association between widespread pain and mortality. This may be due to the low number of identified studies and high heterogeneity between them. Further research is necessary to explore the link between widespread pain, morbidity and mortality.

043 Demographics and Referral Patterns of Non Attendees for New Appointments to the Pain Clinic

Category: EPIDEMIOLOGY

Parveen Dhillon¹, Arun Sehgal¹, Ravi Kare²

¹Peterborough and Stamford Hospitals NHS Foundation Trust., Peterborough, UK, ²Norfolk and Norwich University Hospital, Norwich, UK

Background

Non attendance at Outpatient clinics in NHS has clinical implications for non attendees and other patients on the waiting list. This also results in wastage of resources and can be very frustrating for the clinicians. There appears to be no published data for incidence and demographics of non-attendees in pain clinics. The rate of non-attendance in outpatient clinics for other specialities worldwide has been reported to vary from 15% to 25% . It is recognised from historical data that patients who are young, with low socioeconomic background, unstable families and previous history of non-attendance are more likely not to attend. The aim of this anonymised survey was to identify the demographic and referral factors influencing non-attendance in the outpatient pain clinic in our district general hospital.

Methods

We surveyed Non attendees (DNAs) over a period of 6 months who were scheduled for their first/initial consultation with a pain consultant in the Pain clinic at Peterborough and Stamford Hospitals. After the approval from Clinical governance department at our hospital, we collected the data retrospectively for all DNAs for new referrals over 6 months from January to June 2012 using the ‘e-TRACK system’. We looked at patient’s age, gender, duration and type of pain and source of referral. For further comparison, we collected the similar data for all the patients with new outpatient appointments over 2 months (March, April 2012).

Results

Data collected for the 271 new referrals over 2 months demonstrated overall referral pattern to pain clinic. 39% patients were male, 17% were less than 40 yrs age and 50% patients had pain for over 4 yrs. 71% patients were referred with spinal pain and 88% of referrals were received from primary care settings.

Over 6 months period, we had 848 new appointments of which 54 patients missed their appointments (6.4%). 54% of non attendees were male (39% of all new referrals). 45% of DNAs were under 40yrs of age (account for only 17% of all referrals). 28% of DNAs had pain for less than 2 yrs (22% of all referrals). We found that 11% of DNAs were referred with abdominal and pelvic pain (6% of all referrals ) and 6% with CRPS (1% of all referrals). For 24% of DNAs, referral was sent by secondary/tertiary care settings.

Conclusion

The survey has identified groups of patients who have a significantly higher incidence of non attendance at the pain clinic like patients less than 40 years age and patients with history of abdominal and pelvic pain. Targeted interventions may improve attendance and utilisation of health care resources. Currently we provide ‘Choose and Book’ service, 2 mobile phone text reminders and recently introduced ‘Cronos’ system for sending automated phone calls. Further improvement can be made by early patient education with an information leaflet about the local pain services given to patients particularly from the high risk groups when appointment is booked.

044 The High Prevalence of Neuropathic Pain Detected in a Secondary Pain Clinic Using the Paindetect Questionnaire

Category: EPIDEMIOLOGY

Vivekanand Eli, Harnarine Murally, Arif Hasan

University Hospital of North Staffordshire, Stoke on Trent, UK

Background

Neuropathic pain (NeP) develops as a result of damage to, or dysfunction of the nervous system that signals pain. It is often difficult to treat because it is resistant to many medications and/or because of adverse effects associated with effective drugs¹. Early recognition is a key to the successful management.

The exact prevalence of NeP in the UK is unknown². It is likely to be higher in patients attending secondary care Pain clinics. We wanted to investigate the Prevalence of NeP in our clinic. Since the majority of our patients have spinal pain, we chose the painDETECT (PD-Q) questionnaire to measure this. This PD-Q is well validated for use in patients with low back pain. It has high sensitivity (85%), specificity (80%) and positive predictive accuracy (83%)³.

As a secondary outcome measure we also looked at the percentage of patients on regular drugs for treatment of neuropathic pain.

Methods

We surveyed 51 consecutive patients attending the pain clinic at University Hospital of North Staffordshire over a period of 4 months. Patients were briefed and given the PD-Q to complete in the waiting area by outpatient nurses prior to the consultation with the pain physician.

In addition to the PD-Q we collected demographic data, site of pain, diagnosis, duration of pain and current medications.

All the PD-Q were evaluated for the scores as per the PD-Q scoring (0-12 for Nociceptive pain, 13-18 for unclear and 18-35 for NeP).

Results

All 51 PD-Q questionnaires returned were completely filled. We had 31.4 %(n=16) male and 68.6 %(n=35) female patients. The age group was between 21 to 87yrs old with a mean age of 55yrs. The average duration of the pain was 10yrs. The most common diagnosis was Low Back Pain (LBP) with 70.6 %(n=36) followed by wide spread body pain 9.8% (n=5) and joint pain 5.9% (n=3).

The overall prevalence of NeP was found to be 51% (n=26). The prevalence of NeP in the LBP group was 50 %(n=18).

We found in patients attending our pain clinic that 43.1% (n= 22) were on regular anti neuropathic medications. These include patients on either or combination of Amitriptyline, Duloxetine, Pregabalin and Tramadol. In patients identified with NeP, 50 %(n=13) were on anti-neuropathic medications. This was in comparison to 36 %(n=9) in patients not identified with NeP.

Conclusion

We found a high prevalence of the NeP in our outpatient pain clinic. Our findings were similar to that found in an Arabian study which measured the prevalence (55%) of NeP in patients with chronic LBP⁴. In contrast, our findings were higher than that found by a German multi-centre study using PD-Q with prevalence of 37%³.

Our study also revealed that only half the patients with NeP were receiving regular anti neuropathic medications.

We will advocate using the PD-Q as a screening tool in early diagnosis and initiation of appropriate medications for the management of NeP.

045 A Survey of Pain Medications at a Secondary Care Pain Service and Treatment Recommendations

Category: EVIDENCE & GUIDELINES

Lorraine Harrington¹, Jane Timperley², Steve Gilbert^{2, 3}

¹South East Scotland School of Anaesthesia, Edinburgh, UK, ²Fife Integrated Pain Management Service, Dunfermline, UK, ³Healthcare Improvement Scotland, Edinburgh, UK

Background

Prescribing costs represent a significant expenditure for NHS trusts. All clinicians have a responsibility to ensure that the medications they are prescribing are both economically and clinically effective and repeat prescriptions should be reviewed regularly. In addition, concern has been raised nationally regarding the large increase in the number of prescriptions issued for strong opioids without clear evidence of benefit^1,2. A review of the pain section of the Fife Formulary has been undertaken over the past year with clear recommendations made for 1^st, 2^nd and 3^rd line drug treatments for chronic pain. Concerns have been raised regarding the high costs to NHS Fife of pregabalin and oxycodone prescriptions. In line with SMC guidance pregabalin is placed as a 3^rd line drug for management of neuropathic pain. The Fife formulary choice for 1^st line strong opioid is Zomorph.

Methods

Our survey recorded all pain medications being taken by patients at their first assessment in the NHS Fife secondary care pain service and also recorded what prescription changes were recommended by the clinician seeing the patient. Information relating to 159 consecutive patients was collected from November 2011 to February 2012. Although data relating to all medications prescribed for pain were collected and analysed, particular attention was paid to prescribing of gabapentinoids and strong opioids.

Results

Patients were taking a variety of medications. 13% were taking 4 or 5 different medications for pain and the average number of different medications was 2.14.

Gabapentin was being taken by 35 patients and pregabalin by 36, not all of whom had had gabapentin. Only 1 patient had pregabalin initiated in secondary care and gabapentin was initiated in 9 patients.

Strong opioids were already being taken by 18% of patients and adherence to Fife formulary choice was poor (11 patients on zomorph and 18 patients on other strong opioids).16 patients were taking Tramadol and a Codeine based analgesic in combination, equivalent to being on strong opioids. This equates to 28% of patients. As shown in the graph below the opioid dosage was recommended to be reduced at first consultation in the majority of patients. One patient, newly commenced on zomorph had previously been on a higher dose of oxycodone.

Conclusion

We found that many patients are taking strong opioids when they attend a pain clinic. In addition to these patients, 16 were taking combinations of “weak” opioids.No strong opioids were initiated and in the majority, a recommendation was made to reduce. In many patients with chronic pain, neither analgesia nor quality of life are improved by the use of opioids³.

In the majority, guidance⁴ was being used appropriately. Many medications were of limited effectiveness, reflected by recommendations to reduce. Regular assessment of medication could reduce the amount that patients are taking, reducing drug costs and adverse drug effects.

046 Psychological Therapies for the Management of Chronic and Recurrent Pain in Children and Adolescents

Category: EVIDENCE & GUIDELINES

Emma Fisher¹, Christopher Eccleston^1,2, Tonya Palermo³, Amanda Williams⁴, Amy Lewandowski⁵, Stephen Morley⁶, Emily Law⁵

¹Centre for Pain Research, University of Bath, Bath, UK, ²Cochrane Pain, Palliative and Supportive Care Review Group, Oxford, UK, ³Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA, ⁴Research Department of Clinical, Educational & Health Psychology, University College London, London, UK, ⁵Seattle Children’s Research Institute, Seattle, Washington, USA, ⁶Leeds Institute of Health Sciences, University of Leeds, Leeds, UK

Background

Chronic pain is a common problem for children and adolescents, commonly located in the abdomen, head, and limbs. These children report that their pain to be severely debilitating, and affects all areas of their lives, which can later extend into adulthood. This also impacts on other family member’s lives, particularly the parents. Psychological therapies are used to treat such children with an aim to improve these outcomes. We aimed to update a previous Cochrane review that investigated the effectiveness of psychological therapies to reduce pain and disability and improve the mood of children with chronic pain (Eccleston, in press).

Methods

EMBASE, MEDLINE, and PsychINFO were searched for studies from 2009 to March 2012. To be included, studies had to be randomized controlled trials (RCT), and use a psychological therapy to treat children (<18 years) with a chronic pain condition. ‘Pain’, ‘Disability’, and ‘Mood’ outcomes were extracted at post-treatment and follow-up. The pain conditions were split into headache and non-headache pain. Headache studies measured pain dichotomously, therefore numbers-needed-to-treat-to-benefit (NNT) was calculated. Continuous data were used for disability and mood outcomes.

Results

The updated search added a further eight studies to the previously identified 29 studies included in the 2009 version of this Cochrane Review. This raised the total number of participants to 1938, 506 more than previously. From the 37 studies, 21 investigated psychological therapies for headache (including migraine), seven addressed abdominal pain, four used a mixed pain sample (including headache pain), two used fibromyalgia patients, two delivered treatment associated with sickle cell disease, and one for juvenile idiopathic arthritis. Results revealed five significant effects. Pain was found to significantly improve for both headache (NNT = 2.72; CI 2.32 to 3.29) and non-headache groups at post-treatment, and for headache groups at follow-up (NNT =2.01; CI 1.62 to 2.64). Disability significantly improved for non-headache groups at post-treatment, and mood significantly improved for headache groups at follow-up.

Conclusion

Psychological therapies are an effective treatment for the management of headache. 49% of children who received therapy improved on pain outcomes compared to 17% in the control group. There is, however, limited evidence for disability and mood outcomes for headache groups at post-treatment and follow-up. For children and adolescents with non-headache pain, therapies significantly improve their pain symptoms and disability at post-treatment, but these effects are not maintained at follow-up. Further to this, therapies do not improve of their mood when receiving such treatments. Future studies should concentrate on increasing sample sizes and tailoring treatments for conditions and individuals.

047 Percutaneous Lumbar Epidurolysis by Racz Catheter Technique: Are We Doing the Right Thing?

Category: EVIDENCE & GUIDELINES

Devendra Tilak, Anthony Ordman, Riaz Khan

Royal Free Hospital, London, UK

Background

Managing persistent pain from epidural adhesions following lumbar decompression is challenging. Patients with epidural scarring are at particular risk of recurrent radicular pain(2). Nerve roots encased in collagenous tissue may be tethered, causing neural tension, restriction of arterial supply and venous return. Nutrient and axoplasmic transport may also be impaired. Epidural adhesions are best diagnosed by performing an epidurogram, with adhesions identified as filling defects(3).

Epidural steroid injection is a common treatment for such pain, but outcome studies have not been reported. Secondary, open surgery for removal of epidural scarring has had limited success, with long-term benefit seen in only a small number of patients(1,3).

Percutaneous lumbar epidural adhesiolysis (PLEA) is a technique described for the management of radicular leg pain caused by epidural adhesions. It was first described by Gabor Racz et al as a three-day treatment, and modified by Manchikanti et al. to a 1-day procedure (4).

Methods

We audited our current practice of Racz PLEA. Patients with epidural adhesions as a cause of radicular pain who had failed other treatments, received 1-day PLEA as a single procedure. 23 patients undergoing 26 epidurolysis procedures from January-2011 to July-2012 were included. Data was collected retrospectively from patient’s notes, outpatient clinic letters and telephone reviews. We documented % reduction in pain, and improvement in function following epidurolysis, as reported by the patients.

The epidural space was accessed via the caudal route using Epimed-(COUDE(R)Epidural needle) needle and Epimed-(BREVI(STF)Epidural catheter) catheter, guided to the appropriate level under fluoroscopy. Epidurography was performed to identify the location of scar-tissue. 0.5-1% lidocaine, 0.9% saline, 40-60 mg triamcinolone acetate and 750-1500 units of hyluronidase (total volume 15-20 mls) were injected. Three patients had two procedures.

Patients were telephoned after 8 weeks, and seen in clinic up to 5 months post procedure.

Results

15 patients were male, 8 female, with mean age 56.5 years. Previous lumbar surgery was the cause of epidural adhesions in 22/23 patients, while 1 patient had history of tuberculosis of spine. 20 patients had previous open surgical decompression and 2 patients had microdiscectomy.

20/26 (74%) patients reported some pain relief.
12/26 (46 %) patients reported > 50% reduction in pain for over 2 months, while
4/26(15.3%) reported 20-50% and
4/26 (15.3%) reported < 20% reduction in pain for over 2 months.
18/26 (66.7%) patients had sustained improvement in function and
1/26 (4%) complained of worsening of pain, with reduced mobility secondary to pain.
No other complication was reported.

Conclusion

PLEA is a safe, and cost-effective treatment for chronic pain, as a part of multidisciplinary management, in patients nonresponsive to other conservative treatment modalities.

We implement the one-day protocol as described by Manchikanti etal, who compared hypertonic-saline(HS) with 0.9%-saline(NS)(4). HS-neurolysis has slightly better and longer lasting effect on pain reduction comparedNS-adhesiolysis(4). However, HS inadvertently injected into the subarachnoid space could result in serious complications(3,7).

We recommend that PLEA should be performed using NS and hyluronidase, along with local anaesthetic and triamcinolone. Procedures should be performed upto 4 times(4,7) in the first year to achieve sequential improvements in pain and function(4,7).

048 Good Practice in Opioid Prescribing for Persistent Pain: A Survey of Prescribers Based on BPS Guidelines

Category: EVIDENCE & GUIDELINE

S Prit Anand Singh, Usman Bashir, Margaret Cullen

Western General Hospital, Edinburgh, Midlothian, UK

Background

In 2010, the British Pain Society (BPS) published a comprehensive document (Opioids for persistent pain: Good practice) providing detailed guidance on the prescription of strong opioids for all practitioners in the UK. The guidance included recommendations on the dosage & formulations of opioids, frequency of review and the need to discuss short and long term adverse events with patients at the time of prescribing.

The objective of the survey was to review adherence to the BPS guidelines by local General Practitioners.

Methods

Initially a paper based pilot survey was carried out followed by an online survey (Surveymonkey.com) with questions based on various aspects of opioid prescribing as per the BPS publication. The online survey web link was forwarded to the local GP administrator who distributed it to all the local GPs. The survey was kept open for a period of 4 weeks with a reminder sent after a fortnight. There were 10 objective questions in the survey with areas for free comments where required. A total of 124 responses were received.

Results

98% of survey responders prescribed strong opioids, but only 38% were aware of the BPS guidelines. 56% of responders did not risk stratify patients before commencing opioids, 40% did not document the goals of opioid therapy, whilst 34% agreed that it would be easier to do so if they had a standard opioid contract. 53% used sustained release preparations, 40% prescribed immediate release preparations and 7% were unsure. 35% were not clear regarding dose range at which to refer to specialists and the rest varied between 60 to 180 mgs/ day of morphine equivalent doses.

70-90 % of GPs informed patients about short-term side effects, toxicity, etc but only 13% mentioned long term effects. 87% followed up patients weekly to monthly initially and, once stable, patients were reviewed quarterly or biannually. At these visits 50% of GPs recorded adverse effects. Free text comments further illustrate GP’s concerns regarding opioid prescribing.

Conclusion

Strong opioids are widely prescribed for persistent pain in primary care but existing guidelines on their use are not well known or followed. Comparing GP and patient responses (see other poster) there seems to be discrepancies both between GP and patient recall of drug information delivered and mutual understanding of what exactly is being reviewed during later follow-up visits. Better dissemination of guidelines and printed patient information is clearly required. Some GPs would also welcome the use of opioid contracts to aid clearer long-term communication and goal setting with patients.

049 Good Practice in Opioid Prescribing for Persistent Pain: A Survey of Patients Based on BPS Guidelines

Category: EVIDENCE & GUIDELINES

Usman Bashir, Prit Anand Singh, Margaret Cullen

Western General Hospital, Edinburgh, Midlothian, UK

Background

Chronic pain affects around five million people in the UK. This pain can lead to functional impairment -physically, emotionally and vocationally and thus can be very frustrating and disabling.

Opioids have a well established role in the management of pain in the short and medium term, in a variety of non-cancer pain conditions. Their safety and efficacy in the long term is still under investigation.

In 2010, British Pain Society (BPS), published guidelines about Good practice in opioid prescribing for persistent pain. This comprehensive document provides detailed guidance on prescription of Opioids for all practitioners in UK. A statement based on the above document (in simple language) was also published for patients.

The objective of the survey was to review adherence to the BPS guidelines by the prescribers (GP/Hospital doctors).

Methods

All patients attending local chronic pain clinics were requested to complete a questionnaire on arrival. Those who identified themselves as taking strong opioids were asked to complete information on the frequency of review following initial prescribing and their recollection of advice and warnings given by the prescriber. The data was collected over a span of 6 weeks.

Results

126 patients were taking strong opioids. 67 (53%) were prescribed opioids by the General Practitioner, the rest 59 (47%) were by a hospital doctor.

Common adverse events were discussed with 62% (n=78), of patients.

Long-term adverse events were discussed with a third of patients (n=42).

About 53% (n=67) had a discussion regarding driving and work.

36% (n=46) had been told about features of overdose/toxicity

14% (n=18) of patients were followed up on a monthly basis specifically for review of opioid prescribing.

Conclusion

In our survey we found that, more than half the clinicians had discussed short term side effects and effect on driving and work. However, only about one third of the patients had any communication regarding long-term effects and features related to opioid toxicity/overdose. Although most patient were reviewed during routine follow up appointments (3 to 4 months ) only a minority of patients remembered being followed up specifically for opioid medication review at regular intervals. In conclusion we found that there appears to be very limited adherence to BPS guidelines both in terms of initial discussion of possible adverse events and regular follow up.

050 Brain Cortical Thickness Correlates of Chronic Pain Duration in Knee Osteoarthritis

Category: EVIDENCE & GUIDELINES

Hamza Alshuft^1,2, Jennifer Dixon^1,2, Laura Condon¹, Robert Dineen¹, Dorothee Auer^1,2

¹University of Nottingham, Nottingham, UK, ²The Arthritis Research UK Pain Centre, Nottingham, UK

Background

Pain is the dominant complaint in OA but not all patients develop pain¹. Pain severity in OA is known to be often inconsistent with the degree of joint pathology² and conversely at least 12% of patients do not respond to TKR surgery in terms of pain relief³. Furthermore, placebo surgery can significantly reduce pain associated with Knee OA⁴

Neuroimaging studies of chronic pain have reported morphological changes in brain regions involved in pain processing. These include but are not limited to the thalamus, anterior cingulate (ACC), insula, brain stem, and dorsolateral prefrontal cortex^5,6 (DLPFC), suggesting a central role in the process of pain chronification.

We hypothesised that pain-related changes in cortical thickness correlate with pain duration. To investigate that we undertook a research ethic-committee approved MRI study in patients with chronic pain in knee osteoarthritis (OA) and healthy controls.

Methods

Subjects: 26 adults aged 45-80y 64.7± 8.5 (M± SD), 14 males, with knee OA chronic pain, and no other major medical or neuro-psychiatric co-morbidities. Pain duration ranged 1-38y. 10 healthy subjects aged 43-70y 56.9± 9.5.

Data acquisition: High resolution structural MRI was performed at 3T (GE Discovery 750) using a 32-channel head coil and FSPGR scan(Voxel size= 1mm³, TE=3.3ms, TR=8.5ms TI=450)

Cortical Thickness measurements and statistical analysis: For cortical thickness measurements we used FreeSurfer software package Mac version 5.1 (www.surfer.nmr.mgh.harvard.edu). QDEC (FreeSurfer-statistical tool) was used to perform whole-brain surface based correlation analysis. Significance was set at p <0.001 (uncorrected) controlled for age. Independent t-test was used to compare a selective ROI average cortical thickness between patients and healthy controls

Results

Pain duration showed a significant negative correlation (thinner cortex with longer pain) in a number of cortical areas namely for clusters > 50^mm for the left hemisphere; the inferior-parietal, cuneus, precuneus, superior temporal, and the rostral middle frontal. And for the right hemisphere significant negative correlation was found in posterior insula, pericalcarine, inferior parietal, and caudal middle frontal. Cortical thickness was significantly reduced in patients compared with healthy controls in the left inferior parietal average thickness mm = (2.09± 0.19 and 2.24±0.2.,p<0.05) and in the right insula (2.2± 0.18mm and 2.35±0.18, p<0.05)

Conclusion

Our preliminary results suggest that pain duration in knee OA is accompanied by reduced cortical thickness. This is generally in line with a previous volumetric study ⁵ which reported grey matter decrease in DLPF cortex with pain duration in back pain indicating that prolonged pain experience may lead to regional brain atrophy. Our study was limited by small sample size particularly for healthy controls and the use of a liberal significance threshold of uncorrected p<0.001. In the future we plan to expand the sample and allow for multivariate analysis including the correction for potentially confounding gender and medication effects.

051 Electrodermal Responses to Experimentally Induced Pressure Pain

Category: EXPERIMENTAL (BASIC) SCIENCE

Osama Tashani, Kassra Scholl

Leeds Metropolitan University, Leeds, UK

Background

Electrodermal response (EDR) is a measure of electrical skin conductivity and an indication of sweat gland activity which changes in response to the sympathetic nervous system outflow. The measurement of EDR is used to assess autonomic functional disorders such as lesions of the peripheral nerves and nerve roots, central nervous system disorders and other disorders of the sympathetic system (Kucera et al, 2004). However, there is a lack of research to investigate EDR changes during experimental pain sessions. The aim of this study was to determine whether pressure pain has a significant impact on electrodermal responses.

Methods

Twenty healthy students (age ranges from 18 to 33 years, 10 females) were recruited from Leeds Metropolitan University and pressure pain was applied to the soft tissue between the metacarpals of the thumb and index fingers of the dominant hand using an algometer (SOMEDIC type II) while recording their electrodermal response on a data acquisition system (PowerLab 16/35 with LabChart Pro, ADInstruments) by measuring the electrical resistance between the palmar middle phalanges of the middle and index fingers of the non-dominant hand. After initial baseline EDR recording for 15 minutes participants were informed of the imminent application of the algometer to determine whether there was a reaction to the anticipation of pain (T1) then pressure applied (T2) and pain threshold was measured as participants indicated pain (T3). This cycle was repeated after 10 minutes interval.

Results

EDR in (mean±SD) micro-Siemens (µS) showed no change from 7.2±6.5 at baseline to 7.6±6.5 at T1. However, the values at T2 (8.7±6.4) and T3 (10.5±6.2) were statistically different (P<0.01, paired t-test) from the baseline and T1. There were slight decrease in EDR during the interval but this was statistically insignificant (P=0.087). There were no significant gender differences in the pattern of changes in EDR.

Conclusion

Actual pain rather than anticipation of pain produced significant changes in EDR activity. This study confirmed earlier reports which suggested that sympathetic activity increases in response to pain. However, further research is needed to investigate if EDR records will benefit pain reporting in children and patients with impaired communication skills.

References:

Kucera P, Goldenberg Z, Kurca E. Sympathetic skin response: review of the method and its clinical use. Bratisl Lek Listy. 2004;105(3):108-16.

052 Hormonal Contraceptive Pill Effect on Pain Sensitivity of Healthy Volunteers

Category: EXPERIMENTAL (BASIC) SCIENCE

Hannah Wilson, Oras Alabas, Osama Tashani

Leeds Metropolitan University, Leeds, UK

Background

Findings from previous studies demonstrated that pain sensitivity level across menstrual cycle fluctuates in healthy volunteers suggesting that oestrogens and progesterone levels may affect pain intensity ratings or thresholds. The aim of this study was to investigate the differences in pain sensitivity between women taking hormonal contraceptive pill and women menstruating naturally in cold pressor task.

Methods

45 participants were recruited from Leeds Metropolitan University (mean±SD of age 22.2±4.2 years) and divided into three groups: 15 men, 15 women using hormonal contraceptive pills, 15 women not using contraceptive pills. After initial familiarization session the participants undertook an experiment involving two cycles of cold pressor task with 5 minute interval between thecycles. Participants held their least dominant hand in a water bath set at 32°C for 3 minutes to standardise the skin temperature, then plunged this hand into the ice water bath maintained at 0-1°C. Time taken to reach pain threshold, when participant reported “pain”, and pain tolerance, when participant no longer could tolerate any more pain, were measured in seconds. Participants were also asked to record their pain intensity and unpleasantness levels on a 100mm VAS (visual analogue scale).

Results

While there were no statistical differences between groups in pain threshold (p=0.63, one way ANOVA), pain intensity (p=0.81) and pain unpleasantness (p=0.08) average of pain tolerance of the two cold pressor tests of men at (72±70s) was significantly higher than that of two women groups (with contraceptive= 24.5±43.6s, without contraceptive 15.8±16.1s, p< 0.01). The only difference between the two women groups were in cycle 2 of the cold pressor task in which women on contraceptives rated pain unpleasantness (66.1±17.9mm). This was more than unpleasantness ratings by women off contraceptives (47.5±21.6mm) (P=0.02).

Conclusion

Results suggested, albeit reservedly, that women on hormonal contraceptive pills may respond differently than women not using contraceptive pills in some pain sensitivity measures. However, men still have greater pain tolerance than women regardless of their use of hormonal contraceptive pills. This indicates that differences between men and women are more likely to be due to gender role and other psychosocial factors rather than due to the effect of hormones.More research in experimental settings to compare the pain sensitivity response between women on contraceptive pill and women menstruating naturally is needed.

053 Is there a Correlation Between Pressure Pain Thresholds and the Level of Endocannabinoids in Cerebrospinal Fluid or Serum?

Category: EXPERIMENTAL (BASIC) SCIENCE

Danielle Reddi¹, Katherine Chatten¹, Emma-Louise Page², Celia Morgan², Amod Manocha¹, Sumit Gulati³, Brigitta Brandner¹

¹University College London Hospital, London, UK, ²University College London, London, UK, ³Leeds Teaching Hospitals, Leeds, UK

Background

Exogenous cannabinoids activate neuromodulatory receptors including the specific cannabinoid receptors CB1 and CB2. CB1 receptors are predominantly found in the brain and spinal cord. The two most studied endogenous ligands are arachidonoylethanolamine (anandamide or AEA) and 2-arachidonoylglycerol (2-AG). It is well established that exogenous cannabinoids have analgesic effects ¹, and there is growing evidence that increasing endocannabinoid levels in animals can attenuate pain and reduce the development of hyperalgesia and allodynia. Painful stimuli have been shown to result in increased levels of anandamide in the brain in mice ². Cerebrospinal fluid (CSF) anandamide levels have been studied in humans in relation to a number of conditions ^3,4, but the role of endocannabinoids in pain is less well established. Neither blood nor CSF levels have been previously reported in relation to pressure pain thresholds (PPT). It was hypothesised that lower CSF anandamide levels might be associated with lower PPT.

Methods

Ethical approval was obtained. Cannabis users and non-cannabis users were included to examine the effects of exogenous cannabinoids. Subjects were screened for relevant exclusion criteria. Contraindications to PPT testing included peripheral neuropathy, rheumatological disease, pain symptoms, history of trauma or surgery to the dominant hand and medication which might affect pain thresholds. Informed consent was obtained.

Pressure pain threshold testing was performed using electronic pressure algometry by a single study investigator. A test measurement was performed on the non-dominant hand followed by three PPT readings from the dominant hand, approximately 15 seconds apart.

Following PPT testing participants underwent lumbar puncture with collection of CSF. A blood sample was then taken. Blood and CSF samples were chilled immediately. Endocannabinoid levels were quantified using high-performance liquid chromatography / mass spectrometry.

Data was analysed using the Spearman correlation coefficient and Mann Whitney U test. A P value < 0.05 was considered statistically significant.

Results

33 young, healthy subjects participated in the study. 20 were regular cannabis users, with 10 categorised as heavy users and 10 light users, 13 were non-users. The mean age of participants was 21.9 years (range 19 - 28 years). Male to female ratio 15:18.

Pressure pain thresholds varied from 149 to 1420 (median 390). There was no significant difference between PPT in cannabis users and non-cannabis users (P=0.439). No significant correlation was found between CSF anandamide or 2-AG levels and PPT in any group. There was a trend towards higher PPT in the light in the users, followed by heavy users and then the control group.

CSF anandamide levels varied from 0.0323 pmol/ml to 0.338 pmol/ml. There was a trend towards higher CSF anandamide levels in the light users compared to heavy users.

There was a significant correlation between PPT and serum anandamide level in the control group (P=0.006).

Conclusion

There was a significant positive correlation between PPT and serum anandamide levels in the control group and a trend towards higher CSF anandamide levels and higher PPT in the light cannabis users. This may suggest an analgesic effect of anandamide. The lowest CSF anandamide level was in the heavy cannabis users which may indicate down regulation of endocannabinoid production. Further studies on a larger sample would help to clarify these findings.

References:

Guindon J et al. CNS and Neurological Disorders-Drug Targets 2009;8:403-421
Walker et al. PNAS 1999;96(21):12198-12203
Di Filippo M et al. J Neurol Neurosurg Psychiatry 2008;79:1224-1229
Romigi et al. Epilepsia 2010;51(5):768-772

Conclusion

Although inadequately powered to detect statistically significant changes in BPI or Oswestry scores this study appears to show good results at 8 weeks after ESI in 75% of carefully selected patients with LSS. It is felt to be reasonable clinical practice to offer “responders”, as identified by positive Oswestry and BPI scores at an 8-week telephone follow-up consultation, a repeat appointment for ESI 6 months thereafter. This system allows the responders to be relisted approximately 4 weeks earlier than with conventional “90 day outpatient” follow up and relieves pressure on our outpatient appointments diary.

059 Sphenopalatine Ganglion Pulsed Radiofrequency for Chronic Facial Pain

Category: INTERVENTIONAL PAIN MANAGEMENT

Ravi Nagaraja¹, Arif Ghazi², Charles Gauci²

¹St Bartholomew’s Hospital, London, UK, ²Whipps Cross University Hospital, London, UK

Background

Sphenopalatine ganglion(SPG) block has been done the early 1900s when cocaine was used to block the ganglion for various pain syndromes. Sphenopalatine ganglion block is most commonly used for sphenopalatine ganglion neuralgia, trigeminal neuralgia and atypical facial pain. Slutjer first described the pulsed radiofrequency technique, where the generator output is interrupted to allow for the elimination of heat between pulses. This novel approach is recommended for treatment applied to peripheral nerves where the application of heat carries significant risk.

Methods

A total of 9 patients between January 2010 and May 2012 were included in our audit to assess the efficacy of sphenopalatine ganglion block. A review of case notes was done and also a telephone review to assess the efficacy of the procedure.

Phone Questionnaire:

Has the procedure been effective?
Duration of pain relief
Any reduction of pain medications
Presence of autonomic symptoms

Results

A total of 9 patients had this procedure for chronic facial pain, atypical trigeminal neuralgia and atypical facial pain.

60% of patients reported good pain relief and it lasted from 4 to 6 months. In one of the patients the procedure was repeated for recurrence of symptoms. There was reduction in the use of medication in one patient and the others were too scared to reduce the medications because of fear of recurrence of symptoms.

Conclusion

Sphenopalatine ganglion pulsed radiofrequency can give a variable period of pain relief in select group of patients. The procedure was repeated which means the pain relief was not expected to last permanently. The mechanism of action by which Pulsed radiofrequency controls pain is unclear, but it may be due to a rapidly changing electrical field. This group of patients come to us after having tried various other treatments, it would be worthwhile to consider this technique as one of the options available to provide pain relief

060 Use of Epidural Steroids by Pain Physicians in Chronic Back Pain - A Survey of Current Practice in the UK

Category: INTERVENTIONAL PAIN MANAGEMENT

Deepak Malik¹, Praveen Ganty²

¹Leicester Royal Infirmary, Leicester, UK, ²The Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK

Background

Recently, there has been a series of patients in the US who have had meningitis attributed to epidural steroids. This has led to a debate on the rational use of epidural steroids in patients with low back pain (LBP).

Our survey was aimed at the current usage and rationale of performing epidural steroid instillations in patients with chronic low back pain in the UK, and to look at the evidence base behind current practice.

Methods

An anonymised 10-point questionnaire was sent in October 2012 via an e-link on “SurveyMonkey” to pain physicians from varied backgrounds and experience (pain consultants and pain physicians on Google groups). Questions were aimed to obtain relevant information regarding their current practice in the use of Epidural steroid in patients with low back pain.

Completed responses were received from 74 members. Eighty two percent of the respondents were Pain Medicine consultants, 14% were Advanced Pain trainees and 4% were others. Over 46 % of respondents had more than 10 years of pain experience.

The physicians had several ways of gauging the efficacy of a steroid injection ranging from- pain reduction 30-50%, benefit from 3 to 6 months, feedback questionnaire, functional improvement, VAS score, patient self report, BPI scoring, ability to perform directed regular exercise, Quality of life improvement etc.

Results

Almost 70% of the pain physicians regularly use epidural steroids for LBP. 61% would perform their epidurals in prone position, while 31 % would perform in sitting position. 47% percent would use an 18 G Touhy needle and 11% would use a 22G spinal needle for performing the procedure, with almost 44 % using a combination of techniques e.g. loss of resistance, fluoroscopic guidance with or without contrast. There seemed to be almost an equal divide for preference of steroid, with 48% using Triamcinolone and 44% using Methylprednisolone. 21% would either use (0.25%) Bupivacaine and another 20% (0.25%) Levobupivacaine. Almost 14% of pain physicians are still using either 1 or 2% Lignocaine for their epidurals. Nearly 70% would repeat epidural 1-2 times in a year and 14% would perform 3-4 times.

Conclusion

Although epidural steroid instillation is recommended in the presence of LBP along with lumbosacral radiculopathy, it is a commonly used intervention for LBP in the UK. Although numerous systematic reviews have been undertaken on the efficacy of epidural steroids in chronic back pain, none have revealed the superiority of epidural instillation of steroids as an effective long-term treatment for LBP.

Although the methodology of drug manufacture is different in the UK when compared to the US, clinicians need to be aware of the potential danger of instillation of any drug into the epidural, or indeed, the intrathecal space.

061 BPS-Interventional Pain Sig (2012) Annual Scientific Meeting Spinal Cord Stimulation UK Practice Survey

Category: INTERVENTIONAL PAIN MANAGEMENT

Manish Gupta, Rajiv Chawla, Manohar Lal Sharma

Walton Centre NHS Foundation Trust, Liverpool, UK

Background

Spinal Cord Stimulation (SCS) treatment has substantial evidence base. SCS should be delivered within facilities that can offer multidisciplinary team (MDT) assessments, other pain management options, management of complications or tolerance of neuromodulation and should be used as part of comprehensive rehabilitation process. Not all patients are suitable for SCS. Referring clinicians should be aware of indications for SCS. Techniques of SCS vary. Electrodes may be inserted percutaneously via an epidural needle, or surgically implanted via laminotomy by the neurosurgeon. It is considered good practice to allow patients to undergo a period of trial stimulation. Patients should be screened for methicillin-resistant Staphylococcus aureus (MRSA), and an antibiotic prophylaxis must be administered. Appropriate infrastructure for ongoing surveillance, support and audit must be in place.

Methods

This short survey was distributed to 75 participants at the annual scientific meeting of the Interventional pain special interest group of the British Pain Society (BPS) in Manchester (September 2012). This meeting was attended by pain clinicians (consultants and trainees) all across the country and provided a good forum to survey the practice of SCS. However, not all participants were implanting SCS. The aim of the survey was to get an overview of the current practice of SCS amongst the members, aligned to recommendations by the BPS and NICE (National Institute of Clinical Excellence). We enquired about: indications considered for referral or treatment; infrastructure, competency and audit; MDT approach; length of trial period; number of electrodes/contacts preferred; outcomes measured for conversion to permanent implant; MRSA screening and antibiotic prophylaxis; and permanent implant technique (percutaneous or surgical) and preferred site of battery implantation.

Results

Completed questionnaires were returned by 46 participants, yielding a response rate of 61.3%. The responders were a mix of SCS and non-SCS providers in a ratio of 3:2. The results for indications for this treatment were consistently reflective of the BPS guidelines and NICE HTA / 2008 / 159. Most providers (>2/3) are able to maintain their competency by doing >10 procedures in a year. Most (>2/3) permanent implants are done by the pain specialist. Good proportion (>2/3) are able to audit their outcomes. Almost all responders offer MDT assessment. A trial of 1 week is standard, unless otherwise indicated. More than 80% respondents mentioned using octopolar leads. MRSA screening is done by all; however timing of antibiotic prophylaxis was inconsistent. Surgical method of lead implantation is not offered at most centres (<25%). As regards site of battery implantation, they were no particular preference observed.

Conclusion

A multidisciplinary pain management team is the most appropriate context in which to provide SCS. Teams must have and maintain the competencies needed to offer the most appropriate techniques. Implanting centres should audit their activity and provide patients with information on outcomes and complications. There is currently no national database of patients treated with SCS, but this is being currently established. Antibiotics should be given as a single intravenous dose 30 minutes before the procedure. Collaboration with surgeons competent to deal with complications should be in place. These issues may be relevant for future commissioning of neuromodulation in England.

062 Assessment of Outcomes Following Interventional Procedures for Pain Management - The First Year of Outcomes in Glasgow

Category: INTERVENTIONAL PAIN MANAGEMENT

Clare Bridgestock¹, Lars Williams²

¹Stobhill ACH, Glasgow, UK, ²New Victoria Hospital, Glasgow, UK

Background

A patient questionnaire to assess outcomes after interventional procedures for pain management was introduced into clinical care in Spring 2011 after a successful pilot. Ongoing follow up for patients should only be arranged after return of this questionnaire, requiring engagement from patients with the service and allowing appropriate return appointments to be made. This also allows both procedure specific and operator specific outcomes to be evaluated.

We have collated outcome data from 1/08/11 to 31/07/12 and our primary objective is to report on the findings of the first year of outcomes including procedures performed, duration and degree of pain relief, analgesic use, impact on sleep, mobility and quality of life following interventional procedures for pain management. We will also quantify side effects suffered and examine whether data collection can be further improved and if the interventional procedure process can be modified to optimise service delivery.

Methods

The original outcomes questionnaire was developed by a multi-disciplinary team, then validated and further modified after a pilot study. Every patient attending for an interventional procedure for pain management in Greater Glasgow and Clyde is given the questionnaire immediately after their procedure.

Data recorded on the questionnaire includes date and procedure performed and operating physician. The patient is asked to complete to complete the questionnaire at eight week after intervention, answering questions on duration and degree of pain relief, changes in analgesic use, quality of life, sleep and mobility. There is also a specific field for detailing side effects. The patient is asked to return the questionnaire by post to the pain department.

Data from completed questionnaires is inputted into a Microsoft Access database, primarily by the two authors.

Results

Outcome data from 1/08/11 to 31/07/12 was analysed, with a total of 836 completed outcome forms for 1390 procedures, a return rate of 60%. The most commonly performed procedures are sacro-iliac joint injection, lumbar facet joint injection, high volume caudal, trigger point injections and lumbar nerve root block.

Overall, 57% of patients reported more than 30% pain relief and 47% of patients have a reduction in their pain for more than 5 weeks. If a positive response is defined as >30% relief for >4 weeks, 42% could be defined as responders.

53% of responders reduced their analgesic intake, 58% reported improved sleep, 53% reported improved mobility and 72% reported an improvement in their quality of life.

25% of patients complained of side effects related to the procedures, most commonly pain in the area of injection

Conclusion

In a proportion of patients, interventional procedures provide a period of reduction in pain which may lead to improvement in sleep, quality of life and mobility and a reduction in analgesic medications.

We are investigating the possibility of an SMS reminder service to improve return rates and also focussed patient education at the time of the procedure, including information on pacing, graded activity and reduction of medication.

With a growing database of operator and procedure-specific outcomes, we will be able to provide accurate information to patients and audit our own practice, as mandated by the new GMC revalidation process.

063 Radiofrequency Denervation (RFD) of Peripheral Nerves in the Management of Trigeminal Neuralgia (TGN) in the Elderly and Patients With Multiple Sclerosis (MS)

Category: INTERVENTIONAL PAIN MANAGEMENT

Yee Cze Tang¹, Margaret Bone¹, Jonathan Hayter²

¹Pain Management Department, University Hospitals of Leicester, Leicester, UK, ²Department of Maxillofacial Surgery, University Hospitals of Leicester, Leicester, UK

Background

Trigeminal neuralgia causes recurrent, brief episodes of severe and often incapacitating facial pain. The peak age of onset for classical TGN is 60 years and many patients are elderly. Secondary TGN occurs in patients with multiple sclerosis, usually at a younger age. The first line treatment is pharmacological management but when this fails, interventional therapies may be considered. Current scientific evidence supports microvascular decompression. Elderly patients or those with MS may present significant anaesthetic and operative risks, limiting such treatment.

The authors wished to assess their local practice within Leicestershire in this group of patients with regards to indications and outcomes from the technique of RFD of the peripheral trigeminal nerve.

Methods

This is a retrospective audit of patients undergoing peripheral nerve RDF for TGN over a 10 year period from 2002 to 2012. A review of the theatre records within the Pain Daycase Unit identified patients undergoing Interventional Pain treatments for TGN. The medical records of those undergoing RDF of peripheral TG nerves were assessed.

Demographic data, treatment details and outcomes were recorded.

Thirty three patients were identified. Twenty six patients had classical TGN for 19.8 years, with mean age of onset 67.9 years.

Seven patients had TGN associated with MS for 20.0 years, with mean age of onset 37.3 years. All patients had significant co-morbidities.

Results

Prior to RFD treatment, those with classical TGN had been controlled on medication for a mean time of 7.9 (1 - 21) years and patients with MS for a mean time of 13.4 (1 - 30) years.

The treated divisions were as follows: 1^st division 4; 2^nd division: 16; 3^rd division: 9; 2^nd and 3^rd division: 4.

The average numbers of treatments for all patients was of 3.2 (range 1 - 8) and the mean time between treatments was 14.7 months.

Of the 33 patients, 27 reported benefit (pain relief >50% with reduction in medication) for a mean time of 9.6 months (2 - 48). 21 were able to reduce their medication to a maintenance dose and 2 patient stopped medication.

6 patients failed to gain benefit.

6 patients reported impaired sensation. No serious adverse events were recorded with this treatment.

Conclusion

The scientific literature for percutaneous peripheral procedures is sparse. Peters and Turo noted that series tended to be small with shorter-term follow up and concluded that peripheral procedures should be reserved for emergency use or in patients with significant medical problems restricting other procedures. Gronseth et al reached similar conclusions.

The authors acknowledge the small series but consider the data demonstrates that the technique of RFD in the management of intractable TGN is an effective treatment in this selected group of patients who may present a challenge for alternate interventional techniques. Additionally, we recorded no serious adverse effects.

064 Development of Impedance Guided Nerve Seeking Needle

Category: INTERVENTIONAL PAIN MANAGEMENT

Arindam De¹, John Taylor^{0, 2}, Kaddour Bouazza-Marouf^{0, 2}, Atul Gaur¹

¹University Hospitals of Leicester, Leicester, UK, ²Loughborough University, Loughborough, UK

Background

We aim to develop a needle system, which will detect the tissue type based on electrical impedance and offer unique guidance during regional and neuroaxial block. Currently the accuracy of nerve blocks relies on performers’ experience and judgement, which result in increased risk of damage/harm to the patient/tissues. Presently, there are Nerve stimulator, Fluroscopy (+/- Dye) guidance and recently Ultrasound to locate and guide practitioners to nerve and nerve plexuses, but with their own limitations. Our experiments at the Electronics Laboratory of Loughborough University for developing such needle system is described here.

Literature review: limited amount of impedance testing carried out on animal tissues in the past, all of which have supported the theory that impedance can be used to differentiate between various tissue types.

Methods

The first set of tests done on individual tissues to understand specific impedance characteristic. Muscle, fat and nerve tissues of chicken, turkey, lamb, pork and beef samples, sourced from local butcher, were tested.

The final set of tests done on composite samples submerged in artificial cerebrospinal fluid (CSF). Tests involved measuring impedance as the needle travelled through different tissues. The key variables were the temperature of testing, the signal frequency and the tissues tested.

An oscilloscope was connected to a circuit board capable of generating frequencies up to 80 kHz and a constant current of 1mA. A step motor driven, screw mounted, reproducible needle insertion was set at 3mm/sec. The output value transmitted to a computer using a Picolog 1216 Data Logger. The data logger took reading every 10 ms, which equates to every 0.03 mm travel of the needle.

Results

The results showed a significant difference between the tissues tested, particularly with CSF.

Higher frequencies display larger differences between impedances of different tissue types. At 37°C impedance are less than half the magnitude of the 10°C values, while the 20°C are close to the 37°C. This suggests that impedance reduces as temperature increases and is not linear.

The next stage of composite testing, simulating spinal injection, aimed to identify tissue type based on impedance values as the needle advances. At 5kHz there is no significant change to identify tissues. But at both 10 kHz and 50 kHz significant drop in impedance by 5kΩ was demonstrated as the needle passed from muscle to CSF and into nerve tissues. There was no identifiable difference between muscle and fat tissues. But across majority of the frequency range - significant difference exists between nerve, muscle and CSF of all samples.

Conclusion

Significant leap towards development of impedance guided needle, which can help practitioners who offer invasive nerve block techniques for pain relief.

Tests show clear difference of impedance between tissue types in five different animals. Composite test identified nerve, muscle and CSF. There was a significant impedance drop in CSF. There was a definite trend to suggest that higher temperature decreases impedance of tissues in a non-linear fashion. Differentiation between tissues is more effective at higher frequencies.

Further tests are required for statistical significance. This experiment will need to be taken to cadaver study for further development of nerve seeking needle.

065 Retrospective Audit on Cooled Radiofrequency Denervation of Sacroiliac Joint

Category: INTERVENTIONAL PAIN MANAGEMENT

Satish Kumar Gopa Narasimhula, Saravana Kumar Kanakarajan

NHS Grampian Health Board, Aberdeen, UK

Background

SI Joint complex pain contributes 15-25% of low back pain. The prevalence of SI joint pain is increasing. One of the treatment options for SIJ complex pain in cooled radiofrequency neurotomy. 2 RCTs have established the efficacy of cooled RF in SIJ complex pain.

We recently started offering this type of treatment for our patient population. We use Sacral Lateral Branch Blocks for selection of patients for cooled RF. We present our audited results.

Methods

We audited cooled RF SIJ neurotomy carried out in 18 month period from the beginning of January 2011 to June 2012. Our standard practice is to undertake a third-party evaluation via a nurse-led telephone clinic. We collected information about the diagnostic blocks, % of pain relief, Patient global impression of change scale, complications and duration of pain relief from the last available clinical information.

Results

10 sacro-iliac cooled Radiofrequency neurotomy had been carried out during this period in 9 patients. There were 4 males and 5 females. The average age was 60 with SD of 12.08. 8 patients had the SI joint denervations for the first time while the other 2 had repeated injection. All patients had at least one sacral lateral branch blocks.

2 were failure as they lasted 4 weeks or less. Rest of them were success and reported a pain relief of 78% on average with SD of 14.3 The duration of pain relief 3 to 9 months. 4 patients are reporting ongoing pain relief. 4 had stopped medications and 1 had reduced medications. All of them rated their relief as “very much improved” on PGIC.

Interestingly, the longest duration of pain relief was achieved when patients had comparative of LBB rather than SI joint injection followed by LBB.

Conclusion

Audit has demonstrated that appropriate selection of patients for denervation will get significant improvement in pain relief and improved PGIC scale.

It has also demonstrated that there will be decrease in Medication administration following denervation. Comparative lateral branch blocks may be more predictive of duration of relief than SI joint injections.

References:

Cooled radiofrequency system for the treatment of chronic pain from sacroiliitis: the first case-series.
Kapural L, Nageeb F, Kapural M, Cata JP, Narouze S, Mekhail N.
Pain Pract. 2008 Sep-Oct;8(5):348-54.
Reg Anesth Pain Med.2001 Mar-Apr;26(2):137-42. Radiofrequency sacroiliac joint denervation for sacroiliac syndrome.

066 Radiofrequency Denervation of Medial Branch of the Dorsal Primary Rami at Lumbar Level for Low Back Pain : Use of Diagnostic Block and Pain Reduction/ Relief Following Procedure

Category: INTERVENTIONAL PAIN MANAGEMENT

Yuet Meng Andy Ng¹, Nick Hacking³

¹Royal Manchester Childrens Hospital, Manchester, UK, ²North West School of Anaesthesia, North West region, UK, ³Royal Preston Hospital, Preston, Lancashire, UK

Background

Radiofrequency denervation techniques of articular nerves were first described in 1975 . Since then, the use of radiofrequency (RF) denervation of facet joints for treating lumbar back pain has increased significantly.Facet related chronic back pain ma account for up to 15% of all low back pain. At Royal Preston Hospital, Dr N Hacking is 1 of 5 Pain Management Consultants and associate specialists who perform such procedures on a regular basis. The use of medial branch blocks (MBB) as a diagnostic tool prior to proceeding to RF denervation is a well established practice to minimise treatment failure and achieve high quality pain relief. The Royal College of Anaesthetists’ publication of Audit Recipe (2006 and 2012) have made recommendations regarding RBF denervation including the use of diagnostic MB prior to RF. This audit was aimed to look at compliance of diagnostic blocks and pain relief at 3 months

Methods

A retrospective audit of RBF denervation of facet joints at lumbar level by Dr N Hacking was conducted using electronic clinic letters following outpatient clinic or telephone interviews. These patients would have had their treatment in the first 9 months of 2011. All follow-ups were performed in a 3-5 month window. A target of 50 patients would provide a good snapshot of the local service. Inclusion criterias were patients with low back pain of at least 6 months duration, including those with radicular pain radiating to buttock or lower limb. Patients’ report of pain reduction were obtained and divided into no relief, mild relief, good relief (< 3months), good relief (>3 months) or excellent relief. Good pain relief was classified as relief >50% and excellent as >80%. Any prior diagnostic MBB with local anaesthetic performed were also recorded.

Results

50 patients were obtained from the corresponding 9 months where there was sufficient useful details in the clinic or telephone follow-up letters. 31 patients were female (62%) and 19 were male (38%). 46 patients had prior diagnostic MBB performed at least once before proceeding to RF treatment. 3 patients had no MBB done while there was no documentation in 1 patient.

36 patients (72%) reported good or excellent relief after 3 months. Out of this 36, 12 of them reported excellent relief >80%. 3 patients (6 %) had good relief but lasted < 3 months. 5 (10%) reported only mild pain relief. while 6 (12%) felt no benefit or change in pain severity.

In the small subgroup of patients where no prior MBB were performed, 2 had no benefit from RF treatment and 1 reported only mild pain relief.

Conclusion

Successful treatment with RF requires careful patient selection and diagnosis of facet-joint pain. Almost all patients received diagnostic MBB prior to RF denervation. All of them had follow-up review within a 3-5 month window.

It is encouraging that 72% of patients in the cohort reported good or excellent relief. This compares well with the Gofield trial in Canada (68%) however they were reporting 6 month follow-up. The retrospective nature of this audit would mean reliance complete documentation in the letters which exclude poor documentation. A prospective audit with 6 month follow-up would be beneficial in assessing longer term treatment efficacy.

067 Safety and Efficacy of Lidocaine Infusions in a District General Hospital : A Case Series Report

Category: INTERVENTIONAL PAIN MANAGEMENT

Sally-Anne Shiels, Deepak Ravindran

Royal Berkshire NHS Foundation Trust, Reading, Berkshire, UK

Background

Intravenous lidocaine is a local anaesthetic which is increasingly being used as an infusion¹ for the management of refractory neuropathic pain and in any chronic pain condition where central sensitisation is suspected to be a major contributing factor. Its use in this form can now be applied to a variety of diagnoses² such as complex regional pain syndrome³, herpetic neuralgia⁴, and fibromyalgia^5,6. The drug is usually administered as a slow intravenous infusion although there is no clear consensus on the optimal dose and duration of the infusion. The logistics of administering the infusion and the care of the patient was initially confined to specialist inpatient units but with increasing evidence on its safety and efficacy, lidocaine infusions are now performed in a variety of clinical settings. This study sought to report the safety and efficacy of lidocaine infusions in a district general hospital outpatients setting from 2008 to 2012.

Methods

This report looked at the practice and use of lidocaine infusions in a district general hospital administered over a 5 year period from 2008 to mid 2012. The primary outcome was the frequency of adverse events in relation to lidocaine infusions. Secondary outcomes included efficacy of the infusions in reducing pain, improvement in quality of life and side effect profile.

This retrospective review of clinical notes was approved by the Local Clinical Audit committee. Notes of all patients who received lidocaine infusions from 2008 to 2012 were reviewed. Patients were assessed by a consultant and consented for the infusion. A standard data set included demographics, diagnosis at the time of referral for infusion, dose, rate, side effects, adverse events including need to abandon infusion. Concurrent analgesic medications were also noted.

Results

150 lidocaine infusions were administered in this time period to 64 patients of which 70% were women (11 case notes were not available for review). The majority of patients had only one infusion 44%(64), 23%(34) had 2 infusions and 12%(17) had 3 infusions. The most common diagnoses were chronic widespread pain (fibromyalgia) and refractory neuropathic pain. The most common dose used was 5mg/kg.

Safety

There were no reports of significant adverse effects or local anaesthetic toxicity and only 32 patients (21%) reported side effects. The most common side effects reported were dizziness and temporary paraesthesia. None of these side effects warranted the termination of the infusion before its completion.

Efficacy

Decreased pain and/or improved quality of life was reported for 34% of infusions. Subgroup analysis showed that 24 patients reported a benefit after the first infusion and 9 of those patients had a positive benefit after the second.

Conclusion

Intravenous lidocaine infusions can be delivered safely in the district general hospital outpatients setting. The benefits noted in this case series did not seem to be sustained on repeated infusions. Thorough evaluation of efficacy was difficult due to the variety of patient diagnoses and variable dose regimes. Further studies need to focus on identifying the patient population that will most benefit from lidocaine infusions and determining the appropriate dose regime. We suggest that this could be achieved by starting a national database to collect data which may yield more robust and useful information for patients with chronic pain.

068 A Survey - Dual Antiplatelet Therapy and Interventional Techniques for Chronic Spinal Pain

Category: INTERVENTIONAL PAIN MANAGEMENT

Vinod Sanem Ramulu, Swaroop Sampu

Hull Royal Infirmary, Hull, UK

Background

Interventional techniques are performed very commonly on patients with chronic spinal pain. It is not uncommon to come across patients with spinal pain on dual antiplatelet therapy. Overall risk stratification of interventional techniques in these patients is essential. Since there are no clear established guidelines, management of these patients most of the time is left to the attending pain physician’s discretion.

Methods

We conducted an electronic survey by sending a questionnaire to all the pain specialists registered with the British Pain Society. Questions included in the survey are about their own practice of managing patients on dual antiplatelet therapy coming for interventional procedures for spinal pain. We also enquired if they had any departmental policy or guidelines in managing these patients.

Results

We received 63 responses in total. Consultants, advanced pain trainees and non-consultant career grade doctors took part in the survey. The survey revealed some interesting findings about the management of patients on dual antiplatelet therapy coming for interventional techniques. The results showed

94.8% of the respondents consider stopping dual anti-platelet therapy before intervention
Majority are concerned about continuing Clopidogrel than aspirin
Only 52.6% of the respondents consider speaking to primary physician before stopping dual anti-platelet therapy
There is no consensus amongst pain physicians on when to stop Clopidogrel before the procedure
There is no consensus amongst pain physicians on which pain intervention is safe to perform while the patient is on dual antiplatelet therapy
Only 14% of the respondents had hospital policy in managing this high risk group
88% of the respondents feel clear guidelines would help in managing these patients safely

Conclusion

There is no consensus amongst pain physicians in the UK in managing patients on dual antiplatelet therapy
Risk stratification of each interventional technique for chronic spinal pain is essential in managing this high-risk group
Clear guidelines are necessary for the safe management of these patients on dual antiplatelet therapy suffering with chronic spinal pain

069 Documentation of Pain Management in a Specialist Multidisciplinary Neurology Clinic

Category: MANAGEMENT (AUDIT)

Sizheng Zhao, Turo Nurmikko

Walton Centre for Neurology and Neurosurgery, Liverpool, UK

Background

Pain is an integral but generally underreported symptom associated with Neuromyelitis Optica (NMO). The Walton Centre for Neurology and Neurosurgery (WCNN) is a highly specialist NMO national referral centre, and provides an advisory service through a multidisciplinary clinic including consultant neurologist, specialist nurse, physiotherapist, psychologist, occupational therapist etc. The aim of this audit was to assess how thoroughly the characteristics of pain and its treatment success was documented in the context of a highly advanced unit, set up for the sole purpose of holistic management of a neurological condition. NMO was chosen because pain associated with it has not been clearly highlighted in clinical practice and therefore serves as a rare opportunity to see how it is registered and dealt with, in contrast to conditions where pain is the main presenting complaint.

Methods

A retrospective case note audit was performed for 71 NMO patients at the WCNN, using a questionnaire based on the Department of Health guidelines for assessment of pain in “Essence of Care 2010.” The guidelines stipulate that enquiry about pain should occur at every encounter, where patients’ pain management needs should be identified by staff who are competent to recognise and assess pain. Pain should be then be thoughtfully managed and regularly observed. We audited these guidelines by assessing the ability of WCNN staff to document the presence, type and description of pain, the management of pain and its efficacy, and the effects of pain. Only pain that the patient experiences between relapses was evaluated.

Results

50/71 (70%) of patients had unambiguous documentation of the presence/absence of pain. 50/71 (70%)of patients suffered pain between relapses: documentation of the location of pain was 100%, whilst duration (22%), quality (62%), severity (28%), temporality (30%) and exacerbating/relieving factors (44%) were less frequently recorded. Of the 50 patients that complained of pain, 62% had clear descriptions of the type: 72% had elements of neuropathic pain. 39/50 (78%) were currently on treatment for pain (those with no documentation were presumed not to be on any), 36% of these 39 patients had comments on efficacy: 6 had pain fully controlled, 5 had reduction of pain and 3 had no benefit. Medications were similar to those used to manage pain in MS. Documentation of the effect of pain in terms of mood (18%), psychological tension (5%), sleep (18%), quality of life (8%), disability (13%) were at the respective percentages.

Conclusion

This audit of pain documentation at WCNN showed that despite the multidisciplinary approach, more frequent and specific enquiry into patients experience of pain is needed. Whilst enquiry about pain may have been more frequent in practice, documentation was not complete. Improved identification and documentation of pain would prompt further assessment and management if required. Improved documentation of the descriptions and effects of pain can also help monitor and manage it. The use of a validated questionnaire such as the Brief Pain Inventory may be valuable.

070 Audit Into Ketamine Use in Chronic Pain: Does it Reduce Opioid Consumption?

Category: MANAGEMENT (AUDIT)

Emma Baird, Jillian Davis

Lancashire Teaching Hospitals NHS Trust, Preston, UK

Background

The main mechanism of action of ketamine is as a non-competitive antagonist at the NMDA receptor. It is used to treat complex chronic pain when conventional treatments have failed. Ketamine has a significant side effect profile; from the more common effects of hypertension and psychological disturbance to irreversible chemical cystitis and hepatic dysfunction. The long term use of opioids has been linked to endocrine and immunological dysfunction and the risk of tolerance and addiction. Royal Preston Hospital is a large teaching hospital with six pain consultants seeing 2000 new patients a year. It has a dedicated ‘Ketamine Clinic’ run by a specialist nurse. The rational for a trial of ketamine, in addition to the obvious improvements in pain control, is to reduce opioid consumption.

Methods

A retrospective case note review of all patients taking ketamine in Royal Preston hospital. There is a data base in which all patients started on ketamine are recorded. From this 64 patients were identified; 4 were excluded as they had declined the trial. The remaining 60 patients’ chronic pain notes were reviewed including data from the nurse lead clinic.

Results

The mean age of the patients analysed was 49 years, 53 % were male. 31 % were being treated for lower back pain and 15 % for generalised pain. 58 % of patients were classified as having mixed pain, 32 % as neuropathic and 10 % CRPS. The majority had had their pain for more than five years (86%). The average dose of ketamine in a 24 hour period was 98 mg (range 20 - 200mgs). 20 % of the patients who started taking ketamine stopped after a trial period because of poor response or adverse side effects. 66 % of the patients who persisted taking it experienced side effects. The opiate consumption remained unchanged in 56 %, increased in 25 %, and decreased in 17 % of the cohort. Only 2 % of patients stopped all opioids once started on ketamine.

Conclusion

It would appear from this audit that it is unrealistic to expect this group of patients to reduce their opioid consumption; therefore we must reassess our goals when starting ketamine. Previously follow up was intensive but did not include a formal assessment of global function. Our practice now is to include such an assessment in our ‘ketamine protocol’. We will not continue to prescribe ketamine when there is neither a reduction in opioid consumption nor an improvement in functional capacity over a sixth month trial period.

071 Observations of Patient Controlled Analgesia Out With High Dependency Care: How Safe Are Our Standards?

Category: MANAGEMENT (AUDIT)

Jonathan Seeley, Karen Birnie, Blair Tweedie, Susan Rae, Deborah Morley

Western General Hospital, Edinburgh, Lothian, UK

Background

Patient controlled analgesia (PCA) pumps for postoperative analgesia have been reported in meta-analysis to have significantly greater analgesic efficacy compared to as required opiates¹. The main side effect of respiratory depression has a quoted incidence of 0.1-0.8%². Previous papers have advocated observation regimens of various time intervals³ and indicated that nurses’ basic pain knowledge is poor, which may be reflected in suboptimal pain management of this population⁵. Observation protocols vary throughout the UK and there is no current evidence based consensus other than the requirement for further research^1,2,4.

Established practice in our unit is for 1 hourly observations to include respiratory rate, pain, and mental state score. However, observational evidence suggested that this standard was not being adhered to resulting in concerns regarding patient safety. We therefore formulated an audit to analyse adherence to our observations standard, establish if this standard was adequate, and aim to improve patient safety.

Methods

For a 2 week period, all patients with PCA pumps on non-high dependency colorectal wards (wards 23 and 24) were reviewed, looking at recording of hourly respiratory rate, pain score(1-10), AVPU score; and respiratory depression requiring intervention; specifically naloxone or high-dependency escalation.

Inclusion criteria were all patients on PCAs for longer than 12 hours, with no exclusion criteria. Charge nurses had no prior knowledge of the audit.

Scores recorded as observations per 12 hour period either since return from recovery, or since last recording period. Scores always taken between 1700-1800 daily, and not counted if more than 1 set of observations taken in a 1 hour period.

Following initial audit, our Acute Pain Team undertook a nurse education programme consisting of discussion of audit findings with charge nurses and tutorials regarding risks of respiratory depression.

3 months later, a repeat audit of the same wards with same criteria was undertaken.

Results

Audit-1. 22 observation sets

Ward 23 0/10(0%) sets compliant with our standard of 1 hourly checks. Mean was 7.6 checks every 12 hours or 0.63 per hour.

Ward 24 2/12(16.7%) sets compliant. Mean of 9.6 checks per 12 hour period or 0.79 per hour.

Overall means were 9.3 checks per 12 hour period or 0.77 per hour.

Fewest checks was 5 in 12 hours; no significant episodes of respiratory depression.

Tutorials noted to be poorly attended by both wards.

Re-audit. 27 observation sets

Ward 23 5/16(31%) sets compliant. Mean of 8.9 checks per 12 hours or 0.75 per hour.

Ward 24 1/11(9%) sets compliant. Mean of 9 checks per 12 hours or 0.76 per hour.

Overall 8.9 checks per 12 hours or 0.76 per hour. Fewest checks were 3 in 12 hours.

1 critical incident of respiratory depression requiring naloxone and HDU on day 1 of repeat audit, ward 23

Conclusion

Audit 1 established inadequate standard adherence, whilst re-audit demonstrated improved ward 23 results, alongside ward 24 stagnation and no overall positive educational programme impact.

Improved performance on ward 23 was likely secondary to the critical incident as poor tutorial attendance undoubtedly limited educational benefits. As adherence remained suboptimal, we cannot draw conclusions regarding our standard in comparison with other regimes.

Focus now shifts towards delivering improved education and attendance prior to re-audit; with evolving methodology including an expanded timeframe and continued inclusion of all patients. Only by improving adherence can we draw meaningful conclusions regarding observation regimens and PCA safety.

072 Waiting Times for Access to a UK Multidisciplinary Chronic Pain Service: How Do We Comply With IASP Recommendations?

Category: MANAGEMENT (AUDIT)

Girish Rangaswamy, Quazi Siddiqui

Out of 690 Appointments made for 115 MDT Clinics, 601 patients had attended leaving 89(12.9%) slots empty. These missed Appointments were because of patients not attending or rescheduling the appointments very late leaving not enough time to fill the slot with another patient.

Conclusion

Our Pain MDT Clinics have a missed appointment rate higher than the national average. One of the main reasons for patients not attending appointments is their forgetfulness 3. This could be addressed by implementing one or more methods of reminding them. We recommend 1) Considering patient reminders like a letter week before the appointment, SMS or telephonic voice message. 2)Larger use of Choose and Book system. 3)To take up a bigger survey involving other specialty clinics to see the Trust`s Missed Appointment rate.

075 Glasgow Pain Management Programme Graduates- What Next in the Pain Service?

Category: MANAGEMENT (AUDIT)

Clare Bridgestock¹, Lars Williams²

¹Stobhill ACH, Glasgow, UK, ²New Victoria Hospital, Glasgow, UK

Background

The Glasgow Pain Management Programme (PMP) is a psychology-led outpatient rehabilitation programme for patients with chronic pain, with referrals from local secondary care pain services. Based on the principles of acceptance and commitment therapy, one of the primary aims is to foster self-reliance and self-management of ongoing pain and painful flare-ups, without recourse to treatment-seeking from primary and secondary care services.

We wanted to establish the number of patients who continued to receive treatment from local pain clinics following completion of PMP, and the reasons for this. Ongoing attendance at pain clinics might be led by pain service clinicians arranging a routine follow-up appointment, or by patients or GPs requesting re-referral into the pain service. The former may be a necessity, but the latter might be seen as a failure of the PMP to effect behaviour change in graduates of the programme.

Methods

All patients who completed (definition- attended 8 or more out of 12 sessions) the PMP in the time period Sept 2008 to October 2010 were tracked on the NHS Greater Glasgow and Clyde (GG&C) electronic patient records system. All pain service contacts subsequent to completing the PMP were recorded. Referral and clinic letters and notes were reviewed to establish reasons for ongoing attendance.

To establish clinicians’ opinion on the role of pain clinics following PMP completion, an online survey was created which all clinicians (33 people) working within the pain management service in NHS GG&C were invited to complete. This questioned timing of referral to the PMP in relation to ongoing pharmaceutical and interventional pain management therapy, and also local policy for ongoing management of patients who have completed the PMP.

Results

During the audit period, 132 patients completed the Glasgow PMP.

After completion of PMP, 23% of patients attended 1 return appointment within the local pain service, a further 15% of patients attended between 2 and 11 appointments and 8% remain within the pain service.

By October 2012, 16% had been re-referred to local pain services with a mean interval from completion of PMP to new appointment of 20 months. 38% of those were seen once and discharged, the remainder had between 2 and 10 appointments. The most common reason for re-referral was flare-up of pain and the majority of referrals were from primary care.

25 of 33 clinicians completed the survey. 64% refer once a patient is suitable for PMP, and consensus is the PMP should be an exit route from local pain services. Patients and primary care should be aware of this plan.

Conclusion

A self-management programme, by definition, encourages patients to consider alternatives to seeking medical help for ongoing pain and flare-up management. Patients attending the Glasgow PMP have all been assessed and treated first by local secondary care pain services, and are referred to the PMP on the assumption that all investigations are complete and all treatment options exhausted. Nevertheless, a significant proportion of these patients continue to attend local pain services. The reasons for this are complex, with both clinician and patient factors playing a part. This audit represents a first step towards identifying the nature of this issue.

076 Use of Ultrasound in Chronic Pain – A Survey of Current Practice in UK

Category: MANAGEMENT (AUDIT)

Deepak Malik¹, Edward Lin², Manohar Sharma³

¹Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, UK, ²Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, UK, ³The Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK

Background

Ultrasound (USG) has been increasingly becoming popular as a preferred imaging technique in interventional pain management. It allows identification of various musculoskeletal and neuroanatomical structures avoiding radiation exposure where necessary to the patient and staff.

Current use and possible future applications of ultrasound are nerve blocks of the lumbar and cervical zygapophysial joints, stellate ganglion block, Suprascapular nerve block(SSNB), intercostal nerve block (ICNB), paravertebral nerve blocks (PVB), inguinal nerve blocks(INB), occipital nerve blocks(ONB), caudal epidural injections(CEI), Sacroiliac joint block (SIJB) and injections of trigger points(TPI).

We conducted this survey to determine the current UK wide practise with the use of USG and potential for its use in the future for various physician preferred techniques.

Methods

An anonymised 14 point questionnaire was sent in October 2012 via an e-link on “SurveyMonkey” to pain physicians of various experience backgrounds (via pain consultants and pain trainees googlegroups). Questions were aimed to obtain relevant information regarding their current practice in the use of ultrasound for various procedures.

Completed responses were received from 49 members. Sixty six percent of the respondents were Pain medicine consultants and 32 % were Advanced Pain trainees. Over a quarter of respondents had more than 10 yrs of pain management experience. Almost 90% physicians were unaware of any published guidelines for use of USG in chronic pain.

Results

Fifty-four percent wished to gain experience in the use of USG,25% were novices and only 5% were experts.Forty percent confidently use USG for nerve blocks, but wished to have more training, while 18% were under-confident. Seventy-two percent had easy access to USG machines in theatres, 15% in theatres and clinic, while almost 5% did not have access in either. Eighty-three percent use USG during Ilio-inguinal, Ilio-hypogastric and genitofemoral blocks, 60% during suprascapular block and 50% for trigger point injections. Forty five percent perform facia iliaca, piriformis and ICNB using USG. Eighty two percent would not perform USG guided Lumbar/Cervical facet joint injections. One third respondents think that it would be safe and anatomically correct to perform SIJB and CEI using USG, while 33% thought it may be possible to perform lumbar facet injection using USG.

One-third of the respondents had attended a relevant USG training course more than a year ago and 33% thought that departmental training in USG was inadequate.

Conclusion

It is important for us to have a comprehensive view of the current practice of epidurals in UK, and guide our everyday practice on current evidence base behind it. As nerves could be directly visualised using ultrasound it has potential applications for variety of procedures like radiofrequency, chemical neurolysis or cryo analgesia.

Limitations are the poor resolution of narrow-gauge needles, loss of resolution with increasing working depth and possible interference of echoes from overlying structures with the image of target area.

There still remains a steep learning curve to obtain expertise in its use before it becomes an indispensable tool for every pain interventionalist.

077 Survey of Patients Who Did Not Attend (DNA) Their Outpatients Appointment

Category: MANAGEMENT (AUDIT)

Alifia Tameem², Radhukar Pandrangi¹, Abdul Nazal¹

¹Queen Elizabeth Hospital, Birmingham, UK, ²Russell Hall Hospital, Dudley, UK

Background

Every year the NHS loses 600 million pounds due to missed outpatient appointments and at least 6 million slots are wasted annually depriving other patients of their appointments. It also leads to an increased attendance in the emergency department adding to the workload of the emergency department staff.A quarterly survey of England between January 2012 to March 2012 revealed an average DNA rate of 8.7%. With this in mind, we tried to capture the DNA incidence at our hospital for new and follow up patients and also tried to find out the reason why patients do not attend their designated appointments

Methods

We carried out a retrospective data collection from the pain clinics at the Queen Elizabeth Hospital Birmingham. With the help of the informatics department at the hospital and the intranet tool clinical portal, we noted the number of patients who failed to attend their appointment, new as well as follow up appointment during a 6 week period between April and May 2012. A telephone interview was made for the patients who DNA and they were asked why they were unable to attend their appointment. We also asked them if they received paper as well as text reminders or not prior to their appointment. We then compared the pain clinic DNA rates with the trust DNA rates.

Results

During a 6 week period 39 out of 386 (10.1%)patients failed to attend their appointment of which 15 were new patients and 24 DNA their follow up appointment. The follow up appointment rate with the nurses was much better than with the doctors (8.1% vs 13.4%) which may have been because some of the nurse led follow ups were treatment based.We were able to interview nearly half of these patients (20/39).Only 3 out of 20 confirmed that they had received a reminder before the appointment.The most common reason for nonattendance (35%) was failure to receive an appointment followed by forgetfulness (15%). 4/20 were actually not well on that day and 1 patient left midway due to long waiting times. There were communication problems in nearly 25% of the patients

Conclusion

To conclude, the average DNA incidence for the pain clinics is 10.1% which is higher than the national and trust DNA rates. Half of the patients either forgot or did not receive the appointment. Interestingly 40% of the patients who DNA didn’t register their mobile numbers for a text reminder. We have now introduced a contactschecking service with our patients and register their mobile numbers so that text reminders can be sent out. We are also looking into making a confirmation telephone call 1 week prior to the appointment if possible.

078 Are Patients With Temporomandibular Disorders (TMDS) More Likely to Be Distressed and Have an Increased Tendency to Catastrophise if They Have Been Referred to More Specialists?

Category: MANAGEMENT (AUDIT)

Kate Parker^1,2, Shahid Chaudhry^{3, 4}, Joanna Zakrzewska^1,2

¹University College London Hospital, London, UK, ²Eastman Dental Hospital, London, UK, ³Barts & The London, London, UK, ⁴Queen Mary’s, University of London, London, UK

Background

TMDs involve the muscles of the face, neck and head and rarely the temporomandibular joint itself. TMDs are the second commonest chronic pain disorder after back pain and affect 10-15% of the US population with an estimated annual cost of $4 million. Studies show that dentists are confused about how to diagnose TMDs and lack confidence in their management. Dentists usually refer to other dental specialties whereas GP’s are most likely to refer to medical specialties, most commonly ENT. Patients are often then referred to an Oral and Maxillofacial department (OMFS). Many patients will be seen by busy OMFS who do not have the time for the management of these patients using biopsychosocial methods. Some patient will have unnecessary surgical interventions. We hypothesise that distress and catastrophising increase as patients move from one provider to the next in their quest to achieve pain relief and an improved quality of life.

Methods

The Eastman Dental Hospital runs a multidisciplinary Facial Pain Unit with over 1500 attendances a year. A prospective database is kept of all the patients seen. All patients at their initial consultation complete a series of baseline questionnaires including the Chronic Graded Pain Scale (CGPS, Von Korff) and the Pain Catastrophising Questionnaire (PCS, Sullivan). A comprehensive structured history is taken which includes past providers and treatments. The database was used to select patients who had TMD as their primary diagnosis in the year 2011. 275 patients fulfilled these criteria of which 93 were excluded due to incomplete baseline questionnaires. The data for the 182 patients who had fully completed their questionnaires was analysed, including analysis of their referral pathway, PCS scores and CGPS scores to determine if a correlation exists between the number of specialists a patient has seen and their level of distress and catastrophising.

Results

77% of patients were female with an average age of 42.6 years. 72% of patients had other associated chronic pain.

Most patients had been seen in primary care; 25% seeing their dentist, 17% their GP and 48% both. 51% had seen a specialist. 60% had seen one specialist, 28% two, 9% three and 4% more than three. The overall mean number of specialists seen was 1.6. For those with low pain grades (1 and 2) it was 0.62 compared to 0.88 for those with high pain grades (3 and 4). The difference in the number of specialists seen between low and high pain grades was not statistically significant (t(182)=1.737, p>0,05).

56% of patients scored grade 3 or 4 on the CGPS indicating disability. The PCS showed 48% had no catastrophising, 33% moderate and 19% significant. The pattern of data suggests higher catastrophising and pain scores associated with more visits.

Conclusion

Despite our research showing no significant relationship between number of specialists seen and pain grade we maintain that early, appropriate referral of patients with TMDs could reduce the chronicity and disability these patients experience. Many patients see multiple specialists before achieving satisfactory management; showing many specialists are not equipped to manage TMDs successfully. Patients should be referred to a facial pain unit in the first instance to improve management and reduce distress and catastrophising.

A more biopsychosocial approach, with more dedicated patient services could significantly reduce costs, with OMFS only managing the small proportion of patients requiring surgical interventions.

079 Tapentadol Prolonged Release - A Year in the District General Hospital Setting

Category: MANAGEMENT (AUDIT)

Louise Jeynes, Christine Waters, Heather Riggs, Alison Morris, Dawn Pretty

West Suffolk Hospital Foundation Trust, Bury St Edmunds, Suffolk, UK

Background

Chronic non-malignant pain affects a significant number of people, having an impact on their quality of life as well as society as a whole (1). Opioids have been used to assist in the management of chronic non-malignant pain when other avenues have failed, but they are associated with significant side effects, particularly constipation, nausea and drowsiness and are not particularly effective in neuropathic type pain.

Tapentadol is a new mixed action analgesic, acting at mu-opioid receptors and norepinephrine reuptake inhibition. Initial studies suggested similar analgesic efficacy of tapentadol to the equipotent dose of oxycodone, with significantly less gastrointestinal side effects (1, 2).

Methods

Following the introduction of an Opioid Clinic, aimed at educating patients and assisting the monitoring of the dose and effectiveness of opioids, Tapentadol prolonged release (PR) was introduced as a stage 3 strong opioid option. Due to restrictions in place, all patients had to be able to collect their monthly prescription from the hospital. Following the introduction onto the formulary at the West Suffolk Hospital Foundation Trust, the first forty patients prescribed Tapentadol PR were monitored for changes in pain scores and quality of life (using Pain Assessment and Documentation Tool (PADT)) as well as recording the morphine equivalent dose before and after starting Tapentadol PR. The results were then audited.

Results

More than 50% of the group experienced an improvement in their pain and their function and quality of life. Many also reduced their overall morphine equivalent dose (in one patient this was by a factor of 10). More than 75% continue of those on Tapentadol PR, even in those not experiencing improved analgesia, as there is a significant improvement in side effects which encourages them to continue. The main advantages were: reduction in constipation and nausea, more awake and less fatigue.

Discontinuations occurred because of opioid withdrawal, preference for the previous opioid, dry mouth and headache, urinary retention, hallucinations and because the GP was unable to continue the prescription and the patient was unable to attend the hospital for repeat prescriptions. With the success of this initial trial of Tapentadol PR the local GPs are now able to prescribe it, after an initial successful trial supervised by the hospital.

Conclusion

Tapentadol PR has proven an extremely useful addition to the analgesic armoury and is well tolerated. With its dual action the typical opioid induced side effects are minimised. It has also been a very useful ‘carrot’ to encourage the patients down off large doses of opioid in order to try it, as we aimed to get the patients on to a dose of opioid equivalent to a maximum of approximately 250mg Tapentadol PR twice daily prior to change over. The vast majority managed the reduction, with only a few requiring an additional opioid.

080 Development of a Questionnaire to Facilitate Appropriate Referral of Patients to a Facial Pain Service

Category: MANAGEMENT (AUDIT)

Supriya Ghurye, Roddy McMillan, Artemis Ghiai, Joanna Zakrzewska

Eastman Dental Hospital, London, UK

Background

Pain affecting the oral and facial region (orofacial pain) is a ubiquitous problem with prevalence in the United Kingdom estimated to be around 7% of the population. Pain-related temporomandibular disorders (TMD) are one of the three most common chronic pain entities along with headache and backache. Other chronic orofacial pain diagnoses include: trigeminal neuralgia, trigeminal neuropathic pain, burning mouth syndrome and chronic idiopathic facial pain. Orofacial pain conditions can provide dilemmas in both diagnosis and management; misdiagnosis is common and often results in inappropriate and irreversible dental and surgical interventions. The authors present a prospective clinical study involving patients referred to a secondary care facial pain multi-disciplinary service. The study objectives were to: determine the extent of pain-related comorbidity and chronic pain disability within referred patients. Moreover, to investigate the utility of a self-administered questionnaire to assist clinicians making more appropriate and timely referrals to our facial pain service.

Methods

Consecutive attendees to a facial pain service completed several self-administered questionnaires prior to their initial clinical assessment. These included hospital anxiety and depression scale (HAD) and the graded chronic pain scale (GCPS) which yields four grades with grades 3 and 4 indicating high disability.A structured history and examination was carried out which also determined whether there were other non-orofacial chronic pain sites present, including headache. On the basis of all this a diagnosis and treatment care pathway was determined. Outcomes included the following treatment groups: 1. Information and explanation, 2. Management with medications, 3. Physiotherapy, 4. Physiotherapy with psychology. Patients could be allocated to one or more treatment groups. The results were then analysed to determine whether the screening questionnaires could predict the care pathway used.

Results

A total of 50 participants were entered into the study: 11 male(22%) mean age 58.4±4.7 years (range: 25-80), 39 female(78%) mean age 45.7±2.9 years (range: 22-78) with a male: female ratio of 1:3.5.

The clinical diagnoses provided after clinical assessment were: TMD (66%), TMD with concomitant non-dental facial pain(10%), chronic idiopathic facial pain (10%), trigeminal neuropathic pain (6%), trigeminal neuralgia (4%) and burning mouth syndrome (4%). 58% of participants scored grade 1 and 2 on GCPS, of these 24% showed evidence of anxiety and 34% depression. In grades 3 and 4, anxiety and depression were 57% and 86% respectively. Furthermore, 43% of grades 3 and 4 demonstrated additional pain sites ≥3; compared to 31% in grades 1 and 2. Grade 1 and 2 comprised 66% of treatment group 1 and 71% of group 3. Conversely grade 3 and 4 patients predominated in treatment groups 2 and 4 at (60)%.

Conclusion

The results of this study suggest there are high levels of chronic pain disability and pain-related comorbidity within facial pain patients referred to our service. The authors suggest that screening measures for anxiety, depression and chronic pain disability may be useful in identifying suitable patients for referral. As a result, this may facilitate earlier and more accurate identification of facial pain patients who are at risk of disability and chronicity; thus prompting earlier referral for appropriate specialist management and possibly improving patient outcomes.

081 Demographics and Psychological Correlates of TMD: Use of Questionnaire Data to Inform Multi-Disciplinary Management Pathways

Category: MANAGEMENT (AUDIT)

Aleksandra Herbec, Jenna Love, Joanna Zakrzewska

Eastman Dental Hospital, UCLH NHS Foundation Trust, London, UK

Background

Although no consensus exists on the management of Temporomandibular Disorders (TMD), biomedical treatments and splints have been commonly used. However, there is increasing evidence that TMD is associated with several co-morbidities, including catastrophising, anxiety and depression, which all need addressing in order to improve long-term outcomes. A new interdisciplinary and holistic TMD management programme was established at our specialised facial pain unit (FPU). A baseline referral pathway is used where subsequent TMD management is informed by the presence of co-morbidity. Four pathways are available 1. Information and explanation only 2. Physiotherapy-led TMD education group 3. Cognitive-behavioural pain management programme facilitated by physiotherapy and psychology 4. Medications with or without any of the above. The present study is a first step in evaluating the validity of the referral pathway, and aims to assess the prevalence of co-morbidities and catastrophising among patients who present with TMD symptoms at the first specialist consultation in FPU.

Methods

Participants were all the patients with primary pain diagnosis of TMD at the FPU in the first 8 months of 2011 as identified from prospective databases. Only patients for whom data were available on both catastrophising, measured using Pain Catastrophising Scale (PCS), and on anxiety and depression, assessed with Hospital Anxiety and Depression Scale (HADS) were selected. These measurements were part of a routinely administered battery of questionnaires given to all patients at the first specialist consultations with the facial pain consultant. The proportion of patients presenting with elevated scores (score above 8) on anxiety or depression scales were calculated. Mean PCS scores, as well as proportions of low (scores =<19), moderate (20-30), and high (=>31) catastrophisers were computed. Scores of men and women were compared using t-test and chi-square. After completing a full structured history, examination and discussing treatment options allocations were made to one of the four pathways.

Results

In the assessed time period, 181 patients were given a primary diagnosis of TMD, and data from HADS and PCS were available for 156 of them (25.6% men). Patients’ mean age was 43.3 (SD=15.6), and 151 (96.8%) suffered also from other chronic pains including headache. Eighty-two (52.6.%) patients were classified as having elevated levels of anxiety and 54 (34.6 %) of depression, with no significant differences between men and women (both chi-square tests p> 0.05). Forty-four (28.2%) patients scored high on both anxiety and depression, with a higher proportion of men showing symptoms of both (c2(1, N =156)= 5.65, p < .05). Mean PCS score was 23.5 (SD=14.8), with no differences between men and women (t(154)=.246, p>0.5). Seventy-one (45.5%) patients had low, 30 (19.2%) moderate, and 55 (35.3%) high catastrophising scores. Twenty-six (16.7%) of all patients (of which 30.1% were men) scored high on catastrophising, anxiety and depression.

Conclusion

Symptoms of anxiety and depression, as well as catastrophising were prevalent among both men and women with TMD. This may have important implications for their management, as it indicates that they may require a biopsychosocial management approach. It will now be important to examine outcomes on these patients one year on to evaluate if the baseline referral pathway is appropriate, whether the correct predictors are being used, and finally, if the baseline questionnaires could play a greater role in determining the appropriate level of intervention in this stepped-care approach to TMD management.

082 Explanation of the Spinal Cord Stimulator Devices to Facilitate MRI Scans

Category: MANAGEMENT (AUDIT)

Vijay Bandikatla, Cherilyn Fenech, Stephany Harris, Tom Smith, Adnan Al-Kaisy

Guys and St Thomas’s NHS Trust, London, UK

Background

Removal of Spinal Cord Stimulator (SCS) systems is sometimes necessary to facilitate MRI scans. We aimed to ascertain the incidence of this scenario in our practice, and examine the indications for performing the MRI scans in SCS patients. We avoid implanting SCS systems in patients whom we think have a high likelihood of future MRI follow-up e.g. history of cancer. We sought to identify further factors that might predict future MRI requirement that we might be missing.

Methods

We analysed the SCS database of our hospital from January 2008 to December 2011. We collected all the explanted cases and this data was crosschecked with the hospital electronic patient records and/or the medical records. We identified a total of 363 full implants over the 4 year period (81 in 2008, 89 in 2009, 99 in 2010 and 94 in 2011). The following data were collected: sex, patient age, presenting pain problem, date of implantation, procedure performed, and date of explanation, and reason for performing the MRI scan.

Results

Explants for MRI scans numbered 9 over the 4 year period: 3 in 2008, 2 in 2009, 1 in 2010 and 3 in 2011. There were 6 male and 3 female patients with ages ranging from 42–79 years. The average duration of using the SCS was 6.47 years. In 3 patients the SCS was in situ for over 10 years (range 6 months–16 years).

In 8 out of 9 cases the primary reason for implantation was low back pain +/- radiculopathy and in another case it was secondary to upper limb CRPS. 7 of these cases were failed back surgeries.

The reasons for explanation for MRI scan were: new onset radiculopathy in 5 cases, severe progressive spinal canal stenosis in one case. New unrelated intractable headache, arm pain and abdominal pain occurred in the remaining 3 cases.

Conclusion

The incidence of SCS explanation for an MRI in our centre is reassuringly low. New onset radiculopathy/severe spinal stenosis accounted for 67% of cases. This is not unexpected in a population with progressive spinal degeneration. Unrelated new symptoms account for the other 33.3% scans.

With current technology, explanation of SCS systems to enable MRI scanning is unavoidable. This problem will only be resolved with MRI compatible systems. These are in development and their approval for clinical use will be welcome.

083 An Evaluation of the Outcomes From a Combined Therapies Assessment Clinic for People With Fibromyalgia Syndrome (FMS)

Category: MANAGEMENT (AUDIT)

Richard Walters, Rebecca Chasey, Phillipa Newton-Cross, Andrew Gunatilleke

South Devon Healthcare NHS Foundation Trust, Torquay, Devon, UK

Background

During a clinical commissioning group review it was identified that the service for people with FMS was fragmented in South Devon. A local QUIP target had also been set to reduce secondary care referrals. Therefore a new and localised Map of Medicine pathway was developed. This had an emphasis on primary care diagnosis and management, including advice on medication, physiotherapy, exercise and mental health services. A website with information on pain management skills, FMS and medications was also published to complement the Map of Medicine pathway.

Secondary care services were accessed by a specialist combined physiotherapy and clinical psychology assessment clinic. This was run with the support of a pain consultant. A review of the literature indicates the importance of considering both physical and psychological factors in an integrated manner.

The outcomes of this clinic in its first year of running are described alongside the implications for future changes.

Methods

After each assessment the outcomes for the patients were recorded by the therapists involved. These included one to one and group work within the pain team, further medical advice and appointments, information given and signposting and referral on to services outside of the pain team. The requirement for having both professionals present was also noted.

Results

Over the time period 50 assessments were undertaken and the clinic had three DNA’s.

Of the 50 people who attend it was felt that a joint assessment was helpful for 90% of these with the 4% needing only a pain physiotherapist and 6% needing only a clinical psychologist.

32% were referred on to one of the three team run programmes, 32% to pain management physiotherapy and 50% to pain management psychology (a number of one to one referrals were to both services). 12% were directed to the FMS website.

14% of attendees required a consultant review and 54% required further medical advice communicated via the clinic letter. A single follow up appointment was required for 22% of people.

20% required referral to other clinicians including musculoskeletal physiotherapy, dietetics and mental health services. Extensive liaison with other services was requires in 10% of cases including child protection.

Conclusion

One year of running this clinic shows that a combined FMS therapies clinic with medical advice can aid access to a pain team. The combination of the clinic, primary care advice and medical support minimised the number of patients requiring subsequent consultant clinics and therefore positively affecting waiting times.

Most patients that came through this clinic had complex needs requiring a joint approach. This may suggest other patients were managed effectively in primary care.

The pathway has been reviewed by the commissioning group and is being extended to all widespread pain as well as enabling easier access from rheumatology services.

084 Clinical Evaluation of the Efficacy of Oxycodone/Naloxone (Targinact) in the Management of Moderate to Severe Pain Associated With Opiod-Induced Bowel Dysfunction

Category: MANAGEMENT (AUDIT)

Lorraine Stevens, Margaret Bone

University Hospitals of Leicester NHS Trust, Leicester, UK

Background

Chronic pain affects around 5 million people in the UK. Patients with moderate to severe pain may require strong opioids as part of their management.80% patients treated with opioids experience at least one adverse effect, commonly opioid-induced bowel dysfunction (OIBD) due to binding of opioid receptors in the GI tract reducing peristaltic activity, GI secretions and increasing fluid absorption. OIBD is often debilitating with constipation, abdominal pain and incomplete faecal evacuation despite, despite the use of stool softeners and laxatives. Some patients avoid taking their analgesia because of the adverse effects, resulting in poor pain control.

Targinact (oxycodone/naloxone) was introduced for patients requiring opioids (dihydrocodeine, morphine, oxycodone or transdermal fentanyl) with attendant OIBD. Many patients take a laxative regime of fybogel, senna, lactulose, movical or enemas.

The aim of this audit was to assess the efficacy of targinact on selected patients within a Pain Clinic setting.

Methods

The UHL Therapeutic Advisory Board approved the trial of targinact in 50 patients. All patients had been fully assessed in the Pain Clinic. All were taking regular strong opioids for stable, non-malignant chronic pain and reported significant OIBD requiring the use of laxatives and bowel softeners.

Following informed consent, each prescription of opioid was changed to an equipotent dose of oxycodone/naloxone. The first and subsequent prescriptions were dispensed from UHL pharmacy. Baseline and outcome data was recorded including previous analgesia and laxatives; pain severity; ability to undertake day to day activities; mood; sleep and modified Bowel Function Index (BFI), noting difficulty of defaecation, presence of incomplete evacuation and judgment of constipation. Patients were reviewed by the clinical nurse specialist at 1,4 and 12 weeks.

Results

22 patients were treated and complete data is available on 19. All 19 patients were taking a range of strong opioids and reported significant OIBD.

Mean pain severity: pre-treatment: 8.9 (5 - 10); 1 week: 5.1 (0 - 9); 4 weeks: 4.1 (0 - 7) and 12 weeks: 3.7 (0 - 6)

Day to day activities: pre-treatment: 15 restricted; 1 week: 1 improved; 4 weeks: 3 improved and 12 weeks: 3 improved.

Mood: pre-treatment: 12 anxiety /depression; 1 week:0 improved; 4 weeks:2 improved and 12 weeks:5 improved.

Sleep: pre-treatment: 18 restricted; 1 week: 0 improved; 4 weeks: 6 improved and 12 weeks: 6 improved.

Bowel Function index: pre-treatment: 19 poor; 1 week: 2 improved; 4 weeks: 8 improved and 12 weeks: 16 improved.

2 patients stopped all laxatives/stool softeners and 17 patients reduced their intake.

No adverse effects were recorded.

Conclusion

This audit in a small number of patients on strong opioids with OIBD has shown a trend of improved pain relief and bowel function in 15 out of 19 patients.

Patients with moderate to severe pain requiring opioid medication often suffer from significant drug-induced side effects. In the elderly, these may cause distressing consequences with patients reducing their analgesic medication.

We consider that oxycodone/naloxone may have a place in the pharmacological management of patients with moderate to severe pain.

085 Pain Recurrence and Complications Affect Quality of Life in Patients With Trigeminal Neuralgia Treated With Posterior Fossa Surgery

Category: MANAGEMENT (RESEARCH)

Joanna Zakrzewska

23 trials were analyzed to compare the reported adverse events to the known safety profile of 5% lidocaine medicated plaster in PHN. Of these, 7 trials were randomized controlled whereas 16 were open label trials. All trials conducted between 1991 and 2011 were relevant for efficacy and safety evaluation in localized pain with a neuropathic component. The evaluated clinical painful conditions and baseline characteristics covered a broad population representing the average population with LNP. They included subjects with moderate to severe pain caused by painful diabetic and idiopathic distal sensory polyneuropathy, carpal tunnel syndrome (CTS), neuropathic component of osteoarthritis (OA) of the knee and LBP, surgical or chronic post-traumatic neuropathic pain, myofascial pain with neuropathic component, localized symptoms of neuropathic pain of various etiologies and refractory peripheral LNP. As the reviewed data are only available from publications without direct access to source data the safety information may be incomplete.

Results

The safety profile of 5% lidocaine medicated plaster summarized here covered an exposed population of approximately 2000 patients, thereof about 1500 treated with 5% lidocaine medicated plaster. Across all indications investigated excluding PHN an incidence of drug related adverse reactions (DRAEs) in up to 12% of patients was reported. The events for which the information was available were mostly of mild or moderate intensity and mainly linked to application site reactions. Discontinuations due to DRAEs occurred in less than 5% of patients. In PHN patients the most commonly reported DRAEs were administration site reactions (such as burning, dermatitis, erythema, pruritus, rash, skin irritation, and vesicles). The vast majority of DRAEs were not serious and of mild to moderate intensity. Compared to 16% DRAEs reported for PHN the data do not suggest a departure from the established safety profile of 5% lidocaine medicated plaster in PHN.⁴

Conclusion

5% lidocaine medicated plaster appears to be safe and well tolerated also in LNP models other than PHN. The observed safety profile seems further in line with the one observed from data from spontaneous safety reports collected by consumers and healthcare professionals for approximately 16.47 million patients between 1999 and mid of 2012.

References

Mick et al 2012. CMRO; 28: 937-951
Rowbotham et al 1995. Ann Neurol (37) 246-253
Attal et al 2010. E J Neurol
SmPC Versatis, version 13.0; Sep 2011

089 Should the Treatment of Neuropathic Pain Target More Than Just Pain? Data From an Efficacy Trial With 5% Lidocaine Medicated Plaster in Post-Herpetic Neuralgia (PHN)

Category: NEUROPATHIC PAIN

Ralf Baron¹, Jean Bruxelle², Simone Koenig³, Marielle Eerdekens³, Irmgard Boesl³

¹Division of Neurological Pain Research and Therapy, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany, ²Pain Center, Fondation Adolphe de Rothschild, Paris, France, ³Compound Development and Branding, Grunenthal, Aachen, Germany

Background

Unidimensional pain scales (e.g. 11-point NRS) have been extensively used in clinical trials in a variety of pain models including neuropathic pain. These scales are also recommended by regulatory authorities for use in primary endpoints in trials targeted to support an approval of new compounds.¹ In order to enable translation of these results from clinical trials into clinically meaningful changes, secondary endpoints become more important.

It is thus useful to explore more than just pain relief in patients with neuropathic pain. The impact of a pain treatment on quality of life or sleep might provide additional insights and can be captured via validated rating scales.

Based on data from an 8 week run-in phase of an efficacy trial with 5% lidocaine medicated plaster in patients suffering from PHN, we assessed if treatment effects other than on pain should be considered when installing a new treatment for neuropathic pain.

Methods

In this study 265 patients were treated for up to 8 weeks with 5% lidocaine medicated plaster. After 8 weeks the patient’s response was assessed. When the patients achieved at least “moderate” pain relief (equal to 4 on a 6-point verbal rating scale) they were classified as responders.²

263 patients were included in this efficacy analysis of the initial 8 weeks of treatment (efficacy analysis set).² A sleep questionnaire (CPSI®) was completed at screening, enrollment and thereafter at 1, 4 and 8 weeks. A quality of life questionnaire (SF-36®) was completed at screening and after 8 weeks. Medical history comprised disease status regarding PHN duration and detailed assessment of distribution of PHN location.

Results

The mean PHN duration was 37 months². It was affecting torso (38.8%), head/face (12.5%), extremities (4.2%) or neck (3.0%). The responder rate after 8 weeks was 51.7%.²

After one week of treatment, the proportion of patients usually or always having trouble falling asleep decreased with > 50%. The proportion of patients requiring sleeping medication decreased.

Patients, who usually or always awoke during the night due to pain (18.6% and 9.9% respectively), already improved after one week of treatment (decrease to 7.5% and 4.0% respectively). Likewise patients who usually or always awoke with pain in the morning (22.4% and 19.4% respectively) improved already after 1 week of treatment (8.3% and 12.6% respectively).These effects persisted throughout the 8 weeks.

Improvement was also observed in all categories of the SF-36® and was most pronounced for the sections body pain and role emotional.

Conclusion

Results of this efficacy trial demonstrated the beneficial effects of 5% lidocaine medicated plaster in patients with PHN. The distribution of PHN shows that it can affect any part of the body. In addition to pain relief 5% lidocaine medicated plaster was associated with improvements in sleep pattern suggesting a better quality of life.

References:

EMA: Guideline on clinical medicinal products for the treatment of neuropathic pain, CPMP/EWP/252/03 Rev. 1
Binder, Bruxelle, Rogers, Hans, Bösl, Baron. Clin Drug Invest 2009; 29 (6):393-408

090 The Effect of Capsaicin 8% Patch in Patients With Peripheral Neuropathic Pain. A Case Report Study

Category: NEUROPATHIC PAIN

Maria Pedro, Jan Shepard, Pierluigi di Vadi

University Hospital Lewisham, London, UK

Background

Chronic pain of moderate to severe intensity occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives (1) and is a substantial health care problem. Persistent pain following surgery has been extensively investigated to find out any predictive risk factors and its possible prevention (2, 3). The incidence of persistent localized pain was found to be present in approximately 30 % of patients one year after knee arthroscopy (4). No information is available in literature about the effectiveness of topical treatment in persistent localized pain following surgery.

Methods

We treated 11 consecutive patients suffering from localized chronic neuropathic pain (more than 6 months) following surgery by applying capsaicin patch 8% accordingly with the agreed methodology over the painful area of the skin (6). They were 7 female and 4 male patients. The average age was 49.6. The pain score was measured by the VAS scale (0-10) at baseline and at the 3-month follow up.

Results

A total of 7 patients reported improvement and 4 did not. The mean numeric rate score (0-10) of all 11 patients was 8.3 at baseline and 6.2 at the follow up in three months. The average degree of improvement was 2.1 (25%). Among the patients who did improve 3 reported >50% pain relief. No side effects or serious adverse reaction were reported.

Conclusion

Our case report study shows that the application of capsaicin patch 8% as a treatment for localized neuropathic pain following surgery has a beneficial effect. No side effects were reported. A prospective, randomized control study should be organized in order to confirm these preliminary data.

091 Clinical Evaluation of the Efficacy of Capsaicin 8% Topical Patch (Qutenza) in the Management of Neuropathic Pain

Category: NEUROPATHIC PAIN

Margaret Bone, Lorraine Stevens, Karina Kennett, Lyn Moore

University Hospitals of Leicester NHS Trust, Leicester, UK

Background

Patients with regional neuropathic pain reporting allodynia, hyperalgesia and/or dysesthesia refractory to conventional neuropathic modifying medication, present a management challenge. The capsaicin 8% patch has recently been introduced for the treatment of peripheral neuropathic pain in non-diabetic adults either alone or in combination with other medication.

The UHL Therapeutic Advisory Board approved the trial of capsaicin 8% in 50 patients, with up to 3 treatments per annum. A detailed analysis of tariffs and care pathways was conducted and ratified through interviews with NHS associates including pain consultants and commissioners. Based upon the most applicable OPCS-4.5 and ICD-10 codes, the treatment was mapped to HRG4, code AB04Z.

Involved doctors and clinical nurse specialists completed the pharmaceutical company’s recognised training before prescribing and administering capsaicin 8%.

The aim of the audit was to assess the efficacy of capsaicin 8% on selected patients, within a Pain Clinic setting.

Methods

All patients had been fully assessed in the Pain Clinic and diagnosed with chronic neuropathic pain. All patients had received previous trials of therapies for neuropathic pain as clinically appropriate, including medication of tricyclic antidepressants, anticonvulsants, selective serotonin reuptake inhibitors and topical lidocaine or 0.125% capsaicin cream; complimentary therapy of acupuncture and transcutaneous nerve stimulation and interventional nerve blocks.

Following written informed consent, baseline data and outcome data was recorded including pain severity, pain-related functional impairment and evaluation of quality of life. Patients were reviewed by the clinical nurse specialists at 1, 4 and 12 weeks.

Treatments were undertaken in well ventilated clinical areas. The affected allodynic area was mapped out and standard procedure for capsaicin 8% application was followed.

Statistical analysis for the non-parametric data was undertaken with Wilcoxon Signed Rank test.

Results

Complete data was available for 50 patients: 18 male, 32 female.

The mean area covered was 247 sq cm, with 37 patients receiving one patch and 13, two patches. 13 patients received two treatments. 3 patients received 3 treatments.

Mean Pain Severity: pre treatment: 6.3 (SD 1.8); 1 month: 4.7 (SD 2.4); 3 months: 5.1 (SD2.5) showed statically significant reduction (-1.6 (SE 0.5) p<0.006) at 3 months.

Mean Pain Related Functional Impairment: pre treatment: 5.9 (SD 2.3); 1 month: 4.6 (SD 2.4); 3 months: 4.7 (SD 3.0) showed statically significant improvement (-0.9 (SE 0.5) p<0.08) at 3 months.

EQ-VAS: pre treatment: 49.3 (SD 20.7); 1 month: 61.4 (SD 18.8); 3 months: 63.4 (SD17.5) showed statically significant improvement (11.6 (SE 33.6) p<0.005) at 3 months.

Adverse effects were minor and transitory with most patients reporting mild burning and erythema.

A clinically relevant reduction in oral medication was recorded.

Conclusion

This audit has demonstrated statistically significant improvement in mean pain severity, pain-related functional impairment and EQ-VAS scores in a small number of patients with neuropathic pain, refractory to standard treatments. 35 patients were assessed as improved, with many being able to reduce their consumption of other analgesia. Adverse effects were minor.

We consider that capsaicin 8% was well tolerated in this group of patients who were informed of the recognised attendant effects of treatment.

We consider Qutenza has a place in the management of carefully selected patients whose neuropathic pain has failed to be controlled by other pharmacological means.

092 Results of Patient and Clinician Global Impressions of Change With Tapentadol Prolonged Release (PR) Versus Tapentadol PR/Pregabalin Combination Therapy in Patients With Severe, Chronic Low Back Pain With a Neuropathic Component

Category: NEUROPATHIC PAIN

Ralf Baron¹, Andreas Schwittay², Dietmar Falke³, Daniel Samper⁴, Ilona Steigerwald³

There were 16 eligible patients in both years with an age range of 16-89 and 9 males (56.3%) in 2006 and 18-76 years and 10 males (62.5%) in 2011.On discharge patients in both years were more likely to be on non-opioid analgesics. In contrast in 2011 no patient was discharged on morphine but were on either codeine or tramadol and were twice more likely to be on pregabalin compared to 2006. There was little change in antidepressant prescribing between the two years. In 2011 the co-analgesics were prescribed earlier 3-38 days compared to 20-120 days in 2006.

Conclusion

The neuropathic pain protocol has enabled the early identification and a more appropriate management of post burn pain and stopped the use of strong opioids on discharge following major burns. This protocol could also apply to appropriate patients with minor burns and to other high-risk surgical patients such as in breast surgery and trauma.

095 Participant Evaluation of Pain Management Programme Annual Follow-Up Conference Using Delphi Method

Category: NON-PHARMACOLOGICAL PAIN MANAGEMENT

Ruth Whiteman, Paul Wilkinson

Pain Management Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK

Background

The Pain Management Team in Newcastle-Upon-Tyne has been running 3 to 4 6-week outpatient Pain Management Programmes per year since 2002.

Each year, all patients who have completed a programme at any time over the last 10 years are invited to attend an Annual Follow-Up Conference. The conference offers refresher sessions on Pain Management techniques, and also has a social element. Critically, the question arises of whether this is a worthwhile follow-up model?

Attendees are self-selecting, so the group of attendees varies from year to year. Test-retest approaches using standardised psychometric tests undertaken longitudinally are therefore not feasible. Potential assessable outcomes might include altered utilisation of primary care resources, changes in technical aspects of self-management or well-being. In this study we explored participants’ perceptions of what they “took away” from the conference using focus groups to determine criteria. We then employed Delphi techniques to assess their relative value.

Methods

Following a thorough consent process, delegates attending the Annual Follow-Up Conference for Newcastle’s Pain Management Programme in April 2012 were invited to form small groups of 5 to 10 individuals. Thirty nine delegates were divided into 6 groups with 5 electing not to participate.

Groups were asked to generate responses to the following question.

What will you take away from the annual follow-up conference?

The responses generated by the groups were reviewed to identify key themes. These themes were collated, and a questionnaire was produced by the investigators based on the responses.

A total of 18 distinct themes were generated. Questionnaires were distributed to each individual, including the 5 delegates who had not participated in the group exercise but wanted to participate in the Delphi. Participants were then asked to rate each statement on a scale of 0-10 based on its perceived importance to them.

Results

Forty four questionnaires were returned. Three questionnaires were incomplete, but the responses from these were included in analysis for the questions answered. Data sets for all questions and all but one participant were found to follow a non-parametric distribution with significant left skew. Median scores per question ranged from 8 to 10 (Median 9), and median score per participant ranged from 3.5 to 10 (Median 9).

The most highly valued aspects of the conference were predominantly social, including the opportunity for ongoing contact with the Pain Management Team, and deriving inspiration from other participants. Questions relating to learning and maintaining Pain Management techniques also scored highly. The impact on other healthcare utilisation was less clear, with the broadest range of responses returned to the question relating to a reduction in General Practitioner consultation.

Conclusion

A significant proportion of patients who have completed a Pain Management Programme in Newcastle over the last 10 years continue to choose to attend a one day Annual Follow-up Programme, which they consider to be valuable in maintaining the benefits of the original Programme and in many other ways. While aspects of the Conference were valued by patients, based on these data alone this perceived value cannot be translated into improved health care outcomes as a direct consequence of long term follow-up. However, this study provides credible patient-centred evidence that patients gain from the long term follow up conference.

096 Does Intervention by Specialist Physiotherapists Facilitate Uptake of Exercise and Participation in Exercise on Referral (EOR) Schemes in Patients With Chronic Pain?

Category: NON-PHARMACOLOGICAL PAIN MANAGEMENT

Christopher Carter, Lis Hammond, CRD Laird

County Durham and Darlington NHS Foundation Trust, County Durham, UK

Background

There is strong evidence for the impact of physical inactivity on an ever-broadening variety of health problems including chronic pain. Management of chronic pain often includes increasing physical activity and recovering lost function. This must be done in a safe and graded manner and help sufferers accept responsibility for increasing their functional capacity by promoting a positive view on physical activity (Main, Sullivan & Watson 2008). Specialist physiotherapists working in integrated multidisciplinary pain management teams are ideally situated to provide such support. Once patients have completed their intervention they are often left to manage on their own and can regress to pre-intervention levels of activity. Exercises on Referral (EoR) schemes facilitate physical activity in previously inactive people (Hillsdon et al 2005; Williams 2009). The objectives were to determine the uptake and drop-out rate of EoR schemes and whether individuals in chronic pain continue exercising following intervention by pain management physiotherapist.

Methods

A cross sectional survey design was used. The participants were adults who had completed pain management physiotherapy intervention(s) and had been referred to EoR during the period January 2011 to January 2012. Participants had previously given their verbal consent to be added to a database of patients who would be contacted in January 2012. These participants were telephoned and asked some questions concerning their current exercise levels. Firstly, whether or not they had taken up their EoR referral or whether they had started but dropped out. The second part of the telephone interview involved asking patients what, if any, exercise they were currently participating in.

Results

In total thirty-three patients were recruited to the study, twenty-five female and eight male. The age range was 24 to 73 years. Five patients were lost to follow-up giving a response rate of 85%. Overall sixteen patients took up EoR giving an uptake rate of 57%. Another 25% of patients intended to participate in an EoR scheme in the future. Only 18% of patients had no intention of participating in the EoR scheme. The dropout rate from those who took up the EoR scheme was 38%. A physiotherapy prescribed home exercise regime was the most popular form of exercise followed by walking and participation in the EoR scheme. Only one patient was not exercising at the time of interview due to experiencing a flare-up in their pain. This patient reported they had been exercising and fully intended to get back to the EoR scheme once their flare-up had resolved.

Conclusion

The results appear to indicate that following intervention by specialist physiotherapists most patients in chronic pain continue with some form of exercise including EoR schemes. This concurs with the current evidence. Due to the small sample size it is difficult to draw any clear conclusions from this study. A study with a larger sample size is needed to investigate the impact of specialist physiotherapy on the uptake of exercise and the participation in Exercise on Referral (EoR) schemes in patients with chronic pain in the long-term.

097 Do Patients With Neuropathic Pain Benefit Less From Pain Management Programmes?

Category: NON-PHARMACOLOGICAL PAIN MANAGEMENT

Mark Rockett, Reuben Crossley

Plymouth Pain Management Centre, Plymouth, UK

Background

Multidisciplinary pain management programmes (PMP) have a good evidence base for improving some aspects of chronic pain. Neuropathic pain occurs in 6.9% of the population and is common among patients attending programmes. Patients experiencing pain with neuropathic characteristics are often treated alongside those with chronic nociceptive pain. It is known that neuropathic pain (NeP) results in greater disability and higher levels of distress than nociceptive pain, but it is not known whether these patients respond less well to a PMP approach. We applied the S-LANSS questionnaire at the end of each programme to retrospectively identify patients with predominantly neuropathic pain within a group of PMP patients (the NeP group). We carried out this audit to investigate the possibility that patients with predominately neuropathic pain benefit less than patients with nociceptive pain from a standard PMP approach using multiple questionnaires as outcome measures.

Methods

Participants were recruited from three consecutive PMPs between October 2011 and February 2012 (N=28). We recruited 25 patients. Data recorded at the start and end of each programme included the Brief Pain Inventory (BPI), the Hospital Anxiety and Depression Scale (HADs), the Pain Self Efficacy Questionnaire (PSEQ), the Oswestry Disability Index (ODI) and the Pain Catastrophising Scale (PCS). In addition to these outcome measures, the S-LANSS questionnaire was administered at the end of each programme for all patients attending the Pain Management Programme. Patients were allocated to the neuropathic group if they scored >=12 points on the S-LANSS questionnaire. The demographic characteristics of the two groups were compared. As the groups were not matched on sex or age, further statistical tests were not carried out. The groups were compared on the basis of percentage improvement from baseline scores for the outcome measures under study.

Results

Sixty percent of the patients were female. Neuropathic pain was more common among female patients. Age ranged from 26 years to 68 years. The mean age of patients with chronic nociceptive pain was 53.8 years, versus 46.9 years for the NeP group. The NeP group scored higher initially on BPI pain and anxiety scores, lower on depression and lower on self-efficacy. Mean percentage improvement in questionnaire scores was significantly smaller for the NeP group. In terms of pain interference, catastrophising, anxiety and depression, areas where PMPs often achieve significant improvements, the NeP group improved by 5.5%, 2%, 7% and 8.6% respectively, compared to 30.8%, 29%, 24% and 23% in the nociceptive group. However, self-efficacy scores improved by approximately 20% in both groups. Disability worsened in both groups (15% in the nociceptive group and 4% in the NeP group). Pain scores improved by 6.1% in the nociceptive group and 3.5% in the NeP group.

Conclusion

The majority of the patients attending the PMPs were experiencing NeP. Younger, female patients were more likely to have NeP. This is the first study to demonstrate that patients with predominantly NeP benefit less from a multidisciplinary PMP than patients with nociceptive pain. Further study is required to determine whether patients with high S-LANSS scores had a diagnosis that was consistent with a high likelihood of NeP. It may then be appropriate to develop specialist PMPs based on these diagnostic criteria. It is also not yet clear what aspects of NeP prevent patients from benefitting from a PMP approach.

098 A Service Evaluation on Referrer Awareness and Knowledge of Pain Management Programme in Leicester

Category: NON-PHARMACOLOGICAL PAIN MANAGEMENT

Deepak Malik¹, Alisdair Radcliff², Laura Ambrose³, Margaret Bone⁴, Edward Lin⁵

¹Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, UK, ²Leicester University, Leicester, UK, ³Leicester General Hospital, Leicester, UK, ⁴Leicester General Hospital, Leicester, UK, ⁵Leicester General Hospital, Leicester, UK

Background

An evaluation into the effectiveness of a local PMP found significant improvements in psychological outcomes and physical functioning outcomes for patients who complete the 9 session program. However, a brief audit of the service (324 referrals) highlighted extremely poor conversions of referrals starting a program (30%), although very good levels of adherence to the program once assessed and started (84%). Inappropriate and inconsistent referrals were highlighted to be the main causes of attrition. A service evaluation was devised to investigate the referrals procedure with the aim of improving referral consistency and decreasing in

appropriate referrals. The clinical impacts of this are predicted to be a reduction of inappropriate assessments (wasted clinical contact), an increase in the percentage of referrals starting the program (increased efficiency), a reduction in waiting time for patients starting a PMP and subsequent increase in patient satisfaction.

Methods

Using a mixed-methods, between participants design, a bespoke password secure web-based 20-item survey was emailed to a list of clinicians (N=28) who had referral rights to the PMP. The response rate varied between professions with an overall response rate of 82%. The survey included questions regarding knowledge of and confidence in the PMP, clinical perspectives and expectations of the referral procedure, and improvement suggestions. Statistical analysis was carried out on the quantitative data and Template Analysis was carried out on the qualitative responses for insights into barriers to referrals, potential improvements of referral pathways, referrer knowledge and information sharing.

Results

Qualitative

Themes of consistent knowledge

Structure of PMP (MDT approach for chronic pain), expectations of knowledge and skill development (improve understanding and reducing impacts of pain, improve patient control through coping/management strategies).

Themes of inconsistent knowledge

Eligibility criteria and specifics of program

Referral pathway improvements

Increased information about PMP - leaflets, feedback, and open days. All could be met through revamping the existing PMP information pack and resending to departments.

Quantitative

Positively, 82% of referrers consider the ability of patient to engage with a group when referring and 91% highlighted the presence of chronic pain as an essential eligibility criterion.

Responses highlighted the need for further education regarding eligibility for the program as only 26% gave consideration to physical demands and 61% to psychological readiness to attend the program.

Additionally, 44% do not consider preferred language when referring, highlighting the importance of awareness of specific needs of the local community.

Conclusion

Whilst referrers displayed confident knowledge regarding the structure and expectations of PMPs, there were recurrent themes of inconsistent knowledge of eligibility, explaining high levels of inappropriate referrals. The findings suggest further advertising of PMP literature accompanied by education sessions on the goals of the program and eligibility criteria offered. Service user input in these education sessions will give greater levels of insight for clinicians and observing at least the introduction day of the PMP should be a requirement for referrers. Additionally, the creation of PMPs which are conducted in languages reflecting local demographics would increase the scope of the service.

099 The Effectiveness of Specialised Pain Management Programmes: Benchmarking Against Published Outcomes for General Pain Management Programmes

Category: NON-PHARMACOLOGICAL PAIN MANAGEMENT

Sarah Edwards, Amanda Williams, Maria Brezitski, Katrine Petersen, Rebecca McLoughlin, Melissa Cohen, Anna Mandeville, Natasha Curran, Andrew Baranowski, Julia Cambitzi, Suzanne Brook

University College London Hospitals NHS Foundation Trust, London, UK

Background

Patients with pelvic pain usually attend general pain management programmes (PMPs). Some of their difficulties - embarrassment and social anxiety associated with the location of their pain, and related symptoms - are specific; others are largely shared with people with chronic pain at other sites. The Pain Management Centre established a PMP specifically for pelvic pain patients (Link) in 2009 to which patients are referred by the multidisciplinary urogenital pain team, We have now run 13 programmes, in single-sex groups. This study aims to evaluate this specialised PMP by benchmarking against group cognitive behavioural therapy (CBT) for mixed chronic pain.

Methods

The Link programme is adapted for pelvic and urogenital pain from the well-established CBT PMP at the same Centre. Patients assessed as suitable by a clinical psychologist and a physiotherapist attend a seven-day programme, one of which includes friends and family members, over seven weeks. Patients then attend one-, five- and 12-month follow-ups. Outcome measures are completed at the beginning and end of the programme, and at each follow-up.

The present study examines data from 118 Link patients from 2009 - 2012., when 88 women attended 10 programmes and 30 men attended three programmes. Male and female data were analysed separately, comparing baseline with one-month and one-year follow-up. Data were benchmarked against the evaluation of a PMP for general pain of Morley, Williams & Hussain, 2008.

Results

The median duration of pain was six years, with the most common diagnoses being chronic pelvic pain, endometriosis and pudendal neuralgia. 50% of women and 28% of men reported having had surgery for pain. The mean age of participants was 45.

Repeated measures ANOVA showed statistically significant reductions from baseline to one-month follow-up in pain intensity (BPI), disability (BPI), catastrophic thinking about pain (PCS) and sexual anxiety (MSQ). Mood (DAPOS anxiety and depression subscales) and pain-related self-efficacy (PSEQ) also improved significantly.

Effect sizes (d) were compared to Morley et al. (2008), and found to be within or exceeding the 95% confidence interval for pain intensity, disability and mood for both men and women. There were some gender differences, with pain-related self-efficacy in men, and catastrophic thinking about pain in women, meeting or exceeding the benchmark.

One year outcomes are being collected and will be analysed and reported.

Conclusion

A specialised pain management programme for pelvic pain is effective in reducing pain intensity, disability and unhelpful thinking about pain, and in improving mood and pain-related self-efficacy. Anxiety about sexual activity, a particular difficulty for this group of patients, is also significantly reduced. These changes hold for both men and women, and meet or exceed the treatment benchmark for this type of intervention.

100 Stop! Chronic Back Pain: Preventing Pain From Becoming Problematic

Category: NON-PHARMACOLOGICAL PAIN MANAGEMENT

Meherzin Das^1,2, Barbara Oldale¹

¹Poole Hospital NHS Foundation Trust, Dorset, UK, ²Bournemouth University, Dorset, UK, ³Dorset HealthCare University NHS Foundation Trust, Dorset, UK

Background

Traditional pain services operate in a linear manner: the median time period from onset to pain clinic attendance is 12 years (Schulte et al., 2009) and people in UK wait twice as long as patients in Europe for diagnosis and treatment. (European Consensus Report, 2010). Every year, 3.3 million people do not recover from their first episode of pain, descending into the downward spiral of chronicity and disability. As uncertainty, failed treatment and learned helplessness become enduring, 49% of pain sufferers develop depression and the burden on the individual and their family is intense while the economic burden related to healthcare costs, employment and the benefits system approximates £12.3 billion pa.

The STOP! project offered Early Multi-Disciplinary Intervention to prevent chronicity from developing by recruiting patients earlier in their journey with pain to teach them about self-management. Peer support helped sustain the process and progress.

Methods

The STOP! Chronic Back Pain Project:

recruited people significantly earlier in their pain journey by engaging traditional as well as less conventional referral sources, such as the private sector, chiropractors, osteopaths and the local media;
located PMPs in community settings - leisure centre - as well as traditional out-patient settings;
established a Multi-Disciplinary Group Programme to prevent chronicity from developing. Patients attended 1 day/week for 7 weeks and received Psychology, Occupational Therapy, Physiotherapy, Mindfulness and Medical input;
offered Peer Support to help sustain the process of self-management. Our service users provided unique ‘tiers of support’ by setting up a Wiki, Website and Facebook page. The aim of our Pain Chain - ‘each one reach one’ - was served by offering a trained peer coach to each participant to provide 1-1 support to facilitate change and clarify the concepts of pain management;

Results

A pre/post intervention format was employed using the following battery of tests, which will be repeated at 1 year interval. Results obtained are mentioned next to each test with the difference in pre/post scores represented as a p value:

Roland Morris Disability Questionnaire: <.001
Pain Catastrophising Scale: <.001
HADS - Depression: <.001
HADS - Anxiety: .058
Euroqol: .002
Physiotherapy - Sit-to-stand: <.001
Physiotherapy - Step-ups: <.001
Self-reported change %: <.001

Qualitative feedback from staff (group format) and service users (1-1 semi-structured interview) was uniformly excellent:

“This project leads the way towards less intervention and better self-management.” Commissioner

“The STOP! Project has put pain at the heart of patients’ lives in terms of self management and will lead to cost savings and better practice.” GP

“I think about my pain and what I can do each day, but it doesn’t govern me - I can now live my life.” Service User

Conclusion

The STOP! Chronic Back Pain Project proved that early multi-disciplinary intervention is clinically effective and can be delivered in half the time and at half the cost compared to traditional PMPs.

Peer support furthers individual empowerment and self-reliance and builds a supportive pain fraternity.

Our model of collaborative empiricism helped change clinicians’ attitudes and influence commissioners’ agenda.

STOP! successfully proved that Early Multi-Disciplinary Intervention can significantly reduce pain-related disability and have a positive impact at multiple levels by improving fitness and mood, helping people return to meaningful occupation, increasing independence and effectively enhancing their over-all quality of life.

101 Audit of a Pain Management Programme Held in a Primary Care Setting

Category: NON-PHARMACOLOGICAL PAIN MANAGEMENT

Christina Hambrook¹, Jamie Kirkham¹, Heather Hawksley^1,2

¹Kent Community Health NHS Trust, Kent, UK, ²University of Surrey, Guildford, Surrey, UK

Background

As part of their chronic pain pathway patients may be offered a Pain Management Programme (PMP). In 2011 the course format was altered; this allowed for the content to be reviewed and standardised. This formed the baseline audit following the redesign; and assessed the benefit of patients’ attendance on the PMP. It also jointly analysed data from the point of referral onto the programme and patient attendance or attrition throughout the PMP.

The PMP is a multidisciplinary programme delivered equally by Psychology,Physiotherapy and Clinical Nurse Specialists.It consists of 4 half-days, run on consecutive weeks. Throughout attendance, patients are introduced to a range of pain management techniques. The programme conforms to current guidelines from NICE and the BPS Pain Management Programme SIG: The purpose of which is to assist patients in gaining a greater confidence in their own self management as a measure of improving their quality of life.

Methods

A retrospective audit of patients who were invited to and attended PMPs over a four month period between March and July 2012; it covered eight PMPs, held in 7 different areas across the locality:

Three separat equestionnaires were used in the evaluation of this intervention

Patient Health Questionnaire (PHQ-9)
Owestry Disability Questionnaire
Generalised Anxiety Disorder Scale (GAD-7)

Data was collected at 3 separate intervals in order to capture the influence of both attendance and possible benefits that this attendance yielded. The first measure was taken as a baseline and gathered at patients’ first attendance on week 1 of the programme. A second identical measure was taken at week 4 and a final measure taken at three months after successful completion of the PMP.Successful completion and therefore data of this last set was recorded only if the patient had attended at least 75%of the PMP.

Results

Over the audit period 224 people were invited to a PMP, of these 108 people went onto attend (48%). 66 patients (61%) attended the full PMP, 24 patients (22%) attended 3 parts of the course so also successfully completed, 18 patients (17%) failed to complete the course.

Patient Health Questionnaire (PHQ-9)

There is a 0.2 point (1.5%) reduction by the end of the course which extends to a 3.1 point (23%) reduction in patient’s depression at 3 months. Patients remained in the moderately depressed category.

Owestry Disability Questionnaire

There is a 1 point (2%) reduction in patient’s disability index at 3 months, although patients remain in the severe disability category.

Generalised Anxiety Disorder Scale (GAD-7)

There is a 1.9 point (19%) reduction in patient’s anxiety post course, although patients remain in the moderate anxiety category.

Conclusion

The results from this audit would suggest that although there is a very conservative reduction recorded of patients’ perception of their disability,there is much more of a significant change in both patients’ measures of their depression and anxiety. The significance of these results would support that this type of intervention (Community PMP) has the potential to offer both positive and enduring improvements to the quality of life of those that participate in them. The next logical step for this audit is to now determine if this trend will continue, through further data collection at twelve months.

102 Pain Demands an Explanation: Service Evaluation of 1 Day Pain Management Programme for People With Persistent Pain

Category: NON-PHARMACOLOGICAL PAIN MANAGEMENT

Jill Chanter, Jane Royle, Miranda Lowe

Sheffield Teaching Hospitals, Sheffield, UK

Background

Patient experience of health services is an important part of evaluating any benefit patients gain from an intervention and whether that benefit is meaningful and sustained; it is also a central reference point for those who are planning and commissioning services.

Anecdotal feedback from participants attending the 1 Day Pain Management Programme (PMP) suggested that learning about chronic pain mechanisms resulted in a greater openness to considering self management strategies for living with pain. This suggested a shift was taking place but the nature and consequence of the shift remained hidden. The aim of this evaluation was to explore what it was about the programme that led to anecdotal reports of increased confidence in the intentions to self manage pain and increase physical activity.

Methods

The sample was prospective, recruiting the next 70 out-patients who attended the PMP and agreed to complete the questionnaires. The PMP runs one day a week and the mean attendance is 8. The data was collected over a period of 3 months from consecutive programmes.

The design of the questionnaire was qualitative, asking questions intended to capture any change in attitudes and beliefs as a result of attending the group. Telephone follow ups at mean 6 months using questionnaires designed to elicit information about any reported intended and actual changes and any associated benefit reported

The data from the questionnaires was analysed using Content Analysis methodology. The responses were entered into Excel to enable coding of answers into Categories and then Themes.

Demographic data and Confidence scores were presented using descriptive statistics.

Results

a significant increase in reported confidence in exercise and movement
a significant increase in reported awareness of and plans to use self management strategies
a significant shift of focus away from medication (n=69)

Pre PMP 87% identified mechanical/diagnostic reasons for their pain

Pre PMP 1% identified chemical vicious circles and effective management as explanations for their pain

Post PMP 2% identified mechanical/diagnostic reasons for their pain

Post PMP 72% identified chemical vicious circles and effective management as explanations for their pain

At mean 6 months follow up (n=31)

84% had attempted to implement self management strategies

49% reported sustained positive improvement in self management of pain

19% reported a reduction in medication

Conclusion

Attending the 1 day PMP results in a significant shift in thoughts and beliefs about the reasons for persistent pain and intentions to self manage pain.

At follow up participants report a sustained change in identifying activity and self management strategies to live with persistent pain.

Change in pain cognitions is associated with change in reported physical performance.

Reported reduction in pain medication is associated with sustained implementation of self management strategies.

103 Assessing the Therapeutic Benefits of an Introductory Session Prior to Enrolment on a Pain Management Programme

Category: NON-PHARMACOLOGICAL PAIN MANAGEMENT

Yvette Coldicott, Rosie Odhuba

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

Background

Patients attending the pain clinic at our hospital may be advised to consider attending the Pain Management Programme (PMP). Referral to the programme is then made by the patients themselves. Following self-referral, patients are invited to attend an introductory session (90 minutes’ duration). This was introduced in order reduce DNA rates for assessment and PMP.

At the end of the session patients are given the option to ‘opt-in’. They are then invited to a multi-disciplinary assessment, where their suitability for a PMP is considered, together with which specific programme is most appropriate. If a different intervention from the PMP is necessary, eg medical treatment or individual psychology, this is arranged from here.

This study evaluated how useful patients found the introductory session, as well as whether they learnt anything or made any changes to the way they manage their pain as a direct result of the session.

Methods

Patients who had attended the Introduction to Pain Management Session were asked to complete a questionnaire between September 2011 and January 2012. The questionnaire asked them:

Whether they had found the introductory session helpful
Whether it gave them a better understanding of their pain
Whether it had led them to make changes to how they cope with their pain
Whether it had made them feel better about their problem

The questionnaire used a combination of tick-box style answers and space for free-text comments.

Results

29 people returned the questionnaire.

97% had found the introductory session either very helpful or of some help
97% had a better understanding of their pain as a result of attending the session
- Areas with the biggest increase in understanding were:
- Acute vs Chronic Pain 66%
- Managing activities eg pacing 59%
- Emotions and pain eg vicious cycle 59%
- Importance of exercise and fitness 59%
62% had made changes to how they manage their pain
- Areas with the greatest changes were:
- How you think about your pain 45%
- Managing activities 38%
- Managing exercise 38%
58% felt a little or a lot better about their pain problem In general, comments were positive. 27 patients opted-in to attend the full PMP.

Conclusion

This survey shows that patients do receive some therapeutic benefit from attending the Introduction to Pain Management Session.

Both distributions of drug dosage were positively skewed. Median morphine equivalent dose was 49mg (mean 114mg, range 0 to 520mg); daily median diazepam equivalent was 0mg (mean 3.4 mg, range 0 to 40mg). 20% of the sample were on >180mg of morphine equivalent daily. Opioid consumption was significantly correlated with a range variables indexing poorer mood or function. However, the correlations were objectively small. The size of association did not increase when only patients on higher doses were analysed. In contrast, associations between benzodiazepine consumption and poorer outcomes were more consistent.

Conclusion

Both opioid and benzodiazepine consumption were broadly associated with poorer mood and functioning. In both cases, most patients were on moderate doses, or not taking these drugs at all; however, a minority were on a very high dose. Given the concern about the impact of opioids, associations between morphine-equivalent intake and functioning were not as large as anticipated. Of course, this does not preclude the risk of medical side-effects from opioid use. Benzodiazepine consumption was more consistently associated with poor outcome; the negative effects of this class of drugs merit more attention.

109 Identifying Indicators for Paediatric Pain Adverse Events: A Delphi Study

Category: PAEDIATRIC

Alison Twycross¹, Jill Chorney^{2, 3}, Patrick McGrath^{2, 3}, Allen Finley^{2, 3}, Darlene Boliver³, Katherine Mifflin²

¹Kingston University and St George’s University of London, London, UK, ²Dalhousie University, Halifax, Nova Scotia, Canada, ³IWK Health Centre, Halifax, Nova Scotia, Canada

Background

Healthcare literature in the past 10 years has increasingly focused on adverse events. The evidence for pain management is readily available and so children experiencing moderate to severe pain could be considered an adverse event. Indeed, Chorney et al. (2010) suggest the quality of pain management should be examined in this context. This paper will discuss the results of a two-round Delphi study carried out to identify what experts in paediatric pain management and quality improvement consider paediatric pain adverse event indicators to be. This study, therefore, set out to identify what experts in paediatric pain management and quality improvement considered paediatric pain adverse care indicators to be.

Methods

The Delphi technique relies on the judgment of an expert panel and aims to develop consensus about a given subject area (Graham et al. 2003). When undertaking a Delphi study experts in the field complete a series of questionnaires. The first round is used to generate ideas, which are reconsidered in subsequent rounds (Reid 1988).

In line with the Delphi technique the questionnaire for Round 1 asked a broad question: “In your opinion, what indicators would signify that acute pain in a child has not been adequately controlled?” An e-questionnaire was developed for Round 2 using responses generated from Round 1 and asked respondents to indicate the importance of each potential indicator.

Results

Sixty-three experts responded to the Round 1. The responses were grouped together in semantically similar ideas. This allowed a list of possible adverse event indicators to be produced relating to post-operative and procedural pain. Forty-three experts responded to Round 2. All but one indicator achieved a level of consensus of ≥70% and so a third round was not carried out. Indicators include:

There is no documentation in the child’s notes about their pain or pain management
PRN pain medication is given without a pain score being documented
No evidence that the child received teaching (preparation) about what the procedure is and what strategies they could use to help manage their pain.

Conclusion

A set of retrospective and prospective adverse event indicators for post-operative and procedural pain were developed.These need testing further but may provide a useful tool for improving children’s pain management.

110 Surgeons’ Aims When Managing Paediatric Post-Operative Pain: A Qualitative Study

Category: PAEDIATRIC

Alison Twycross¹, Anna Williams¹, Allen Finley^{2, 3}

Adolescents showed sustained improvement in most self-reported and objective physical domains at three-month follow up. Mean uncontrolled effect size was 0.45. Most changes in outcomes (pre-treatment to follow-up) were associated with early changes in acceptance (pre-treatment to post-treatment). The same was not true of early changes in catastrophising. To address the possibility that early changes in acceptance were caused by a non-specific ‘boost’ in functioning, rather than treatment, we examined whether overall changes in acceptance (pre-treatment to follow up) were associated with early changes in functioning (pre- to post-treatment). With one exception, they were not.

Conclusion

Intensive, residential ACT therapy can be a broadly successful treatment for severely affected adolescents with chronic pain. Successful treatment outcomes were achieved in a manner consistent with the theoretical model, that is, early changes in acceptance were associated with long-term clinical improvements. All improvements were achieved with no thought-challenging interventions or attempts to change physical or emotional states. Early changes in catastrophising were not associated with most long-term improvements, consistent with this process not being targeted in therapy.

113 Lidocaine 5% Patch (Versatis) for Localised Chronic Neuropathic Pain: A National Multicentre Evaluation of Use in Children And Adolescents

Category: PAEDIATRIC

John Goddard^1,2, Rebecca Reaney^1,2

¹Sheffield Children’s Hospital, Sheffield, UK, ²BPS pain in children SIG, London, UK

Background

Chronic neuropathic pain in children and young people results from a variety of medical conditions, e.g. trauma, infection, surgery, cancer. Neuropathic pain frequently causes great distress and compromises quality of life. Neuropathic pain often responds poorly to standard analgesics. Adjuvant analgesics such as antidepressants and anticonvulsants are often effective but tolerability is frequently a problem due to unpleasant side effects.

The safety and tolerability of the 5% lidocaine patch in adults is established.

In children, most drug treatments used to treat chronic pain are extrapolated from adult trials without evidence of efficacy in children.

Studies in adults have demonstrated that lidocaine 5% patches can reduce the intensity of neuropathic pains.

This service evaluation was initiated to document the usage and efficacy of the 5% lidocaine patch in paediatric patients being managed by paediatric pain teams in the UK. No change to current clinical practice was required.

Methods

A two year service evaluation was initiated by the British Pain Society’s Pain in Children Special Interest Group supported by an unrestricted educational grant from Grunenthal. Co-ordination of the project was at Sheffield Children’s Hospital, where the service evaluation was registered with the Trust’s clinical audit and effectiveness department. The database was registered with the Healthcare Quality Improvement Partnership.

Invitations to take part along with questionnaires to be used were distributed to 13 paediatric pain teams across the UK.

Anonymous pre-treatment data included: Age, sex, weight, location & type of pain, diagnosis, duration of pain, pain score 0-10, current medication, previous medication, application site, duration and time of application planned. Follow up data were collected approximately 3 to 6 months post treatment. They included current pain score, length of time patch used, side effects, reduction in other medication, satisfaction score and any improvements in sleep and function.

Results

Interim data from the first year of the evaluation are presented for 46 patients; 31 females and 15 males. Not all centres invited to take part have provided data to the evaluation. Ages range from 6 – 17 years with a mean of 12 years 9 months. Diagnoses and causes for neuropathic pain were very varied as were the sites of application. Pain descriptors were typical for neuropathic pain. Complex regional pain syndrome was the most common diagnosis (8 patients); the back was the most common site of application (10 patients). Duration of use ranged from one to six months. Overall benefit was reported by 28 patients, no benefit by 7, with 11 unsure. Local side effects only were reported by 4 patients. 28 patients reported improvement in their physical function and 18 reported improved sleep.

Conclusion

Analysis of interim data suggests that Lidocaine 5% patch (Verstais) is helpful in treating localised neuropathic pain in children and adolescents. Over 50% of children and adolescents reported benefit to their pain symptoms with concomitant improvement in physical function and sleep. Only local side effects were reported in a few patients. Given the risk / benefit ratio of this treatment, the only issues with this treatment in children and adolescents with localised neuropathic pain would seem to be cost and lack of marketing authorisation.

114 Paediatric Pain Clinic - Referral Pattern, Demographics, Pain Symptoms, Diagnosis and Management at First Appointment of 139 New Patients Over a 3 Year Period (2009 - 2012)

Category: PAEDIATRIC

Julie Hui, Elaine Wilson-Smith

Sheffield Children’s Hospital Chronic Pain Unit, Sheffield, UK

Background

Paediatric chronic pain has been shown to be higher in females with a prevalence of up to 88%, with abdominal pain and headache being most prevalent. There has been no published data from individual paediatric pain management clinics in Britain regarding referral patterns, patient demographics, pain conditions and management.

Established in 1994, we have evolved into a tertiary multidisciplinary paediatric pain clinic composed of anaesthetists, neurologists, pain nurses, physiotherapists, occupational therapists, psychologists and psychiatrists specialised in paediatric chronic pain medicine. During our 4 clinics each month, joint consultations encompassing these professions are conducted to address the biopsychosocial impact and management of chronic pain.

The purpose of this study was the precise description and management of children referred to our pain clinic at the first presentation, over a 3 year period.

Methods

Data from new patients presenting to Sheffield Children’s Hospital (SCH) chronic pain clinic from April 2009 - April 2012 was collected retrospectively from new patient letters at first appointment.

Paperless records were not obtainable due to accessibility. Therefore, of 182 patients, data was collected from 140 patients. 1 patient had incomplete records and was excluded.

We examined 4 different aspects of our pain clinic activity:

Referral patterns - trend in number of referrals over 3 years, the referring specialty and their location
Patient demographics - age, gender
Pain symptoms and diagnosis - site of pain, pain intensity (11 point VAS scale), pain mechanism, effects on physical activity, sleep, mood, school absenteeism and social interactions
Management - alteration in analgesia, interventions, pain management programme (PMP)

Information was gathered manually and inputted into a database (Numbers, Apple Inc) and analysed using database functions.

Results

Referrals increased over 3 successive years (49, 52, 81).

Of 139 referrals, 109 came from SCH, mostly from orthopaedics (45%), 20 from other hospitals and 10 from General Practitioners.

Females presented more commonly (71%).

We saw children between 6-17 years old with 12-14 years (29%) and 14-16 years (33%) most prevalent.

Lower limb (22%), back (17%) and combined lower limb and back pain (12%) were the commonest pain sites, with overall mean pain intensity 8.48.

Pure somatic (48%) and neuropathic pain (36%) had the highest incidence by mechanism.

73% reported pain limited physical activity. Self reported disturbances in sleep (53%), mood; anxiety, feeling low, anger, stress or behavioural change (45%) and social interactions with friends or being bullied (50%) were documented.

School absenteeism >20% affected 56 (40%), 12 required home schooling, 8 were not in education.

Prescriptions were given for simple analgesics (19), moderate (34) and strong opioids (3), adjuvant analgesics (41) and lignocaine patches (16). 10 interventional procedures were planned.

All but 2 were referred to PMP.

Conclusion

Females and children between 12-16 years old are most likely to present at our pain clinic.

Most referrals are made by SCH orthopaedic surgeons which probably explains the higher incidence of back or lower limb pain, compared with headache and abdominal pain in previous studies.

As well as high pain intensity scores, more than 50% reported adverse affects on physical activity, sleep and social activity, and 45% reporting mood being affected.

With referrals increasing year on year and the almost absolute need for managing the complex biopsychosocial dimensions of chronic pain with PMP, there is discernible demand for specialised paediatric multidisciplinary chronic pain clinics.

However, it is important to appreciate that referral patterns and patient cohorts maybe specific to individual pain clinics according to surrounding local paediatric services in order to improve referral pathways, accessibility, and appropriate targeted resource management, particularly with the advent of clinical commissioning groups.

115 The Prescribing Practice of General Practitioners in Scotland When Managing Patients With Chronic Non Malignant Pain and the Factors That Influence That Practice

Category: PRIMARY CARE

John Macleod, Catherine Plant

NHS Highland, Inverness, UK

Background

The perception of staff within NHS Highland Pain Management Service was that a large percentage of new patients referred to the service were already being prescribed strong opioids and adjuvants prior to their referral to the Pain Management Service.

The purpose of this audit was to firstly identify whether our perceptions were accurate and to see if this differed from other parts of Scotland and secondly to try and clarify why these differences existed identifying where further training might be required.

Methods

Data was collected from 200 patients across 3 differing services between March and July 2012, a well established MDT clinic in Lothian, a newly established clinic in the Highlands and a unidisciplinary clinic in Dumfries. The General Practitioners’ of those patients involved were contacted requesting them to fill in an anonymous questionnaire via survey monkey.

This looked at 4 areas

External influences on prescribing such as requests from other Doctors,
Personal Influences such as following guidelines and access to psychology
The prescribing of specific medication, opioids adjuvants etc
Other influences such as cost, drug seeking behaviour or addiction
A 39% response rate was obtained from both the Highlands and Dumfries but only one response was returned from Lothian therefore Lothian has not been included in the second set of results.

Results

Although the case load in each area did differ this was not reflected in patient’s prescribed analgesia on referral which varied from none to multiple medications.

The percentage of patients utilising strong opioids and NSAID’s differed between different areas.
Not all patients with a neuropathic element to their pain were prescribed adjuvant medication
43-50% failed to take their medication as prescribed but few admitted overmedicating.

The factors influencing prescribing though were similar across areas

Most common being Consultant requests, continuation of prescriptions, patient pressure and cost.
High adherence was demonstrated to Trust Formularies and Government Guidelines but prescribing was frequently utilised due to lack of access to psychology
Confidence to utilise different analgesic groups varied. Especially around combining medications, escalation of doses, prescribing for those with co morbidities and unlicensed drugs

Conclusion

Differences were found across the areas in the analgesic medication prescribed to patients by their GP’s for chronic non-malignant pain. A limitation of the audit was that medications which had been utilised and discontinued for any reason had not been recorded.

Education would be beneficial in both the Highlands and Dumfries and Galloway on;

The use of adjuvant medication, l particularly their therapeutic properties and dosing regimes
Unlicensed medications
Utilising analgesics with the patient with co morbidities
Taking patients off unhelpful medications
Discussions will be had as to how best this training can be supplied.

116 Sheffield Health Trainers Community Chronic Pain Service Pilot

Category: PRIMARY CARE

Tim Williams¹, Janet Harris², Oliver Hart³, Chris Nield⁴, Gareth Johnstone⁵, Aziz Muthana⁵, Chris Hanson⁶

¹Sothall Medical Centre, Sheffield, UK, ²School of Health and Related Research (Sheffield University), Sheffield, UK, ³Sloan Medical Centre, Sheffield, UK, ⁴Department Public Health, NHS Sheffield, Sheffield, UK, ⁵NHS Sheffield, Sheffield, UK, ⁶Shipshape, Sheffield, UK

Background

A recent health needs assessment demonstrated that Sheffield health services are dealing with a high burden of chronic pain with secondary care able to see just 7% of even the most severely effected(1). Health Trainers, used to support behaviour change in other long term conditions, have been incorporated as part of an MDT, in a tier 2 chronic pain service in Kirklees. In 2011 a team, including PCT commissioners, GPSIs, Health Trainers, Community Nurses and a University Researcher, from Sheffield won a regional £50,000 award to pilot a Tier 1 community-based service. This used Health Trainers, to support patients with chronic pain to self-manage their condition, alongside their normal GP care. The aim of the evaluation was to assess the feasibility and effectiveness of the pilot service and to establish whether this approach would alter the treatment pathway for a subset of patients with chronic pain pre- or post-Pain Clinic attendance.

Methods

Training in chronic pain was delivered, to Health Trainers and primary and secondary care pain teams over two days, by Francis Cole (GPSI, Kirklees) and Pete Moore (author of the Pain Toolkit).It was assessed using before-after questionnaires for satisfaction, surveys for self-rating knowledge and confidence, and a knowledge test. 7 GP practices were recruited including 4 with a GP with an interest in chronic pain and 3 practices with previous experience of the generic Health Trainer service. They were presented with an overview of the referral process into the service and also sent a monthly newsletter on how the 9 month pilot was progressing. Implementation of the pilot was evaluated via interviews with Health Trainers and referral statistics. Patient’s ability to self-manage chronic pain was evaluated quantitatively using the Department of Health national Data Collection and Reporting System (DCRS) for Health Trainers, and qualitatively through patient interviews.

Results

All health providers consistently rated themselves higher in terms of knowledge, ability and understanding of chronic pain following their training. Knowledge tests confirmed a consistent increase in knowledge of how to work with patients with chronic pain.

143 referrals were received, exceeding the projected number of referrals by 50%. 45% of patients would have been referred to a secondary care pain service if the community service had not been available.

Patients reported increases in Self-efficacy (8%), General Health (35%) and Wellbeing (53%) measures. Generic life goals fully or partly achieved by 75% of participants provided the foundation for achieving health outcomes such as increased physical activity. These goals included, more accurate or less use of medication, greater participation in family life and social activities, ability to negotiate changes in work environment with their employers, and motivation to collect information on alternative employment and training programmes.

Conclusion

This pilot demonstrates that such a community pain service can be successfully implemented, allowing potentially more appropriate use of NHS resources. Both quantitative and qualitative assessments showed that Health Trainer support was instrumental in helping patients to develop capability and motivation to self-manage pain. This is consistent with the capability-opportunity-motivation model proposed by Michie et al, 2011 (2). It was clear that, although patients found services offered by GPs and secondary care pain services useful, the Health Trainer programme is clearly filling a need for help in terms of overall condition management in the context of everyday life.

117 Psychological Stress and Widespread Pain: The Moderating Effects of Childhood Abuse

Category: PRIMARY CARE

April Woodward¹, Paul Campbell¹, Francis Creed², Barbara Tomenson², John McBeth¹

¹Keele University, Stoke on trent, UK, ²Manchester University, Manchester, UK

Background

The aetiology of widespread pain (WP) is complex. Psychological stress, including anxiety, depression, somatisation and recent life threatening events, predict symptom onset. Childhood abuse may act to confer a susceptibility to developing WP on exposure to psychological stress in adulthood. The aim of the study was to test the hypothesis that the relationship between psychological stress and

WP was moderated by childhood abuse.

Methods

In a population-based cross-sectional study, 2,490 adults aged 25-65 years were mailed a questionnaire that collected data on the number of pain sites (range 0 - 29) and psychological stress (anxiety, depression, somatic symptoms, recent threatening events). A childhood abuse questionnaire assessed physical (often hit, kicked or beaten or any threat to life), emotional (often insulted, humiliated or made to feel guilty), and sexual (touched or made to touch someone; attempted or completed intercourse) abuse before the participant was 17 years old. Structural equation modelling tested the association between psychological stress and the number of pain sites, adjusted for age and sex. Multiple-group analysis tested the moderating effects of childhood physical, emotional and sexual abuse individually and combined, as childhood abuse. Results are presented as standardised regression weights (β) with 95% confidence intervals (CI) and variance explained (R2). Model fit was assessed by root mean square error of approximation (RMSEA).

Results

1430 (57%) individuals returned a questionnaire with complete pain, stress and abuse data. Childhood abuse was reported by 255 (18%) participants; 57 (4%) reported physical abuse, 200 (14%) sexual abuse and 70 (5%) emotional abuse. Overall, the hypothesised model adequately fit the data (RMSEA = 0.04). Higher levels of psychological stress were associated with a higher number of pain sites (β = 0.51, 95% CI 0.43, 0.58), explaining 26% of the variance in the number of pain sites reported. Multiple-group analysis showed that reporting childhood abuse increased the strength of this association (β = 0.58, 95% CI 0.41, 0.73, R2 35%) compared to reporting no abuse (β = 0.47, 95% CI 0.38, 0.55; R2 23%). This moderation effect was strongest for those reporting physical abuse (physical abuse β = 0.62, 95% CI 0.25, 0.86, R2 40%; no physical abuse β = 0.47, 95% CI 0.38, 0.55; R2 24%).

Conclusion

The association between psychological stress and number of pain sites was stronger in those individuals reporting childhood abuse. The amount of the variance explained in number of painful sites increased by 12% for those reporting child abuse in general, and by 16% for those experiencing physical abuse specifically. These data add further weight to the hypothesis that events in early childhood confer a susceptibility to developing WP later in life.

118 Attentional Bias to Generalised Threat in Fibromyalgia: A Visual Probe Study. Preliminary Results for Discussion

Category: PSYCHOLOGY

Marianne Roberts², Gary Lee^1,2, Lucy Cowans¹, Isobel Rice¹, Matt Garner²

¹Chronic Pain Team Isle of Wight NHS Trust, Isle of Wight, UK, ²University of Southampton, Southampton, UK

Background

Threat processing accounts of pain are significant when considering conditions like fibromyalgia(FMS), and there is general agreement that underpinning FMS are adaptive changes to the central nervous system including central structures associated with general threat processing.

We posit that exposure to sustained periods of environmental threat (common to FMS) lead to augmented threat processing. If pain is conceptualised as the conscious output of the unconscious perception of somatic threat, then both this and environmental threat may share a common adaptive neural architecture. Consequently, central changes from exposure to sustained threat may prime pain perception in response to decreasing levels of somatic (nociceptive) stimulation .

From this model, we would predict a generalized elevation of threat perception in FMS. This preliminary study presents data suggesting that fibromyalgia could associated with a generalised threat processing bias, notably selective attention to threat.

Methods

17 FMS patients and 17 healthy controls completed a modified visual probe paradigm that measured selective attention to general threat words. In this task participants viewed pairs of words (threat and neutral words matched for length) that were presented for 500msec. Participants were instructed to classify a visual target (left vs. right arrow) that immediately appeared either behind the threat word or neutral word (with equal probability). Speeded reaction times to classify targets that are presented in the location of threat (relative to neutral) words is commensurate with selective attention (vigilance) to threat.

Results

Mixed design analysis of variance (ANOVA) revealed a near-significant interaction between group (FMS vs. control), threat word location, and target location (threat or neutral location), F(1,32) = 3.06, p = .09. This interaction was characterized by selective attention to generalized threat in the FMS group (mean = 15.2msec) but no bias in control group (mean = -2.6 msec). Correlations confirmed that increased MPQ total pain score was associated with greater attentional bias to threat. Consistent with previous studies, vigilance to threat was associated with state anxiety and trait anxiety.

Partial correlations indicated that severity of pain and anxiety were both associated with attention to threat, but not independent of one-another.

Conclusion

Although the study was limited by low power, these findings offer preliminary evidence of broader sensitivity to generalized threat in fibromyalgia. Our data further suggest that elevated threat (AB) may represent a unifying mechanism that covaries with pain severity, and anxiety, and imply a complex relationship between anxiety, pain, and threat processing that warrants further investigation.

119 The Use of Eye-Tracking to Assess Attentional Bias and Attentional Control in Chronic Pain

Category: PSYCHOLOGY

Daniel Schoth, Hayward Godwin, Christina Liossi, Simon Liversedge

University of Southampton, Southampton, Hampshire, UK

Background

Research using the visual-probe paradigm has shown patients with chronic pain to demonstrate attentional biases for pain-related information compared to healthy individuals. Two important questions remain to be addressed. First, the time-course of attentional bias has not been sufficiently explored. The visual-probe task only captures a snapshot of attention, and it is unknown how quickly biases arise. Second, attentional bias may be moderated by attentional control. Patients with poor attentional control may have difficulties inhibiting attention from shifting automatically towards pain-related information. Eye-tracking is ideally suited to explore these questions, providing moment-to-moment information on attentional processes. This technology was therefore used in the current investigations, with different samples of chronic-pain participants completing a visual-probe task and an anti-saccade task to explore attentional bias time-course and attentional control respectively.

Methods

Experiment 1: 44 participants (22 chronic headache, 22 healthy) completed a pictorial version of the visual-probe task, which presented headache-related/neutral and pain-related/neutral images simultaneously in different locations. After 500 or 1250ms, one of these images was replaced with a dot, the location of which participants had to indicate as quickly as possible. Response times and eye-movements provide an indication of whether participants bias towards or away from pain-related information.

Experiment 2: 47 participants (23 chronic headache, 24 healthy) completed an anti-saccade task. In this task, participants fixate their gaze upon a central cross, which is then replaced by a peripheral cue (i.e. dot, painful, angry, or neutral face) to either the left or right. Participants must avoid looking at this, instead shifting their gaze to the cue’s mirror location. Attentional control is needed to inhibit fixations to cues, which is more difficult for information relevant to the individual’s emotional concerns.

Results

Experiment 1: chronic headache participants made significantly fewer fixations during headache trials than pain-related trials, which were of significantly longer duration. No significant between-group differences were found for initial saccade onset latency (i.e. the time taken to initiate the first eye-movement), or initial fixation direction (i.e. the first image fixated). For manual response times, the healthy control group responded significantly faster to probes during 1250ms trials than the chronic headache group.

Experiment 2: The chronic headache group, compared to the healthy control group, took significantly longer to i) initiate their first eye-movement, and ii) fixate their gaze in the correct location during anti-saccade trials. No evidence was found to suggest the chronic pain group had specific difficulties inhibiting automatic eye-movements towards painful faces.

Conclusion

The visual-probe task showed disorder-specific information influences attention differently than general pain-related information. This confirms the results of former investigations which highlight the attention-capturing quality of information specifically relevant to the participant. The results of the anti-saccade task also support those of former research, showing poorer levels of attentional control in individuals with chronic pain compared to healthy controls. As eye-movement latencies were slower for the chronic headache group, this may reflect greater effort needed to suppress the automatic tendency to shift attention towards stimuli presented in the peripheral field.

120 Opiate Medication Reduction Following Pain Management Programme

Category: PSYCHOLOGY

Catherine Stack, David Pang, Estelle Barker, Sandesha Kothari, Arni Woolfenden

St Thomas’ Hospital, London, UK

Background

Reducing patients’ opiate medication use and/or dose is of interest given the significant problems associated with long term opiate use. The main objective of this prospective observational study was to examine whether attending an inpatient multidisciplinary pain management programme (INPUT-PMP) led to a reduction in patients’ daily dose of opiate pain medication. This had been noted as a secondary finding on a previous audit several years ago. This previous audit had found that the mean morphine equivalent dose reduced from 88.78mg/day pre-programme to 59.14mg/day post-programme.

Methods

The study was done at the INPUT-PMP at St Thomas Hospital, London. INPUT_PMP is a residential course that the patients attend for 4 days a week over 4 consecutive weeks. This provides over 128 hours of therapy. INPUT-PMP is multidisciplinary cognitive behavioural therapy programme for chronic pain patients delivered by clinical psychologists, pain doctors, specialist nurses, occupational therapists and physiotherapists.

A prospective analysis was performed of all patients attending (INPUT-PMP) between January 2011 and January2012. A record was kept of the drugs (type and daily dose) that the patients were taking prior to starting INPUT-PMP. This data was also recorded at the end of the programme and at the follow up sessions. 125 patients completed the INPUT-PMP during the study period. All of these were included in the study.

The data were analysed using mean and 95% confidence interval calculations.

Results

125 patients took opiate medication prior to attending INPUT-PMP at a morphine equivalent mean dose of 40.89mg/day (95%CI = 20.77 - 61.00mg)

At the end of the 4 week programme the mean morphine equivalent dose was 28mg/day and at 1 year follow up it was 25.41mg/day (95%CI = 12.59 - 38.24mg)

Reductions were also observed in daily dose of non-steroidal anti-inflammatory drugs, total number of drugs and number of classes of drugs.

Conclusion

A 4 week inpatient multidisciplinary pain management programme (PMP) incorporating pain management principles within a cognitive behavioural framework can lead to a reduction in opiate pain medication use.

This reduction was sustained at 1 year follow up.

121 Maximising Self-Care Through Familiarity: The Role of Practice Effects in Enhancing Active and Passive Pain Management

Category: PSYCHOLOGY

Katherine Finlay, Joanna Rogers

University of Buckingham, Buckingham, UK

Background

Distraction and relaxation are regularly recommended as part of multimodal Pain Management Programmes (BPS, 2009). However minimal research has assessed the role of practice effects or familiarity with such cognitive pain management strategies when used consistently over time. It is possible that their efficacy declines with repeated use, and that their recommendation for self-care is time-limited and low in clinical relevance. The perceived benefits may also be related to the level of active engagement required of the user by the distractor, in accordance with Multiple Resource Theory (Wickens, 2002). Active distraction approaches must be compared with passive strategies, practiced consistently in a familial setting, in order to justify their continued inclusion in multidisciplinary Pain Management Programmes.

Methods

Passive distraction (participant-selected preferred music) and active distraction (standardised, guided Progressive Muscle Relaxation; PMR) were compared against a no distraction control on the cold-pressor test (CPT) using a JeioTech circulating water bath at 0°. In a repeated measures, between-subjects design, seventy healthy participants were recruited from a community-based sample (31 males, 39 males; mean age = 37.5 years). Participants completed the CPT four times, at baseline and with distraction or no distraction at week 1 and again at week 2. Participants’ dominant arms were used for testing and hand temperature was returned to baseline temperature between trials. Participants in the music and PMR conditions practised their distraction strategies daily between trials (7 days), with control participants keeping an activity log. Primary outcome measures were pain tolerance and intensity. Secondary outcome measures included state-trait anxiety (STAI), pain threshold, heart rate, sensory/affective pain (SF-MPQ), general self-efficacy and perceived efficacy of distraction.

Results

Manipulation checks demonstrated that mean familiarity with and preference for distractors increased significantly from week 1 to week 2 (p<.001), demonstrating practice did enhance familiarity and preference in experimental participants. Repeated measures ANOVAs showed that pain tolerance increased across Weeks of Testing, with Tolerance during PMR/Music trials significantly enhanced over control (p<.01), therefore pain tolerance was enhanced with greater familiarity with distraction. Practice with PMR significantly increased pain threshold at week 2 over music or control (p<.01), with PMR delaying onset of pain. Pain intensity also showed reductions with distractor familiarity, but only for the music group (p<.05). PMR significantly reduced anxiety over music or control, but familiarity provided no additional enhancement. Self-efficacy was significantly elevated after practice in both PMR (p<.05) and music groups (p<.001). Finally, PMR reduced Heart Rate to a greater extent at week 2 than music, demonstrating that physiological control is facilitated through PMR repetition.

Conclusion

These findings emphasise the role of practice in maximising the impact of cognitive distraction strategies, justifying their continued recommendation on Pain Management Programmes for patient self-care at home. Repeated exposure to distraction approaches enhanced optimal arousal and complexity, maximising pain management (Berlyne, 1971). Active and passive distractors were beneficial; active distraction through PMR enhanced coping through improved tolerance, threshold and anxiety management, but passive distraction through music reduced pain intensity and improved self-efficacy to a greater extent. It is suggested that both PMR, and music, are used together as part of a multidimensional toolkit for use in pain management.

122 Pain Communication Through Body Posture: The Creation and Validation of a New Stimulus Set of Affective Body Posture Images Including Pain

Category: PSYCHOLOGY

Joseph Walsh, Edmund Keogh, Christopher Eccleston

University of Bath, Bath, UK

Background

Pain does not occur in isolation, but is influenced by social interactions and contextual cues. Being able to effectively communicate pain facilitates helping behaviour from others. Emotions are communicated through the use of nonverbal behaviours, including facial expression, vocalisation, and body posture. Pain has also been shown to be communicated through these channels. However, whilst cues associated with facial expressions (Simon et al, 2009, Craig, 1992) and vocalisations (Belin et al, 2007) of pain have been identified, less is known about specific body postures. This is surprising considering the importance given to postural-based pain behaviours such as guarding. The present study therefore aimed to start a programme of research that looks at pain postures. The first goal was to create and validate a new stimulus set of affective body postures which included pain, in order to investigate pain body postures and facilitate further research in this area.

Methods

Part 1: 21 actors (11 male) were filmed performing a series of affective body postures. Each actor produced 8 affective postures (happiness, sadness, fear, anger, disgust, surprise, pain and no emotion), resulting in 374 stimuli. Each of these was edited to 2 seconds in length (50 frames at 25 frames per second), sound removed, and faces blurred to control for any communicative effect of facial expression.

Part 2: The stimuli were presented to 20 adults (10 male). They identified the emotion presented in each clip, and rated its valence and arousal. A final stimulus set of 128 stimuli was selected based on recognition rates. This set was made up the 16 actors with the highest overall recognition rates (8 male), all performing each emotion once. These stimuli were then coded using the Body Action Posture Coding System (BAPS) to provide and objective description of postures which communicate each emotion.

Results

ANOVA was used to examine whether emotion, participant sex and actor sex had a significant influence on recognition accuracy, valence and arousal. No significant effect, or interaction, involving either sex variable was found. However, a significant main effect of emotion was found (F(7,2612)= 479.81, p<0.001). Emotion recognition was generally good, apart from “disgust” and “surprise”. Pain had a high recognition accuracy rate (93.7%). Post-hoc Tukey tests showed that pain accuracy was significantly higher than fear, surprise and disgust. Pain was rated the most unpleasant emotion, and was rated significantly more unpleasant than any other emotion. Arousal ratings for pain were significantly higher than for sadness or happiness, with no significant difference with the other emotions.

BAPS results showed that specific actions were consistently present throughout stimuli recognised as communicating pain. High muscle tension, rigid movements, angular postures, and hand interaction with specific pain/injury sites were all demonstrated.

Conclusion

We have created a new stimulus set of affective body posture that seem to convey pain and other core emotions. Our results suggest experimental stimuli can be developed that communicate pain through body posture images. These stimuli reflect specific actions and postural cues that observers perceived as reflecting pain, and which seem to be differentiated from other emotions. This suggests that pain might be communicated, much like other affective states, through the body. We hope that this new stimulus set will facilitate further research into both pain communication through body postures, and more generally into emotion communication.

123 Impact of Psychology Assessment in Our Mdt Clinics...Are Our Patients Getting Benefits From Our Psychology Service Provided?

Category: PSYCHOLOGY

Alifia Tameem¹, Kumar Vasappa¹, Karen Lemarchand², Vish Siddalingaiah¹

General practitioners are encouraged to look for evidence of depression in their patients with chronic disease. In those with a new diagnosis of depression an assessment of severity should be made and repeated at 5 -12 weeks. The PHQ-9 is one of the validated instruments that GPs commonly use to assess their patient’s clinical state.

Depression is common in patients with chronic pain. Whether the depression follows the establishment of chronic pain or the chronic pain is a manifestation of a form of depression is a question that has vexed physicians. Whichever is the case, attempting to treat the pain without considering and managing the depression is unlikely to be successful.A formal assessment of depression is important in all patients attending the pain clinic. Using an assessment tool which the GPs are currently using in their practice seems sensible as we rely on the GP to initiate treatment.

Methods

New and follow up patients attending the pain clinic were asked to complete The PHQ-9 form whilst waiting to be seen and then hand the completed form to their pain doctor in the clinic. The Doctor would then score the form to determine if the patient appeared depressed or not and the severity. The doctor recorded the pain diagnosis, whether or not the patient was on antidepressants (with details if so), and if the GP had been informed of the score.

Results

Over a 2 month period, 109 patients completed the PHQ-9 form and these were collated and analysed. The age ranged from 19 - 91 years, mean of 54, (median 52y), 57 were new referrals. The majority were female (65%). Out of a total score of 27, 34 patients (30%) scored 4 or less indicating none or minimal depression. 24 patients (22%) scored between 5 - 9 indicating mild depression. 16 patients (15%) indicated moderate depression (score 10 - 14). 20 patients (18%) scored at a level to indicate moderately severe depression. 15 patients (14%) gave a score between 20-27 indicating severe depression.

Of the 35 patients with significant depression (score > 15), 25 were female, with a mean age of 51y (range 23-91). 15 were new patient referrals. Only 16 patients were currently on treatment for depression. In all these patients the GP was informed of the PHQ-9 score.

Conclusion

32% of the patients attending the pain clinic in this 2 month period had evidence of major depression. Less than half the patients were receiving any form of treatment for this. Informing the GP, having assessed the patient with a tool that they already use, will hopefully allow them to start treatment and assess the success by repeating the PHQ-9 form. It is also a very helpful tool in the pain clinic to allow you to approach the subject of the patient’s mood and explain to them how depression impacts on pain and encourage them to seek treatment.

127 An Assessment of the Impact of Psychological Variables on Outcome Following Total Knee Replacement, a Single Centre Study

Category: PSYCHOLOGY

Mark Alexander-Williams^1,2, Charlotte Smith², John Lambie²

¹Mid Essex Hospital NHS Trust, Chelmsford, UK, ²Anglia Ruskin University, Cambridge, UK

Background

The main purpose of a total knee arthroplasty (TKA) is to reduce knee pain and improve mobility. In 20% of patients however knee replacement surgery is ineffective in significantly alleviating these symptoms1. There appears to be no common organic reason underlying poor recovery in this subset of patients. Researchers have hypothesised that patients therefore may have maladaptive cognitive tendencies prior to the operation that leave them markedly vulnerable to this surgery2. The two main psychological factors that have been specifically implicated are pain catastrophisation 3-7 and kinesiophobia 3. Whilst the role of pain catastrophisation in poor outcome following TKA is firmly established, the research on kinesiophobia is more conflicting 5. Sullivan in 20118 found that within a multivariate regression analysis of TKA outcome, whilst pain catastrophisation was a significant predictor, kinesiophobia was not. Also worth noting is that this body of literature has been mainly conducted on US or Canadian samples.

Methods

This study reports on longitudinal findings from a cohort of 75 patients. Patients attending pre-assessment prior to their knee replacement were recruited to the study. If subjects chose to consent they were given an envelope and asked to complete the pack before their operation and return it. The pack included four psychological standardized questionnaires: the hospital and anxiety depression scale (HADS)9, the pain catastrophisation scale10, the multidimensional health locus of control scale (MHLC)11 and the tampa scale of kinesiophobia (TSK)12.

Six months after the date of their recruitment, subjects were posted a second questionnaire pack. This pack included the following outcome measures; the HADS, an assessment of satisfaction of post operative functioning (satisfaction survey)13 and a measure of perceived physical health (the SF-12)14. Subjects were asked to complete this following their operation.

Results

Pain catastrophisation correlated with post surgical patient satisfaction, r(47) = -.297, p<0.05. Anxiety correlated with satisfaction levelr(47) = -.28, p<0.05.

An assessment of the SF-12 revealed a significant correlation with internal locus of control r(48) = .28, p<0.05, depression r(48) = -.25, p<0.05 and kinesiophobiar(48) = .348, p<0.05.

Multiple regression was carried out using 7 predictor variables- pain catastrophization, anxiety, chance locus of control, internal locus of control, depression, kinesiophobia and powerful other situated locus of control. The initial model accounted for 33% of the variance, and there were two significant predictors, kinesiophobia and internal locus of control. This model was significant, F(7, 42) = 2.99, p<0.05.

A model that emerged from these findings was analysed; it involved kinesiophobia, internal locus of control and powerful other locus of control (two MHLC subscales). This model accounted for 27% of the variance, F (3, 51) = 6.405, p<0.01)

Conclusion

This study found that high levels of kinesiophobia, internal locus of control, and powerful other situated locus of control predicted a poorer post-operative outcome (as measured by the SF-12) 6 months post surgery. Our patient group had a high initial TSK score compared with previous studies, which could partially explain this difference. Pain catastrophisation interestingly appeared to have a unique role in predicting lower satisfaction, along with anxiety. These findings will inform a future screening tool to identify vulnerable patients in a UK TKA pre-assessment setting, and in terms of tailoring an effective psychological intervention for this subgroup.

128 Influence of Very Early Change in Catastrophisation After an Initial Visit With a Physical Therapist for LBP on Self Reported Outcome at Three Months

Category: PSYCHOLOGY

Jonathan Field^{2, 3}, David Newell³

¹Back2Health - private practice, Petersfield, Hampshire, UK, ²University of Portsmouth, Portsmouth, Hampshire, UK, ³AECC, Bournemouth, Hampshire, UK

Background

Psychological factors such as catastrophic thinking (CAT) measured at presentation are found to have significant influences on future disability, pain and self reported improvement in LBP patients (Gauthier et al., 2006).

It has been suggested that change within a few days or weeks of starting physical therapy may be a powerful predictor of outcome after a course of care (Axen, I. et al., 2002, Bolton, J.E. & Hurst, H., 2011). In a preliminary study we found that psychological variables assessed a few days after an initial visit with a physical therapist provided greater prognostic utility than when assessed at baseline (Field, J. et al.)

This study describes changes in CAT in a patient population over a period of a few days during which they have had an initial visit with a physical therapist. It also explores any relationship between these changes and patients self reported outcome at three months.

Methods

Consecutive patients meeting the inclusion criteria who presented privately to one of 33 physical therapists (chiropractors, osteopaths and physiotherapists) using the Care Response system to collect patient reported outcomes in the UK were invited to participate via emails sent at the time of booking their initial appointment. Inclusion criteria were; aged 16-70, presenting with LBP and having access to the internet and email. Patients were subsequently excluded if they were not offered treatment or if LBP was not their primary complaint.

Assessment questionnaires including the Pain Catastrophising Scale (PCS) were completed online, before and two days after, the initial visit. A follow up assessment of patients’ global impression of change (PGIC) was sent by email link 90 days after the initial visit.

Not responders to an emailed invitation to complete an assessment were sent a reminder after two days and were subsequently contacted by phone.

Results

412 subjects were recruited with a mean age (SD) of 46.3 (12.6), with 56.8% being female. Just over half (53.6%) had pain of less than six weeks duration and 35.7% reported leg pain. Completed assessments sent at 2 and 90 days were received from 95.4% and 78.2% of participants respectively.

PCS scores at presentation; 13.0(11.0), had reduced (p>0.01) by 2 days following the initial visit; 9.9 (10.4), with 66.9% of individuals having some improvement.

ROC analysis utilising percentage change in PCS against dichotomised PGIC scores gave an AUC of 0.69 (CI 0.57-0.81). A PCS change score of 40% was identified as providing an optimum balance of sensitivity and specificity.

For the population as a whole having less than a 40% improvement in PCS increased the odds of reporting a poor outcome by 3.85 (CI 1.83-8.10). For those with above median PCS at initial assessment this increased to 8.17 (CI 2.34-28.45).

Conclusion

This population of LBP patients presenting privately for physical therapy had generally low levels of CAT. Despite this, lack of improvement in PCS scores was found to significantly reduce the chance of a good recovery. Unsurprisingly this risk was greater in those with more negative thoughts and belief regarding their pain at presentation.

Preliminary studies suggest that very early changes in psychological variables in populations like this are not related to early change in pain or expectation of recovery.

Further work is indicated to explore reasons behind early change in CAT.

129 The Design and Development of a New Task for Investigating the Interruptive Effect of Pain: A Proof of Concept Study Using Mobile Technology

Category: PSYCHOLOGY

Edmund Keogh, David Moore, Geoffrey Duggan, Stephen Payne, Lisa Austin, Efthymia Mitella, Christopher Eccleston

Clinical experience within our pain service shows fibromyalgia is often preceded by periods of sustained personal threat. Pain is now understood as the conscious correlate of a threat input to the brain. There is general agreement that underpinning FMS are adaptive changes to the central nervous system and that central structures associated with general threat processing are particularly affected.

We posit that exposure to sustained periods of environmental threat (common to FMS) lead to augmented threat processing.

Methods

22 Patients and members of the local fibromyalgia support group were asked to participate in an anonymous questionnaire survey. Information was gathered regarding age of onset of fibromyalgia and which broad category of threat was sustained, and the age it occurred. Threats were categorised broadly into neglect, medical misendeavour, verbal abuse, violence, sexual abuse, and other serious threat. Patients were to tick all boxes that applied; thus multiple threats could be registered

Results

All patients surveyed felt they had suffered stressful life events, 95% had occurred before diagnosis. 82% suffered direct severe personal threat before the onset of pain.

67 threats were registered; the number of reports per patient varied from 1 to 9. 40% of these occurred before 18 years old; 82% involved verbal abuse; 68% violence; and 55% sexual abuse. 36% of reports involved childhood sexual abuse, with 41% of patients having experience violence or sexual abuse in childhood. These figures are significantly higher than the nationally quoted statistics¹.

Conclusion

Whilst this survey is small the results are startling and have prompted us to undertake a more extensive national survey. They underline the importance of taking a history of previous threat when considering a diagnosis of a central hypersensitivity syndrome such as fibromyalgia. These results lend weight to the theory that exposure to prolonged periods of personal threat can lead to augmented pain processing.

References:

Radford, Lorraine, Corral, Susana, Bradley, Christine, Fisher, Helen, Bassett, Claire, Howat, Nick and Collishaw, Stephan (2011) Child abuse and neglect in the UK today. London: NSPCC.

134 Training Health Professionals to use the Pain Management Plan CBT Workbook

Category: PSYCHOLOGY

Polly Ashworth¹, Robb Hunt^1,5, Patrick Hill⁴, Frances Cole^{2, 3}

¹Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK, ²Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK, ³NHS Kirklees, Kirklees, UK, ⁴Birmingham Community NHS Trust, Birmingham, UK, ⁵Cardiff University, Cardiff, UK

Background

The Pain Management Plan (PP) is a cognitive behavioural, self-management support programme for people living with long-term pain, in the form of an interactive, accessible, pictorial workbook. This workbook is designed to be supported by a trained facilitator who introduces the concept of pain self-management. The facilitator acts as a guide to understanding the impact of pain on the individual and enabling them to develop a range of self management skills needed to manage pain effectively. This abstract reports on an evaluation of the facilitator training.

Methods

Training took the form of a one-day interactive workshop, delivered by the clinicians who contributed to the development of the PP, and aimed at clinical staff already experienced in the management of pain. The workshops presented the rationale and evidence for the PP, an introduction to the content of the workbook, usage of an introductory Health Needs Assessment and six role-plays to practice working with the PP. Participants were asked to self-rate their own knowledge and skills in 15 domains covered in the training pre and post workshop. One week after training, all participants were also invited to complete an online survey to rate their confidence in using the programme and to comment on the workshop design and content.

Results

Data were collected from 94 participants, attending 5 workshops around England between December 2011 and December 2012.

Participants (N=58) from 3 of the workshops self-rated their knowledge and skills, pre and post training, on a Likert scale ranging from 1 (no confidence) to 10 (complete confidence). They reported a mean improvement in all aspects of the training, with the greatest improvements seen in using Health Needs Assessment tools (mean pre-workshop score = 3.89, mean post-workshop score = 8.34), and in understanding the ‘5-areas’ CBT model (mean pre-workshop = 5.30, mean post-workshop = 8.19).

Participants (N=68) from 4 of the workshops gave feedback online, reporting high levels of confidence in using the programme. Feedback on the training indicated that it was valued, with participants reporting most positively about the printed materials (71%), and least about the time available to practise interactive skills during the workshop (62%).

Conclusion

The results show that after attending a PP skills training workshop, participants report a greater understanding of the skills needed to deliver the programme and high levels of confidence in using it. The feedback provided highlights how the training might be improved with more time allocated to practising the interactive skills needed by the facilitators to support the people using the PP programme.

135 Prevalence and Relationship Between Self-Stigmatization and Self-Esteem in Chronic Pain Patients

Category: PSYCHOLOGY

Dominic Hegarty^1,2, Mary Wall²

¹Cork University Hospital, Cork, Ireland, ²University College Cork, Cork, Ireland

Background

Stigma and poor self-esteem (defined as the internalized cognitive, emotional, and behavioural impact of others’ negative attitudes on a person) are associated with many chronic health conditions; however, they have not being quantified in chronic pain patients to date. Stigmatization and poor self-esteem has indirect but strongly negative implications for clinical efforts to combat the diseases or conditions concerned (van Brakel, 2006). We sought to estimate the prevalence of perceived stigmatisation and self-esteem in individual diagnosed with chronic pain and its relationship with general health markers.

Methods

Using a cross-sectional, anonymous and convenience sampling study design, which was approved by the local research ethics committee, 160 adult patients (n=160, >18 years old, chronic pain > 3 months) attending a chronic pain clinic were asked to complete a set of validated questionnaires which included; Stigmata Scale for Chronic Illness (SSCI), Rosenberg’s Self-esteem Scale (RSES); Hospital Anxiety Depression Scale (HADS); Brief Pain Inventory short form (BPI); and the General health survey (SF12v2). Data was recorded using Microsoft Excel and analyzed using SPSS.

Results

Our study population (n=160) was 69.1% female (mean age 59.9 + 15.2 years), with a mean duration of pain of 7.7 + 8.8 years (range 0.5-56 years) reported a mean pain intensity score (Visual analogue score (VAS)) of 6.1 + 1.7. 77% of patients (123/160) had a lowered self-esteem (RSES score = 17.2 + 14.5) with a mean SSCI score of 50.8 + 19.0 (normal range 24-120). An inverse relationship between stigmatization and self-esteem (Pearson correlation, r = .58, p<0.001) and self-esteem and pain interference (r = .48, p<0.001) was identified. Partial correlation analysis demonstrated a weak a relationship between stigmatization and self-esteem (r= .174, p = .04). A positive correlation between stigmatization and anxiety (r = .228, p < .05) and an inverse relationship between self-esteem and depression existed (r = .234, p <.05).

Conclusion

The prevalence of self-stigmatization and poor self-esteem identified in this study is greater than those levels reported in mental illness and HIV patients. It is recognised that stigma about chronic illness may determine how and even whether people seek help, their level of engagement with treatment and the clinical outcome (Hayward & Bright, 1997). For these reasons identification of chronic pain patients with low self-esteem and feelings of stigmatization would allow us specifically target and tailor management interventions in order to improve clinical outcome.

136 Measuring Pain: Patient and Healthcare Professional Concordance, a Systematic Review

Category: REVIEWS

Tim Seers³, RA Moore², Sheena Derry², Kate Seers¹

¹University of Warwick, Coventry, UK, ²University of Oxford, Oxford, UK, ³Imperial College, London, UK

Background

Pain is highly prevalent throughout all areas of healthcare and is an important component of patients’ quality of life. Current evidence suggests that underestimation of patients’ pain by healthcare providers is widespread across many care environments and patient sub-groups. As pain is a subjective experience, its assessment normally needs to involve the person in pain. Those who care for people in pain routinely make assessments of pain that inform its management. If the health professional under or over estimates the patient’s pain, this can lead to sub optimal care. We aimed to review the research evidence to assess the degree of concordance between patient and health professional assessment of pain.

Methods

We undertook an initial scoping search of the literature, and built up our search iteratively. The search was undertaken in Medline, EMBASE, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Psychinfo, and was limited to studies reporting data since 1990 in order to make any comparisons and conclusions of contemporary value. Electronic searches were backed up by considerable eclectic searching using review articles, reference lists, and electronic suggestive applications in PubMed and Google Scholar as studies looking at pain assessment can be hard to locate. Inclusion criteria: any study design that used any type of pain measurement. The data had to measure concordance between patients and professionals from individual paired results, average discrepancy or any statistical measure of concordance. Pain scores were considered concordant if patient-professional scores were within 1cm on a 10 cm visual analogue scale or 1 point on a 0-11 numerical rating scale.

Results

We have currently identified 53 studies, with 12,151 patients. Most studies (39/53; 74%) had small samples,between 20 and 199 patients evaluating their pain. The majority of data (54.6%) were derived from five large studies with more than 500 patients. Pain assessments took place in a number of different settings, including various hospital departments (inpatients and outpatients), community, and primary care, and all used standard pain scales for measurement.

From the studies identified so far, the proportion of pain assessments where health professionals were concordant with patients, or over- or underestimated their pain showed a wide variation. Concordant assessments ranged from 24-67% of assessments, underestimation from 12.2-65% and overestimation ranged from 1-34%.

Conclusion

The findings so far suggest that underestimation of pain by health care professionals remains a significant problem. Overestimation also occurs, but is less common. The lack of concordance is not limited to one area of practice or profession. Underestimating pain can result in inadequate pain management, and over estimation may put patients at increased risk from adverse events if the dosage is increased in response to this assessment. It is important to be aware that health professionals regularly underestimate pain, and unless the patient is involved in the assessment, this situation is unlikely to improve.

137 A Population Study into the Prevalence and Genetic Profile of Patients With Chronic Pain Who Do Not Respond to Oral Codeine: Oral Transudate Subset Results

Category: TRANSLATIONAL PAIN RESEARCH

Helen Radford^1,2, Karen Simpson^1,3, Suzanne Rogerson^1,3, Mark Johnson^{2, 3}, Pauline Fitzgerald², Steve Martin²

¹Pain Management Services, The Leeds Teaching Hospital NHS Trust, Leeds, UK, ²Faculty of Health and Social Sciences, Leeds Metropolitan University, Leeds, UK, ³Leeds Pallium Research Group, Leeds, UK

Background

Approximately 5-10% Caucasians are poor metabolisers (PM) of codeine and other CYP2D6 substrates because of non-functioning CYP2D6 gene alleles; 10-15% are intermediate metabolisers (IM) who have weakened enzyme activity¹. Normal extensive metabolisers (EM) account for 70%; however 1-3% are ultra metabolisers (UM) with multiple copies of functioning alleles. The ability to predict the clinical efficacy of codeine and identify these genetic variations using an easy, repeatable, cost effective clinical test would be valuable. Benefits may include better patient concordance due to improved clinical response, increased safety and reduced costs. This development may be a step towards tailoring analgesic management to the individual². This study assessed the proportion of chronic pain patients who lacked an analgesic response to codeine. We conducted salivary CYP2D6 genotyping and correlated this to measurements of urine and oral transudate morphine metabolites to determine if this could predict codeine non-responsiveness in a clinical setting.

Methods

Caucasian patients aged 18-80 years attending a Pain Management clinic were recruited after informed consent (n=23). Participation lasted 15 days. Baseline pain assessments and concomitant medications were recorded and any prohibited analgesic medications (codeine and CYP2D6 inhibitors) were ceased. Two days later saliva was collected via the Oragene•DNA Self-Collection Kit. A baseline urine sample was also collected. Then 2 hours after oral dosing with 30mg Codeine Phosphate a sample of oral transudate was obtained via an Orasure Intercept® device for measurement of codeine and morphine metabolites. The patient was given a pain diary and asked to take oral codeine 30mg QDS for 5 days. On day 4 the patients collected another urine sample and returned on day 5 to provide a further urine sample, oral transudate sample and complete final pain assessments. Patients were followed up a week later to assess any adverse events.

Results

Genotype frequencies (n= 23); PM (8.3%), IM (25%), EM (66.7%), UM (0%). Baseline NRS mean pain scores: 6.1 (SD 1.5, median 6, range 3-10). Day 4 mean scores: 5.8 (SD 1.8, median 5, range 2-9). 19 (80%) had suboptimal analgesic response to codeine (< 30% reduction in NRS).

Urine analysis conducted (n=21); 3 samples were excluded as missing/leaked. Genotype PM urine samples (9.5%) were negative for morphine metabolites on day 4; IM and EM samples ranged from low to high positive for morphine metabolites (table 3). Five samples recorded <500 ug/L morphine (23%). 80% codeine responders had high morphine metabolites. Urine morphine metabolites were grouped and scored using a novel approach similar to a gene activity score (table 4); this showed a strong correlation (0.82) to the actual genotype.

Oral transudate morphine metabolites did not correlate with genotype; 1 EM genotype produced a low positive morphine metabolite result (2.8 ug/L).

Conclusion

Prevalence of PM’s was as expected from the literature; 10% higher proportion of CYP2D6 IM genotypes were observed than expected. Genotyping is expensive and difficult to conduct in a clinical setting. Phenotyping using urine morphine metabolites is cheaper. PM status can be predicted accurately using this method. Low morphine metabolites (≤ 500 ug/L) indicate a poor analgesic response. If no CYP2D6 inhibitors are identified in concomitant medication this would clinically indicate the IM genotype. Oral transudate sampling was not effective in identifying CYP2D6 phenotype following codeine dosing. Larger study and further refinement of urine grouping methods is ongoing.

PERMALINK

Acute Pain

001 A Follow-Up Pilot Study Looking at Pain Management After Discharge, Following Major Surgery

Background

Methods

Results

Conclusion

002 A Survey on the Use of Surgical Site Catheter Analgesia in the United Kingdom

Background

Methods

Results

Conclusion

003 Improving the Quality of Analgesia After Shoulder Arthroplasty Using an Analgesic Pathway

Background

Methods

Results

Conclusion

004 Use of Targinact (Oxycodone and Naloxone) in the Management of Acute Post-Operative Pain: A Preliminary Case Series

Background

Methods

Results

Conclusion

005 Acute Neuropathic Pain: How Prevalent is it in Hospitalised Patients?

Background

Methods

Results

Conclusion

006 National Inpatient Pain Study -Using Real Time Data Collection to Measure the Quality of Inpatient Pain Service Techniques and Identify Variations in Practice

Background

Methods

Results

Conclusion

007 Examining the Effects of Perioperative Pain Management on Pain at First Waking in the Recovery Room

Background

Methods

Results

Conclusion

008 Efficacy of Patient Controlled Analgesia (PCA) for Post Operative Pain for Level 2/3 Critical Care Patients: Does Early Connection Make a Difference?

Background

Methods

Results

Conclusion

009 Pulsed Radiofrequency Electromagnetic Field Therapy for Menstrual Pain, a Double Blind, Randomized and Placebo Controlled Pilot Study

Background

Methods

Results

Conclusion

010 Do Pre-Operative Screening Questions on Pain Predict a Worse Post-Operative Pain Experience? An Exploratory Audit

Background

Methods

Results

Conclusion

011 An Audit to Evaluate the Efficacy of Transversus Abdominis Plane Blocks in Total Abdominal Hysterectomy in a District General Hospital

Background

Methods

Results

Conclusion

012 Paracetamol Dosage - Are We Prescribing Correctly? An Experience From a District General Hospital

Background

Methods

Results

Conclusion

013 Documentation of Pain Observations Following Implementation of the New Uhbristol Observation Chart

Background

Methods

Results

Conclusion

014 The Assessment of Chronic Pain After Knee Replacement: A Systematic Review

Background

Methods

Results

Conclusion

015 The Colour of Pain: Can Patients Use Colour to Describe Osteoarthritis Pain?

Background

Methods

Results

Conclusion

016 Is Confidence the Key to Accurate Paediatric Pain Assessment or Is There More We Need to Learn?

Background

Methods