Abstracts

doi:10.1177/2049463714527262

. 2014 Apr;8(2 Suppl):5–72. doi: 10.1177/2049463714527262

Abstracts

PMCID: PMC4590118

Acute Pain

001 Rectus Sheath Catheters as Part of a Multimodal Analgesic Approach For Enhanced Recovery after Open Cholecystectomy

Category: Acute Pain

Ronan Haughey, Patrick McKendry, Leonore Keenan

Mater Infirmorum Hospital, Belfast, UK

Background

Open cholecystectomy requires a substantial sub-costal incision. Simple analgesics plus patient controlled morphine (PCA) are traditionally the mainstay of post-operative pain management. This retrospective study looks at the influence of surgically placed rectus sheath catheters (RSCs) with regular post-operative levo-bupivacaine top-ups on total morphine consumption, analgesic side effects, length of stay and other ERAS outcomes.

Methods

Notes were analysed from patients who underwent open cholecystectomy in our institution between June 2012 and June 2013. Group PCA (n=23) were managed post-operatively with PCA morphine, Group RSP (n=22) were managed with RSCs and PCA, and Group RSO (n=15) were managed with RSCs and oral oxycodone. All patients also received regular intravenous paracetamol. Patients with RSC catheters who had received less than two top-ups were considered ineligible for inclusion, leaving 10 patients in Group RSP and 11 in Group RSO. Demographics (age, gender, ASA grade) were comparable between the groups. Sixteen patients in total were excluded as they had received inadequate numbers of top-ups.

Results

Average morphine consumption in the PCA group was 101.8mg (range 28-238mg). Opiate consumption was reduced markedly in the groups receiving RSC boluses, by 21.6mg (21.2%) in group RSP and 30.9 mg (25.7%) in group RSO. These figures approached statistical significance (p=0.093). PCA duration was decreased significantly (p=0.007) by a mean of 20 hrs (33.3%).

The median day of discharge for the rectus sheath catheter was 5.3 when adjusted for outliers, compared with day 6.3 for the PCA group. There were no significant differences in time to first oral solid or liquid intake.

Nausea occurred in 13% of group PCA, 70% in group RSP and 18% in group RSO. Antiemetic doses were correspondingly high in group RSP (range 0-15 doses). Constipation (28.5%) was also increased in the groups RSP and RSO compared with PCA only (13%). There were technical problems with 5/37 (13.5%) of the catheters necessitating early cessation.

Conclusion

We have be able to demonstrate that surgically placed rectus sheath catheters are a safe and effective method of managing pain following open cholecystectomy, have a demonstrable morphine-sparing effect, provide high levels of patient satisfaction (patient feedback regarding the RSC top-ups was overwhelmingly positive), and reduce length of hospital stay.

There were no issues with local anaesthetic toxicity in any of the patients who received RSCs.

002 An audit of pain documentation and prescribing practice in the acute medical setting

Category: Acute Pain

Emma Horton, Magda Niestrata

North West Thames NHS Hospital Trust, London, UK

Background

Suboptimal pain control in the acute medical setting leads to increased patient morbidity and longer hospital stays. Pain management needs to be multimodal and the easiest strategy to follow is the WHO Analgesic Ladder. The ladder advocates a stepwise approach to pain control based on patient evaluation of pain intensity with prescription of regular analgesics. In addition, omission of opioid adjuncts such as antiemetics and prescription of inappropriate analgesic administration routes compromises patient care and delays drug administration. In electronic prescribing systems, the option of prescribing a drug as multiroute affords immediate flexibility of administration of common analgesics should the patient’s requirements change. Little attention has been given to the assessment of these important parameters in the context of acute pain management on medical wards. We therefore undertook an audit of sixty medical patients in AAU to evaluate pain-prescribing practice.

Methods

We collected pain data from sixty medical admissions to AAU over the course of November 2013. We only included patients who had been admitted to AAU within the last three days and those who were experiencing new onset pain on admission. Several parameters were assessed including documentation of pain severity in the admission clerking proforma (using either a numerical scale of 1-10 or verbal descriptors of mild, moderate or severe pain), adherence to the WHO Analgesic Ladder and prescription of ‘on demand’ or regular analgesics. Additional parameters included prescription of laxatives and antiemetics with opioids and the route of analgesic administration (‘multiroute’ being the preferred).

The data was put into a database and analyzed by means of Excel.

Results

17/60 patients had no analgesia prescribed (28%). Pain severity was only recorded in 24/60 patients (40%). Only 2 out of these 24 patients were prescribed analgesia in accordance with the WHO Analgesic Ladder (8%). 17/ 24 patients described severe pain; 2 of these patients received no analgesia, and only 2 were prescribed a strong opioid (12%). In total, analgesia was under-prescribed in 16/24 patients (67%) but was never overprescribed.

Analgesics were prescribed as multiroute in 16 out of the 43 patients who received analgesia (37%). Nearly half of patients with analgesics prescribed (19/43) were given ‘on demand’ analgesia alone, as opposed to regular analgesics or a combination of the two. 43% of patients receiving an opioid were prescribed an antiemetic and only 10% were prescribed a laxative. The most commonly prescribed analgesics were paracetamol (66% of patients) followed by tramadol (30% of patients).

Conclusion

Pain severity is infrequently documented and doctors do not adhere to the analgesic ladder: analgesia is often prescribed as ‘on demand’ only, and is under-prescribed, especially in cases of severe pain. This may be because junior doctors are unfamiliar with strong opioids and are reluctant to prescribe them due to a fear of side effects. In addition, analgesics are seldom prescribed as multiroute and antiemetics and laxatives are rarely prescribed alongside opioids. Further interventions are required to improve analgesic prescribing practice on medical wards, such as educational sessions for foundation doctors and addition of pain assessment sections to clerking proformas.

003 The influence of an acute pain service on the quality of postoperative pain management in Jordan: a comparative case study

Category: Acute Pain

Atef Al-Tawafsheh^1,2, Linda East¹, Nick Allcock³

¹The University of Nottingham, Nottingham, UK, ²Hamad Medical Corporation, Doha, Qatar, ³Glasgow Caledonian University, Glasgow, UK, ⁴University College London Hospitals, London, UK

Background

In the 1990s, many professional bodies recommended the establishment of acute pain services (APSs) to improve the quality of postoperative pain management^1-2. Following these recommendations the number of APSs increased dramatically worldwide. A nurse-based, anaesthetist-supervised APS has recently been developed in one of Jordan’s teaching hospitals to promote effective postoperative pain management in surgical wards. This service is the first of its kind in Jordan, thus providing an interesting and timely opportunity to explore the influence of an APS on the quality of postoperative pain management and the experience of postoperative patients, as compared to a similar hospital that has yet to develop this service.

Methods

A comparative case study was performed over a period of three months involving two Jordanian hospitals, one of which has an established APS (Hospital-A), and one which does not yet have such a service (Hospital-B). Fifty adult in-patients from each hospital who underwent elective major surgery completed the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) questionnaire at 24 hours after surgery³. SCQIPP comprises 14 items in four subscales (communication, action, trust and environment), three questions concerning pain intensity level, and two complementary questions regarding patient satisfaction. Local Ethics Committee approval from both hospitals was obtained prior to the start of the study. Written informed consent was given by all patients who participated in the study. Data was analysed Using SPSS version-18. Mann-Whitney U and Chi-Square tests were appropriately used to analyse the data.

Results

The total SCQIPP scores for both hospitals did not reach the ‘high quality of care’ threshold score of 63 suggested by Idvall et al. (2002)³. Patients in hospital-A reported a significantly higher quality score in the total scores, and in the subscales of communication and action (P < 0.001). There was no significant difference in the subscales of trust (P = 0.927) and environment (P = 0.344) or in the patient satisfaction scores (P = 0.059). Patients in hospital-A also reported significantly lower pain intensity scores (P < 0.001).

Conclusion

Although patients were satisfied with their care in both hospitals, our findings suggest that that the presence of an acute pain service is associated with better managed pain experience and a higher quality of patient care. Regular pain assessment and preoperative information were found to be the key areas in which the acute pain service had an impact. Additional research is needed to validate the high quality of care threshold demanded by the SCQIPP particularly in countries with developing health care systems.

004 Catheter Wound Infusion of Local Anaesthetic Is an Effective Alternative to Epidural Analgesia in Vascular Patients Undergoing Lower Limb Amputation for Peripheral Vascular Disease

Category: Acute Pain

Jamie Douglass, Nicola Pawley, Allen Pinto, Lorraine Robinson, Alasdair Strachan, Donald Graham

Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, South Yorkshire, UK

Background

Epidural analgesia is considered the gold standard for postoperative analgesia following lower limb amputation. However, contra-indications including coagulopathy, anti-platelet agents and sepsis are common.

Optimal analgesia may reduce the physiological consequences of severe pain, and the incidence of chronic pain syndromes following amputation.[i]

Patients without epidural analgesia rely upon systemic analgesia, including strong opioids, which may be suboptimal and may produce significant side effects.

Catheter Wound Infusion (CWI) of local anaesthetic agents may both improve patients’ analgesia and reduce opioid analgesic requirements.

At Doncaster Royal Infirmary, wound catheters are placed intra-operatively for post-operative infusion of local anaesthetic following lower limb amputation if epidural analgesia is contraindicated.

We have compared the relative efficacy of CWI and epidural analgesia using follow up data from patients undergoing lower limb amputation for peripheral vascular disease between September 2011 and November 2013.

Methods

Between August 2011 and November 2013 the Acute Pain Team followed up all patients undergoing wound catheter placement intra-operatively for continuous local anaesthetic infusion (0.25% bupivicaine at 5ml/hr) post-operatively for 3 days.

A proforma was used to collect data relating to daily pain scores, adjunctive analgesic use and side effects.

CWI patients continued their pre-operative analgesic regimen, with the addition of enteral strong opioid analgesia. A standardised protocol was used to adjust doses where strong opioid analgesic use had been instituted pre-operatively.

The data were collated and comparison made with data obtained for a cohort of patients receiving epidural analgesia with continuous infusion of 0.1% bupivicaine and fentanyl 5 micrograms/ml for lower limb amputation during the same period.

A four point pain scale was used (1-no pain, 2-mild, 3-moderate and 4-severe pain).

Only patients with complete follow up data for the first 3 post-operative days were included.

Results

15 CWI patients had sufficient data available for inclusion (5 AKA, 8 BKA, 2 through knee amputations). Comparison was made with data for 10 epidural patients (6 AKA, 4 BKA).

Mean daily post-operative pain scores were lower in the epidural cohort (1.3 vs. 1.1, 1.2 vs. 0.2, 0.9 vs. 0.4 on days 1, 2 and 3 post-operatively).

However, a comparable proportion of CWI and epidural patients had mild or no pain post-operatively (66% vs 60%, 73% vs. 100% and 86% vs. 90% on days 1, 2 and 3 respectively).

Postoperatively 20% and 6% of CWI patients had periods of severe pain on postoperative days 1 and 2, compared with none in the epidural group

There were no documented complications in either group.

Conclusion

Whilst epidural analgesia remains the gold standard for the management of perioperative pain in patients undergoing major lower limb amputation for peripheral vascular disease, CWI analgesia may be comparable in many respects.

Where epidural analgesia is contraindicated, CWI provides a valuable adjunct to systemically acting analgesics, and may both improve analgesia over systemic agents alone and reduce strong opioid requirements.

CWI of local anaesthetic with supplementary systemic analgesia is therefore an effective alternative to epidural analgesia where contraindications to epidural analgesia are present.

005 Ionsys® (Iontophoretic Transdermal Fentanyl) For Post-Operative Pain Control Improved Mobilisation and Resulted In Higher Nurse Ease Of Care And Patient Global Assessment Ratings Compared With Morphine Iv Pca

Category: Acute Pain

Kuang-Yi Chang, Richard Langford

Pain and Anaesthesia Research Centre, St Bartholomew’s Hospital, London, UK

Background

The self-contained, adhesive, fentanyl HCl iontophoretic transdermal on-demand drug delivery device (IONSYS®) has been used to manage acute moderate to severe post-operative pain requiring parenteral opioid analgesia. IONSYS and IV PCA have demonstrated equivalent pain control in several published studies; however, more patients rated their overall satisfaction as “excellent” when treated with IONSYS. Greater patient satisfaction may be attributed to a number of benefits of IONSYS, including the ability to mobilise more effectively during post-operative pain management. The primary objective of the current study was to demonstrate the superiority of IONSYS over morphine IV PCA with regard to the patient’s ability to mobilise during the management of acute moderate to severe post-operative pain in patients who had undergone orthopaedic (unilateral primary total hip arthroplasty) or major abdominal (abdominal hysterectomy) surgery.

Methods

In this multicentre, open-label, active-controlled, prospective phase IV study (funded by Janssen Cilag EMEA), patients (following abdominal hysterectomy or unilateral primary total hip arthroplasty) received IONSYS (fentanyl 40 mcg over 10-minutes during which device is locked out), or morphine IV PCA (up to 30 mg morphine per 2 h) following initial titration with IV morphine to a pain score ≤4 out of 10 on a numeric rating scale. The primary efficacy measure was ability to mobilise, assessed using patient responses to three validated questions regarding mobility on a 6-point Likert scale. Secondary assessments included pain intensity, nursing ease-of-care, fitness for discharge, patient global assessment of pain control, amount of treatment delivered, usage of rescue medication, anti-emetics, and non-opioid analgesics, and adverse events.

Results

Demographic characteristics were similar between patients in the IONSYS and IV PCA groups. Overall, 72% of the 108 recruited patients underwent orthopaedic surgical procedures and 28% underwent major abdominal procedures. IONSYS patients had a greater ability to mobilise at the time of stopping study drug, with an adjusted mean (95% confidence interval [CI]) of 0.14 (-0.19, 0.47) for IONSYS patients and 2.37 (1.98, 2.76) for morphine IV PCA patients (p<0.001). Nurses reported better ease-of-care ratings for patients treated with IONSYS (p<0.001) than for morphine IV PCA. Other measures such as patient global assessment, mean pain ratings at 24 and 48 hours, as well as the median time to fitness for discharge, trended towards a benefit for IONSYS compared to IV PCA. Commonly occurring adverse events were similar between groups.

Conclusion

IONSYS was generally well tolerated in these post-operative pain settings, meeting the primary objective (significantly) with better ability to mobilise, and secondary objectives trending towards better nursing ease-of-care ratings, and patient global assessments of pain control than morphine IV PCA. While not reaching statistical significance for the secondary objective of ‘fitness for discharge’ (due to lower than planned enrolment), improved mobility with IONSYS may offer potential clinically meaningful benefits for patients, while also addressing the challenge of achieving accelerated recovery and earlier fitness for discharge.

006 Peri operative pain management: an audit of patient satisfaction

Category: Acute Pain

Christine Waters, Dawn Pretty, Alison Morris, Heather Riggs, Patricia Harris, Jane Sainsbury, Johanna Hunter, Patricia Mills, Nicholas Levy, Aligail Hallett, Nigel Penfold

West Suffolk NHS Foundation Trust, Bury St Edmunds, UK

Background

Patient satisfaction is an important measure of outcome in health care which can be used to drive quality improvement.

We based a patient satisfaction questionnaire on work presented at the International Study of Pain World Congress in 2008¹ and the pain management sections of The Royal College of Anaesthetists (RCoA) Audit Recipe Book (sections 11.2,11.4,11.5 and 11.8)².

Aim: To obtain patients’ experiences of the quality of peri operative pain management

Methods

Setting: English District Hospital

Approval: Organisational

Sample: 125 post surgical in-patients were recruited into the audit

Inclusion criteria: Elective or emergency orthopaedic, gynaecological or general post-surgical

Data retrieval strategy: Retrospective audit undertaken between 2012 and 2013

Data Sources: Paper based patient questionnaire prior to discharge

Results

125 patients returned the questionnaire. The Results revealed that compliance with the audit indicators varied between 51.2% and 97.6%. Overall, 90 % of patients rated satisfaction with their pain management to be good to excellent.

Conclusion

Despite suboptimal Results particularly relating to quality of patient information, overall 90 % of patients perceived their pain management to be good to excellent.

We plan to establish a interdisciplinary working group consisting of preadmission, anaesthetic, surgical and pain services to agree on recommendations for quality improvement with a focus on patient information.

We feel that the development of a national validated patient reported outcome measure questionnaire for perioperative pain management would be beneficial to assist with benchmarking of in- patient pain services.

007 Patient Compliance with Post-Operative Analgesia

Category: Acute Pain

Nisreen Fahmy^1,2, Julian Siah^1,2, Richard Gordon-Williams^1,2, Joanna Umo-Etuk^1,2

¹Barking, Havering and Redbridge University Hospitals NHS Trust, Queen’s Hospital, Romford, UK, ²Barking, Havering and Redbridge University Hospitals NHS Trust, King George Hospital, Ilford, UK

Background

Pain is the commonest reason for delayed discharge and readmission post-day surgery with 30% of patients reported to suffer moderate to severe post-surgical pain 24 hours post-discharge (1). The importance of post-surgical pain management extends beyond the acute phase when one considers that all chronic post-surgical pain was once acute. Although much focus is given to perioperative analgesia, a patient’s pain management once discharged can be overlooked. Importantly, the operation may stay the same but the patient changes along with their individual subjective experience of pain. Furthermore, once discharged a patient’s pain management is within their own hands. Hence not only is it vital to prescribe procedure- and patient-specific analgesia, but it is also important to educate and empower them with the ability to manage their own pain. Our study reviewed patients’ experience of pain management following discharge after day surgery in terms of effectiveness and compliance with prescribed analgesia.

Methods

This study was conducted in a multi-site trust in East London. Day Case adult patients were recruited over both sites of the trust between the 21^st October and 9^th December 2013. Potentially suitable patients were identified and their consent to be contacted at home post-operatively was gained pre-operatively. Data was then collected on the nature of the operation, intra- and post-operative analgesia administered and discharge analgesia prescribed. Patients were then contacted at home by telephone 48 hours after discharge and asked: (1) if they had experienced any pain following discharge, (2) if they received discharge analgesia from the hospital, (3) if they had been compliant with the analgesia and (4) if that analgesia had been adequate to manage their pain. The patients were also given the opportunity to feed back any comments they had with regards to their perioperative pain management.

Results

One hundred and fifty patients were recruited into the study, but 50 patients were lost to follow up. Out of the remaining 100 patients, 68% of patients reported pain following discharge with 35% reporting moderate to severe pain (i.e. a pain score of ≥6) and an overall median pain score of 5 and range of 0-9. Furthermore, 28% of patients were not prescribed and dispensed analgesia. For the 72% who were prescribed and dispensed analgesia, 83% of them were compliant with their prescription. These patients rated the efficacy of the analgesia they received as: less than adequate (27%), adequate (47%) and more than adequate (20%). The level of satisfaction reported differed in the cohort who had analgesia prescribed by the surgical team when compared to those prescribed by anaesthetist. The significance of this observation is yet to be determined.

Conclusion

Our findings support previous studies which suggest that moderate to severe post-discharge pain is prevalent in approximately 30% of Day Case surgical patients and a third of patients who were prescribed analgesia experienced less than adequate pain relief. In the face of significant advances in post-operative pain management, we hypothesised that this poor analgesia could be a result of poor patient compliance. However, our findings do not support this. We conclude that the level of dissatisfaction with post-operative analgesia may be improved by providing procedure-specific pain management education to both prescribers and patients, empowering patients to utilise optimal analgesia.

008 A Snapshot Audit of Pain Assessment and Management In A Tertiary Hospital In Qatar

Category: Acute Pain

Atef Al-Tawafsheh^1,2, Wael Saleem¹, Brigitta Brandner², Nick Scott¹

¹Hamad Medical Corporation, Doha, Qatar, ²University College London Hospital, London, UK

Background

Effective pain management in acute hospitals is fundamental to patients’ quality of care. The Joint Commission (JCI) mandates that patients have a right to appropriate assessment and management of pain, observing that many patients suffer severe postoperative pain in surgical wards without referral to the acute pain service (APS). Hamad Medical Corporation (HMC) has recently appointed consultant anaesthetists and a clinical nurse specialist to improve the quality of pain management at Hamad General Hospital (HGH). This audit was designed to assess the current practice of pain assessment and management prior to the introduction of key improvement initiatives.

Methods

We performed a snapshot audit over one day. All patients in the 9 surgical wards were included except patients who were unable to communicate effectively. Patients were asked to rate their current pain on a 100 mm point VAS (0 = no pain and 100 = worst possible pain). The most recent documented pain scores were taken from the patients’ medical file. Analgesia prescribed and received in the last 12 hours was documented. Information about surgery, days after surgery, mobilization out of bed and whether seen by the APS were also documented. Data recorded were entered into a database and analysed using Excel.

Results

A total of 164 patients were included in the audit. Specialities were classified as Orthopaedic (29%), General (29%), Urology (13%), Neurosurgery (8%), Vascular (25) and others (19%). The mean current pain score was 20.2 and the mean documented was 5.3. The percentage of patients who reported moderate or severe pain (>30mm) was 23% compared to 5% documented on the files.

Medications most commonly prescribed paracetamol (73%), Celecoxib (17%), morphine SC (15%), tramadol (15%), pethidine IM (6%), diclofenac (6%) and no medication prescribed for 7%.

Patients most commonly received paracetamol (37%), Celecoxib (19%), morphine SC (7%), tramadol (6%), pethidine IM (6%), and diclofenac (4%). Epidural and PCA were rarely given (1%), although available. 37% of patients did not receive medications.

The mean hospital stay since surgery was 11.4 days. 15% of patients were still on bed rest. Only 2% of patients were referred to the APS.

Conclusion

This audit highlights that postoperative pain management at our hospital can be improved. Currently, PCA and epidural guidelines and acute pain protocols are under process for approval. In addition, the PCA and epidural infusion pumps purchasing is under process. The APS programme of teaching staff about acute pain assessment and management, PCA and epidural analgesia as well as awareness sessions of the APS is ongoing. Support and education to facilitate the introduction of these programmes are taking place by the APS. This audit will be repeated in 6 months time to assess the impact of these changes.

009 Does perioperative spinal diamorphine improve patient pain outcomes and satisfaction scores after open midline general surgical laparotomy?

Category: Acute Pain

Lenny Ng, Alison Moss, Pallavi Dasannacharya, Rozanna King, Tanya Carr, Mairi-Clare Macleod, Melissa Mellis, Caroline Keighley-Elstub, Sonia Mongia, Jeremy Cashman

St George’s NHS Trust, London, UK

Background

The main Methods of pain relief after open midline general surgical laparotomy are epidural analgesia or patient controlled analgesia (PCA). The use of epidural analgesia has been declining in recent years due to a combination of surgical and anaesthetic techniques. Spinal diamorphine, which is thought to be a safer neuraxial technique compared to epidural, is increasingly being used as an alternative.

Effective pain relief is important in the recovery of the surgical patient and spinal diamorphine may be used as part of a multimodal technique in combination with PCAs.

Methods

This was a prospective survey from January to July 2012 involving all general surgical patients who underwent midline laparotomy. The anaesthetic charts were examined and two groups of patients were identified:

Group SD - patients who received spinal diamorphine as part of their pain management in addition to morphine PCA.

Group NSD - patients who received morphine PCA only.

All the patients were followed up by the Acute Pain Team for 4 days postoperatively and the following data was collected for each patient: age, gender, morphine use (first 24 hours and total), duration of PCA use, pain scores, analgesic failures (pain scores ≥2 on two consecutive occasions), incidence of ileus and patient satisfaction with postoperative pain control (scored “as expected”, “better than expected”, or “worse than expected”)

Results

The sample size was 58 comprising 24 in the SD group and 34 in the NSD group. The demographics of the groups were comparable. The mean values for 24hr morphine consumption were: SD 35.2mg and NSD 52.2mg, and for total morphine use: SD 67.7mg and NSD 100.2mg. In addition the SD group utilised the PCA for a shorter duration; the mean total duration of PCA use was 2042 minutes in SD group and 3198.9 minutes in the NSD group. The incidence of ileus was less in patients who received spinal diamorphine (4%) compared to patients who received only morphine PCA (11.7%) for postoperative analgesia.

There was an increased satisfaction rate in the SD group with 87.4% of patients reporting their pain “as expected” or “better than expected”, compared to 73% of patients who received PCA only.

Conclusion

Spinal diamorphine reduced both the first 24hr consumption as well as total morphine use. Patients who received spinal diamorphine needed PCA for a lesser number of days and also had a reduced incidence of ileus, both of which would contribute to the enhanced recovery programme for these patients. Patient satisfaction was higher with this technique than with PCA alone. We would therefore recommend anaesthetists and surgeons to consider spinal diamorphine as part of a multimodal technique for perioperative pain relief in patients undergoing open midline general surgical laparotomy.

010 Investigating Pain after Orthopaedic Surgery – The Importance of Asking the Right Question

Category: Acute Pain

Natasha Rall¹, Mark Rockett²

¹University of Plymouth, Plymouth, UK, ²Department of Anaesthesia, Derriford Hospital, Plymouth, UK

Background

Acute pain following surgery is common and a significant risk factor for persistent post-surgical pain (PPP). Analgesia for elective orthopaedic surgery continues to evolve following the introduction of “enhanced recovery after surgery” protocols. The impact of these techniques on acute and chronic pain has yet to be assessed. This poster presents the Results of an audit to determine the incidence of pain following elective and emergency orthopaedic surgery. The findings of the audit have highlighted the importance of the exact wording of pain assessment questions in patient interviews for research purposes. Following this audit, we will investigate the effect of multiple biological and psychological factors on the prevalence and severity of short and long-term pain following elective orthopaedic surgery using a case-control paradigm (the 4P study).

Methods

Potentially eligible patients were identified from orthopaedic operating lists on the morning of surgery over a 4 week period. Participants were approached on post-surgical day one. They were asked “what was your worst pain score on movement since surgery”. Two pain scales were assessed for acceptability. Either a verbal rating scale (VRS) of none, mild, moderate or severe or a numerical rating scale (NRS) of 0-10; with 0 indicating no pain and 10 indicating the worst pain imaginable were employed. Patients with moderate or severe pain on the VRS or scores ≥4 on the NRS were identified as cases and patients with no/mild pain, controls. The sensitivity of this method of identifying cases and controls was compared to previous published data.

Results

The VRS is used routinely in our trust, however patients in this study preferred to use the NRS. Of the 130 patients identified, 73% (95) were assessed. 12 patients declined to be interviewed and 23 were not available. Of the assessed patients 75% (72) had elective surgery. Of these, 54% (39) were male with a mean age of 58yrs. The mean age for female elective patients was 63yrs. 74% (29) of all females presented with significant pain in comparison to 54% (18) of males. For trauma patients the mean ages were lower: 60yrs for females and 41yrs for males. The trauma patient group included 60% (14) females and 40% (9) males. In this group, 64% (9) of females presented with significant pain and 55% (5) of males. Overall, 65% (47) of the elective patients and 60% (14) of the trauma patients experienced significant pain on movement since surgery.

Conclusion

Significant pain on movement occurred in 60% of patients following orthopaedic surgery. A recent study revealed a prevalence of 36% for significant pain in a similar cohort of patients when asked “what was your average pain on movement over the last 24 hours”. It would seem that the “worst pain on movement in the last 24 hours” is too sensitive a measure to be helpful in identifying patients with significant post surgical pain problems at risk of PPP. Subsequently, application of the modified question: “what is your average pain score since surgery” has revealed a 33% incidence of significant pain.

011 A Survey of the Peri-Operative Use of Sustained (Prolonged) Release Strong Opioid Analgesics In The UK

Category: Acute Pain

Kuang-Yi Chang¹, Alex Darbyshire², Richard Langford¹, Bernadette Ratnayake³

¹Pain and Anaesthesia Research Centre, St Bartholomew’s Hospital, London, UK, ²St Georges Hospital Medical School, London, UK, ³Kingston Hospital NHS Trust, Surrey, UK

Background

Albeit unlicensed, subject to a warning or even absolutely contraindicated, there is anecdotal evidence of increasing use and clinical claims for benefit of oral and transdermal prolonged release strong opioid analgesics in the early post-operative setting, in previously ‘opioid naïve’ patients. This survey aims to investigate the frequency and various aspects of the postoperative use of prolonged release analgesics currently in the UK, with a particular focus on fentanyl transdermal patches. For the latter, the ‘Summary of Product Characteristics’ states that they are: “contraindicated in acute or postoperative pain because there is no opportunity for dosage titration during short term use and the possibility of serious or life-threatening respiratory depression”.

Methods

A paper questionnaire survey was conducted during a national scientific anaesthetics meeting held in the UK in November 2013. The questionnaire contained five questions regarding the use, dosage and timing of oral and transdermal strong opioids in the early post-operative setting, and the types of surgery. Descriptive statistics were used to summarise the Results.

Results

Of the 94 participants who returned the questionnaire, 71 (75.5%) reported use of prolonged release strong opioid analgesics in the acute post-operative setting. Use following major orthopaedic surgery predominated, often following neuraxial block or PCA. The 71 affirmative responses revealed that the most commonly employed sustained release opioids were: oxycodone in 57 centres (80.3%), morphine in 19 centres (26.8%), and transdermal fentanyl in 13 centres (18.3 %). In ten of these 13 centres, the respondents reported routine use of transdermal fentanyl patches following total knee or hip replacement. The most commonly used fentanyl dosages were 12 and 25 mcg/hr, although two respondents reported use of 50 mcg/hr. In most cases, the transdermal fentanyl patches were applied postoperatively in the first 24 hours, but two respondents reported pre-operative application. Buprenorphine patches were used in two centres.

Conclusion

This paper questionnaire survey confirms that the use of oral and transdermal sustained (prolonged) release strong opioid analgesic in the acute post-operative setting is becoming common in the UK. Given previous experience and reported safety concerns over PCA Background opioid infusions, there is a case for urgent auditing, study and evaluation of the risk:benefit profile of this unlicensed and controversial use, with particular attention given to monitoring the safety of transdermal fentanyl in previously opioid naïve postoperative patients.

012 Audit of Perioperative Pain Management of Proximal Femoral Fractures at Blackpool Victoria Hospital

Category: Acute Pain

Andy Yuet Meng Ng, Christopher Dunkley

Department of Anaesthesia, Blackpool Victoria Hospital, Blackpool, Lancashire, UK

Background

Proximal femoral fractures present unique challenges for anaesthetic departments in the NHS. This involves the perioperative care of large numbers of older patients with signiﬁcant comorbidities despite guidance since the early 1990s concerning best practice management for these vulnerable patients, there remains considerable variation in models of peri-operative care, rehabilitation and orthogeriatric input. AAGBI together with Age Anaesthesia Association, British Orthopaedic Association and the College of Emergency Medicine released guidelines in 2011 to focus on the acute hospital episode, particularly the pre-operative period, intra-operative management and immediate postoperative phase. The audit focuses on the recommendations related to perioperative analgesia. The recommendations are

Avoid opioid analgesics as the sole adjunct to anaesthesia
Peripheral nerve blockade should be considered as adjunct to spinal or GA
Either spinal anaesthesia or general anaesthesia is administered
Co-administration of intrathecal opioids: fentanyl is preferred to morphine/diamorphine
Regular paracetamol prescribed
Codeine should not be administered

Methods

A retrospective audit was conducted over a 3 month period from March to May 2013. . Data was collected via patient notes including anaesthetic charts and prescription charts. Patients with proximal femoral fractures who underwent surgical repair of the fracture were recruited. A proforma was used to gather the relevant data. This included demographic data, type of anaesthesia, use of opioids and route of administration, peripheral blocks used and post-operative analgesia prescribed.

Results

60 patients were recruited during the period. 52 patients underwent surgical fixation with spinal anaesthesia and 8 patients had general anaesthesia. Heavy bupivacaine 0.5% were used in all spinals. Mean volume was 2.748 ml.14 spinals were administered with intrathecal diamorphine. 38 spinals were administered with no adjuvants. There was no combined spinal/ general anaesthesia recorded. 22 patients had a peripheral nerve blockade performed, 20 had a fascia illiaca block and 2 had a femoral nerve block. All GA patients had a peripheral nerve block performed. 14 out of the 38 who had spinal anaesthesia had a peripheral nerve blockade. Postoperative, all patients had paracetamol prescribed. 54 patients were prescribed strong opioids. 9 patients were prescribed codeine or dihydrocodeine. All GA patients had fascia illiaca block./ 52 spinal patients; 12 had fascia illiaca block, 2 with femoral nerve block

Conclusion

This was the first audit done in Blackpool which were based on the latest guidelines from AAGBI. The majority of patients had spinal anaesthesia which is common practice locally. Diamorphine remains the preferred choice of adjuvant instead of fentanyl which is recommended. There was a low rate of peripheral nerve blockade performed. Codeine was still prescribed in a small number of patients. The Results were presented at a joint anaesthetic-orthopaedic department meeting. Greater awareness of the guidelines will increase the use of peripheral nerve blockade and avoiding use of codeine. A re-audit is planned within the next 12 months.

Assessment & Measurement

013 A Cross-Sectional Survey of Chronic Pain-Related Attitudes and Beliefs Among Physiotherapy Students

Category: Assessment & Measurement

Senthil Paramasivam Kumar^1,2, Umasankar Mohanty², Vaishali Sisodia¹

¹Srinivas College of Physiotherapy and Research Centre, Mangalore, India, ²Manual Therapy Foundation of India, Mangalore, India

Background

Studies have documented that health care professionals are inadequately prepared to care for patients in chronic pain. Several reasons have been identified including inadequacies in education, absence of curriculum content related to pain management, and attitudes and beliefs related to chronic pain. Physiotherapists play an integral role in pain management in terms of facilitating symptom control, improving functional independence and enhancing quality of life. This study aimed to evaluate the chronic pain-related attitudes and beliefs among physiotherapy students so as to explore the biomedical or behavioural orientation for chronic pain in formative/developing stage as a pain management team professional.

Methods

International cross-sectional survey of 212 physiotherapy students who participated in four professional conferences from 2009-2012 was performed using Chronic pain attitudes and beliefs scale (CPABS)- a self-report questionnaire with 31 items (statements about pain) for each of which the person had to indicate the level at which he or she agreed or disagreed with each statement using a five-point Likert scale. Factor-1 score indicated a biomedical dimension while factor-2 score indicated a behavioural dimension to pain. Comparisons across individual and professional variables for both dimensions were done using one-way ANOVA and correlations were done using the Karl–Pearson co-efficient using SPSS version 16.0 for Windows (SPSS Inc, Chicago, IL).

Results

The overall factor 1 score was 57.91 ± 8.44 and factor 2 score was 22.24 ± 5.64 (P = 0.00). The female students had a higher behavioural dimension score (27.6 ± 3.13) than their male counterparts (17.56 ±2.66) which was found significant at P < 0.05 level. There was also zonal differences in responses (p > 0.05) indicating a geographical influence on their perceived dimension of chronic pain.

Conclusion

Physiotherapy students had a greater orientation toward the biomedical dimension of chronic pain than the behavioural dimension. This difference was more pronounced in female students and, in those from developing countries. The study findings have important curricular implications for physiotherapy and practical implications for pain education and management.

There is need for future studies in physiotherapy professionals, multidisciplinary perceptions, and evaluation of pain-related attitudes and beliefs across the globe.

014 Distribution of Pelvic Floor Muscle Trigger Points in Vulvodynia

Category: Assessment & Measurement

Fiona Hart, Dympna Sherry, Rachael Matthews, Winston de Mello

Pelvic Pain Clinic, UHSM, Manchester, UK

Background

Vulvodynia has been defined by the International Society for the Study of Vulvovaginal Diseases (ISSVD) as vulval discomfort, most often described as a burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder. Patients can be further classified by the anatomical site of pain (e.g. generalised vulvodynia, hemivulvodynia, focal vulvodynia, clitorodynia) and also by whether pain is provoked or unprovoked.

Methods

Following tertiary referral, 17 consecutive patients with vulvodynia underwent pelvic floor muscle assessment by the pelvic pain physiotherapist to establish the distribution of trigger points.

Results

Of the 17 patients, 2 had no trigger points. None of the 9 patients with generalised vulvodynia had provocative factors but in contrast 6 of the 8 (75%) patients with focal vulvodynia had one or more provocative factors such as penetrative intercourse or insertion of internal tampons.

The remaining 15 patients had trigger points distributed as follows: iliococcygeus (86.6%), pubococcygeus (80%), puborectalis (50.3%) and ischiococcygeus and obturator internus both with 26.7% There was no difference in ranking if the groups were analysed as either having generalised or focal vulvodynia.

Conclusion

The majority of patients with vulvodynia are likely to have trigger points in their pelvic floor muscles ranked in descending order: the iliococcygeus, pubococcygeus and puborectalis. These need attention by the physiotherapist as part of a multimodal approach to the management of vulvodynia.

015 Development and Validation of The Keele Musculoskeletal Patient Reported Outcome Measure (Msk-Prom)

Category: Assessment & Measurement

Jonathan Hill, Elaine Thomas, Susan Hill, Nadine Foster, Danielle van der Windt

Keele University, Staffordshire, UK

Background

Evidence for the benefits to clinical services from gathering patient reported outcome measure (PROM) data to evaluate quality of healthcare and monitor progress over time is growing. However, practical, brief clinical tools for this purpose within musculoskeletal health are lacking. We aimed to develop and validate a musculoskeletal PROM (MSK-PROM) to add to the widely used EQ5D-5L quality of life measure that was suitable for evaluating care and also monitoring patient progress within community healthcare settings.

Methods

There were two phases; development and validation. In Phase 1 two consensus workshops (to identify and prioritise the key domains for inclusion in the tool), an online consultation survey with relevant stakeholders, and two face validity workshops to test the readability and comprehension of the draft tool were used. In Phase 2 we tested the reliability and responsiveness of the draft tool with a prospective cohort of adults attending musculoskeletal physiotherapy services in the West Midlands region, and discussed acceptability and feasibility with samples of participating patients and clinicians.

Results

Eleven key MSK-PROM domains were prioritised: independence, physical function, worst symptom severity, pain, work interference, activities and roles, quality of life, understanding, anxiety/depression, and overall impact. Items from the EQ-5D-5L mapped to five of these domains and six additional new single items were developed.

425 patients with musculoskeletal pain completed the MSK-PROM at every physiotherapy visit (88% had a completed MSK-PROM for at least 1 follow up), and 225 (53%) responded to three month follow-up. The 11-item MSK-PROM had excellent reliability (ICC=0.98 (95%CI 0.96 - 0.98) and showed superior responsiveness compared to EQ-5D-5L (MSK-PROM: standardised response mean: 0.66 vs 0.44, AUC: 0.81 vs 0.74). The feedback workshop confirmed the tool was acceptable and feasible to patients and clinicians.

Conclusion

A new PROM has been developed using domains that matter the most to musculoskeletal patients, clinicians and service managers, and has been shown to be valid and reliable for use in musculoskeletal physiotherapy practice. The Keele MSK-PROM tool will be made freely available for clinical use.

016 The Role of Pain Catastrophising In The Distorting Effect Of Negative Expectancy On Pain-Positive Cues

Category: Assessment & Measurement

Abeer Almarzouki, Christopher Brown, Richard Brown, Anthony Jones

University of Manchester, Manchester, UK

Background

In our previous work, we were able to experimentally prove a clinical phenomenon in which prior negative expectancies about a given positive suggestion will reduce its efficiency 1. We also found that this effect was positively correlated with pain catastrophising scores, i.e., pain ratings in the prior negative expectancy condition were positively correlated with scores on the pain catastrophising scale. For this reason, we suggested that, compared to low catastrophisers, patients with high pain-catastrophising scores may be more affected by negative expectancy suggestions even if these suggestions were subsequently violated by more positive ones. Pain catastrophising may be the mechanism in which prior negative expectancy has its distorting effect on positive messages.

In our current study, we aim to explore this relation further, by investigating to what extent catastrophising influences the effect of prior negative expectancy cues on a given pain stimulus.

Methods

Initial screening and volunteer recruitment: This screening was aimed to recruit two groups of high vs. low catastrophisers. This was done by asking the initial participants to complete the pain catastrophising scale (PCS)2. Participants scoring in the upper 25% (high catastrophisers) and the lower 25% (low catastrophisers) are selected. 22 Low catastrophisers and 11 High catastrophisers were recruited. The study consisted of 2 major sessions; each was divided to 2 small blocks in which the expectancy paradigm was applied (figure1). In the second part of the study, a distraction sensory focusing task was applied in critical trials only.

After each laser stimulus, participants rated their felt pain level on a 0-10 numerical scale. EEG recording was obtained during the study.

Results

Preliminary analysis

Pain ratings: ANOVAs analysis showed a Significant effect of expectancy with a p value 0.001, a Significant effect of task p value 0.005, and a Significant interaction effect between expectancy and task p value 0.023. No significant effect of the group was found.

EEG analysis: Laser-evoked potentials (LEPs) were generated at Cz electrodes, In the low-pain catastrophising group there was no difference between the two conditions before and after the task LEP peak (N2), while in the high-pain catastrophising group there was a reduction in the LEP peak (N2), particularly in the prior negative expectancy condition after applying the pain catastrophising manipulation task.

Conclusion

Although Analysis is still on-going, EEG Results suggest that High pain catastrophisers show a higher pain response in the prior negative expectancy condition, an effect that was significantly reduced by the distraction task and was not present in the low pain catastrophisers. This suggests that Pain catastrophising may be the mechanism in which prior negative expectancy has its distorting effect on positive messages.

017 Defining Recovery from Complex Regional Pain Syndrome: The Patients’ Perspective

Category: Assessment & Measurement

Candy McCabe^1,2, Yvette Hibberd¹, Rebecca Blight¹, Johan Marinus³, Roberto Perez⁴, Ilona Thomassen⁵, Florian Brunner⁶, Carol Sontheim⁶, Frank Birklein⁷, Andreas Goebel⁸, Richard Haigh⁹, Robyn Connett¹⁰, Christian Maihöfner¹⁰, Lone Knudsen¹¹, Norman Harden¹², Andrzej Zyluk¹³, David Shulman¹⁴, Francois Gobeil¹⁵, Helen Small¹⁶, Peter Moscovitz¹⁷

¹Royal National Hospital for Rheumatic Diseases, Bath, UK, ²University of the West of England, Bristol, UK, ³Leiden University Medical Centre, Leiden, The Netherlands, ⁴VU University Medical Centre, Amsterdam, The Netherlands, ⁵Patiëntenvereniging CRPS, Amsterdam, The Netherlands, ⁶Balgrist University Hospital, Zurich, Switzerland, ⁷University Medical Centre Mainz, Mainz, Germany, ⁸The Walton Centre,, Liverpool, UK, ⁹Royal Devon & Exeter Hospital, Exeter, UK, ¹⁰Klinikum Fürth, Fürth, Germany, ¹¹Aarhus University Hospital, Aarhus, Denmark, ¹²Rehabilitation Institute of Chicago, Chicago, USA, ¹³Pomeranian Medical University, Szczecin, Poland, ¹⁴Markham-Stouffville Hospital, Markham, Canada, ¹⁵CSSS Pierre Boucher, Longueuil, Canada, ¹⁶PARC (Promoting Awareness of RSD and CRPS in Canada), Canada, Canada, ¹⁷The George Washington University Hospital, Washington DC, USA

Background

Complex Regional Pain Syndrome (CRPS) is a chronic pain syndrome that usually develops post-trauma characterised by persistent limb pain that is disproportionate to the initiating event with signs and symptoms of sensory, motor, autonomic and trophic abnormalities. It has a significant impact on the sufferer’s quality of life with 15-20% of patients developing long-term disability and handicap. For those whose symptoms do not spontaneously resolve, long-term residual symptoms or impairment are common. This leads to problems with defining recovery from CRPS and evaluating the efficacy of therapeutic interventions in those with chronic disease. An international consortium was convened, funded via Reflex Sympathetic Dystrophy Syndrome Association and the Netherlands CRPS patient group, comprising of Patient Research Partners (PRPs), clinicians and academics to define recovery, and the priorities for recovery, from the perspective of patients with CRPS. We report here the qualitative data from the first round of a two-stage Delphi process.

Methods

Potential participants ≥ 18yrs who met Budapest diagnostic criteria for CRPS, were identified from 8 country specific databases (UK, Netherlands, Germany, Denmark, Switzerland, Poland, Canada and USA). Each received a letter of invitation, pack of self-report questionnaires and pre-paid envelope to return documentation to their country specific site. Additional recruitment was conducted via outpatient clinics within the participating centres to optimise distribution of disease duration (≤ 1 yr, 1-3yrs, ≥ 3yrs) and CRPS recovered versus non-recovered. Questionnaire packs included demographic details, standardised outcome measures to assess pain, function, mood and quality of life and an open text box asking participants to respond to the question: ‘I would consider myself recovered from CRPS if…” or ‘I do consider myself recovered from CRPS because…’. Qualitative responses to the latter two open statements were anonymised and translated as required within each country prior to sending to the UK for content analysis via NVivo.

Results

Thematically categorised qualitative responses from 33 recovered (mean age 54yrs (SD=12), 27 females, disease duration 3 ≤ 1 yr, 15 1-3yrs, 14 ≥ 3yrs), and 292 non-recovered participants (mean age 53yrs (SD=13), 234 females, disease duration 36 ≤ 1 yr, 98 1-3yrs, 154 ≥ 3yrs) were ordered under the WHO ICF Classification. The themes reported by at least 50% of respondents per country, disease duration, recovered/non-recovered, employment status, upper/lower limb and age were identified. A study sub-group including PRPs ensured consistency and agreement with the aggregated top 50% themes under ICF codes for recovered (60 items) and non-recovered (28 items) responses. The most dominant themes for recovery for participants were Activities (e.g. moving/handling objects, walking) and Bodily functions (e.g. CRPS related symptoms including pain) with External factors (e.g. medication use) and Participation (e.g. housework, preparing meals) being the next largest categories. Personal factors (e.g. anxiety, depression) were the least represented.

Conclusion

Our data suggests that patients with CRPS rate relief of their physical symptoms, participation in day-to-day tasks and engagement with work/leisure activities as important for them to potentially or actually consider themselves recovered. The psychological consequences of persistent severe pain appeared less important for our patient group. The reason for this needs further exploration. PRPs in this study proposed that psychological factors would automatically be resolved if physical function improved. Future work of this Delphi study will identify the top priorities of recovery from the thematic list and how patient demographics and current health status may influence this.

018 The Elephant in the room? Central sensitization syndrome

Category: assessment & measurement

Sapna Dhuna², Tony Davies^1,2

¹Plymouth Hospitals NHS Trust, Plymouth, UK, ²Peninsula College of Medicine and Dentistry, Plymouth, UK

Background

Central Sensitisation Syndrome (CSS) is an increasingly popular construct describing the plethora of symptoms found in nonspecific disorders such as Fibromyalgia and Chronic Fatigue Syndrome. The syndrome is also associated with other conditions such as rheumatoid arthritis, SLE, hypermobility syndrome and widespread pain syndrome. This diagnostic component is potentially overlooked when the medical referral is focussed on a specific pain complaint. The postulated pathophysiological mechanism is based on the development of central sensitisation. The importance of identifying this phenomenon was recently demonstrated in a study on shoulder impingement surgery where its presence had a significantly negative impact on surgical outcome.

A questionnaire called the Central Sensitisation Inventory has recently been developed and psychometrically validated as a screening tool to help identify the presence of the syndrome. The authors were keen to assess the potential utility of introducing this questionnaire within a specialist pain clinic.

Methods

The Central Sensitisation Inventory (CSI) was completed by all new patients attending a multidisciplinary pain management centre in South West England over a 4 week period in autumn 2013. Data was anonymised. This study was approved by the institutional R+D department.

The CSI was completed independently by each patient prior to the specialist consultation in addition to the other two questionnaires routinely used (Brief Pain Inventory and Hospital Anxiety and Depression Scale). Following the consultation, the authors scored the CSI and documented the relevant diagnoses made by the specialist. Both the specialist comments and GP referral letter were reviewed to confirm whether a Central Sensitisation Syndrome had been verified by a clinician. The authors used the threshold score of 40 to support the diagnosis of CSS as recommended by the developers of the CSI. The individual scores ranged from 0-100.

Results

148 questionnaires were processed. Two forms were rejected with incomplete documentation and inability to access to medical notes. The age range of the cohort was: 19-93, with a mean age of 50.8. 45.9% were male and 54.1% female. 23 patients (15.7%) were diagnosed by the specialist as having a CSS. A further 8 (5.5%) patients confirmed this diagnosis on the CSI but there was no independent clinical corroboration.

The CSI scores obtained ranged from: 1-90. 97 patients (66.4%) had CSI score >40. 38 patients (26%) scored >60. The mean CSI score for those clinically diagnosed with CSS was 59.8 (range 38-80). 7 patients (4.8%) had CSI scores equivalent or higher than the maximum score for patients diagnosed with CSS by a clinician in this study (range 80-90). For CSI scores <40, 14.3% had a concomitant diagnosis of depression, as opposed to 44.3% of those with a score >40.

Conclusion

The CSI demonstrated good sensitivity for patients clinically diagnosed with CSS: only 2 marginally failed to score 40. The data suggests that CSS is an extremely common presentation to this specialist clinic with clinicians typically failing to recognise its presence.

Patients with Central Sensitisation Syndrome typically have ongoing physical or emotional stressors. The concomitant diagnosis of depression is clearly more common in those positively identified. Overlooking this syndrome using a more limited clinical focus may well result in suboptimal therapeutic strategies impacting on quality of life and cost. The CSI could make this metaphorical elephant in the room more visible!

019 Role of an Opioid Review Clinic in Improving The Quality Of Care For Patients With Chronic Pain On Strong Opioids

Category: Assessment & Measurement

Usman Bashir, Lorraine Harrington, Marie Fallon, Lesley Colvin

Western General Hospital, Edinburgh, Midlothian, UK

Background

Opioid drugs have been used as analgesic medication successfully for centuries. Their use in the short or medium term has been demonstrated to provide symptomatic benefit in non-cancer pain. There has been a dramatic increase in the use of opioid for chronic non-malignant pain, with an increase of ~600% in opioids prescribed in the US from 1997 to 2007. Controversy exists about long term efficacy, particularly in view of potential adverse effects, including iatrogenic dependence, tolerance and addiction, In addition to commonly suffered side effects such as constipation and nausea, there is a greater awareness of the potential of endocrine suppression.

We have implemented a pilot opioid review clinic to allow a formal assessment of efficacy and adverse effects in individual patients on strong opioid medication. The aim of this report is to assess whether problems with opioid use can be usefully assessed using this mode.

Methods

A pilot clinic was set up and run over a period of 6 months to review patients in the Lothian Chronic Pain Service on strong opioids, referred by the relevant pain consultant. Areas assessed included review of patient’s current opioid use, overall benefit in terms of quality of life and detailed analysis of adverse effects including blood tests for endocrine monitoring.

Patients were sent clinic appointments, in addition to their routine follow up appointments. After review further management information was sent to patient’s General Practitioner and pain consultant.

Results

56 patients were offered appointments, of which 37 attended. 13/37 (35%) patients were on a transdermal fentanyl patch, 11/37 (29%) on slow release morphine; 8/37 (21%) on OxyContin and remaining on other opioids (buprenorphine, tapentadol).

13 (35%) patients were on ≥ 180 mg oral morphine equivalent (OME) dose (7 were on ≥ 300 mgs OME), whereas 24(64%) were on ≤ 180 mg OME.

Patients on OME doses of ≥ 300 mgs scored a mean of 8.1 and 6.5 for worst pain and interference with life activity on brief pain inventory respectively. Patients on OME doses of ≤ 180 mg showed almost similar scores.

Endocrine abnormalities were found in total of 12 patients (8 males, 4 females). Other side effects found were constipation (54%), drowsiness (29%), muscle jerks (18%) and hallucination and vivid dreams (10%).

Out of 37 patients seen, 30 patients had some change in management (including endocrine referrals).

Conclusion

The high intervention rate for patients on strong opioids, in addition to their routine appointments, would indicate that there is a role for this type of clinic.

Finding endocrine abnormalities in 32% patients within this cohort suggests that all patients on strong opioids should have routine endocrine blood tests. We did not find any correlation between type or dose of opioid and endocrine abnormality.

Overall it is evident from above data that by attending opioid review clinic, patients have an improved and safe quality of care delivered by health care professionals.

Cancer Pain

020 How do parents’ manage their child’s cancer-related pain at home?

Category: Cancer Pain

Alison Twycross¹, Roslyn Parker^2,1, Anna Williams³, Faith Gibson^1,3

¹London South Bank University, London, UK, ²Kings College, London, UK, ³Great Ormond Street Hospital, London, UK

Background

Children with cancer experience pain from their disease, treatment and procedures as well as psychological distress associated with cancer. Advances in treatment mean children are increasingly cared for by their parents at home during cancer therapies, leading to a shift in responsibility from healthcare professionals to parents. Little is known about parents’ pain management experiences and the aetiology of pain suffered by children with cancer especially when outside the healthcare setting. A rapid review of the literature was undertaken investigating children’s cancer-related pain, with emphasis on the management of pain outside the healthcare setting.

Methods

A rapid structured review of the literature was undertaken. Electronic databases searches (PsychInfo, CINAHL, PubMed and EMBASE) using the following search terms: child OR children OR pediatric OR paediatric, AND cancer pain. To ensure relevant papers were not missed in the database the reference list of each included article was searched. Electronic database searches were conducted for English, peer-reviewed, quantitative, qualitative or mixed Methods research articles published between 1990 and October 2013 exploring children’s cancer pain. A quality assessment was also conducted. Papers were excluded if they only investigated health care professionals’ perspectives; related primarily to the palliative phase of the disease or the effectiveness of analgesic drugs. Books, book chapters, commentaries, and dissertations were also excluded from the review.

Results

Forty-five papers were included. Most children’s cancer-related pain is a result of treatment side-effects or painful procedures. Pain is regularly cited as the most prevalent symptom. However, studies have reported on inconsistent variables and so a single prevalence figure is difficult to determine. Parents find dealing with their child in pain emotionally distressing and demanding. There is a need for better education on how to manage pain for parents. Limited research has been carried outside the healthcare setting. There is some evidence that parents’ may hold misconceptions about pain and analgesic drugs.

Conclusion

Children continue to experience pain throughout their cancer trajectory. Knowledge of children’s cancer-related pain remains sparse. There is a need to explore the prevalence of cancer-related pain in children as well as investigating parents’ attitudinal barriers to pain management and their experiences of managing pain at home. This paper has revealed methodology as well as findings that indicate further research is needed to explore parental roles and their experiences of delivering care in the home.

Education

Conclusion

027 The relationship between pain and mortality is mediated by frailty

Category: Epidemiology

Diane Smith, Ross Wilkie, John McBeth

Keele University, Keele, Staffordshire, UK

Background

Pain is common in older adults with two thirds of those aged 50 years and over reporting pain that lasts for one day or longer during a one month period. Up to 80% of pain reported in that age group originates in the musculoskeletal system. The impact of pain increases with age and may be associated with an increased mortality risk. Phenotypic frailty, a geriatric syndrome characterised by declining function across a number of physiological systems (weight loss, exhaustion, weakness, slow walking speed and low physical activity) may mediate the relationship between pain and mortality. This study tested the hypothesis that pain was associated with mortality and that this relationship was mediated by frailty.

Methods

Participants in the English Longitudinal Study of Ageing (ELSA) wave 2 (conducted in 2004, complete cases n=4372), a population-based prospective cohort study of adults aged ≥50 years, were asked to report if they were “often troubled by pain” and for those responding positively to report the severity of their pain (mild, moderate/severe). Frailty status was determined from the number of indicators calculated from measures of weight loss, grip strength, walking speed, physical activity levels and exhaustion (≥3 frail/<3 not frail). Vital status was determined up to 2012. Cox’s proportional hazard models determined mortality rate ratios (MRR) with 95% confidence intervals (CI). Path analysis tested for mediation of the association between pain and mortality by frailty. All analyses were adjusted for putative confounders age, gender, wealth and education.

Results

The mean age of the sample was 70.7 (SD 7.8) and 54.9% were female. 36.4% reported being often troubled by pain; 26.4% reported moderate/severe pain; 330 (7.6%) were frail. 790 (18.1%) participants died over the period of follow-up. Being often troubled by pain was not associated with mortality (MRR=1.13; 95% CI (0.98-1.30)). However reporting moderate/severe pain was associated with mortality (1.23 (1.05-1.44)). The strength of this association was not attenuated following adjustment for age, gender, wealth and education (1.19, (1.02-1.39)). Frailty explained 42.7% of the effect of moderate/severe pain on mortality.

Conclusion

In this study there was a relationship between moderate/severe pain and mortality and this was mediated by frailty. Strategies to prevent or reduce frailty in persons with moderate/severe pain may reduce mortality risk.

028 Population Incidence Rate of Surgical Treatments for Trigeminal Neuralgia (Tn) In The Southwest Peninsula (Devon & Cornwall)

Category: Epidemiology

Rachel Patel^1,2, Mark Taylor¹, Susan Blowey¹

¹Plymouth Hospitals NHS Trust, Plymouth, Devon, UK, ²Oxford University medical School, Oxford, UK

Background

TN is a rare severe neuropathic facial pain. The diagnosis is made from the pain history using International Headache Society diagnostic criteria of three or more episodes of brief, severe electric shock or stabbing pain which can be triggered by innocuous stimuli to the same side of the face. Although the pain is characteristic there is wide variation in the published incidence and prevalence rates. There is a tendency for other severe facial pain which could for example, be secondary to dental infection or a Trigeminal Autonomic Encephalgia to be labelled as TN.

We undertook a retrospective audit aimed at looking at the prevalence of patients undergoing trigeminal ganglion and trigeminal nerve root microvascular decompression operations at Derriford Hospital, Plymouth between 2010-2013.

These patients have a certain diagnosis of trigeminal neuralgia and allows the calculation of a population incidence rate for significant surgical treatments for Devon and Cornwall.

Methods

The established referral pathway for patients in Devon & Cornwall with possible TN and difficult pain is to Derriford Hospital either to Neurosurgery or the Pain Management Centre who work in close co-operation. This is facilitated by a local Map of Medicine referral pathway. Surgical treatment options include Trigeminal ganglion treatments and microvascular decompression (MVD), and referral for radiosurgery.

Retrospective data covering a 3 year period 2010-2013 for patients seen in the Pain Management Clinic was collected. We took demographic data such as age, sex, diagnosis, prevalent side and pain distribution. Short term outcomes of patients who had Trigeminal ganglion treatment with Thermocoagulation or glycerol injection were analysed and compared with published demographic data for TN patients. The number, age and sex of microvascular decompression and radiosurgery patients were also reviewed. The incidence rate for these procedures was calculated for the population of Devon & Cornwall over this time period.

Results

During the review period 237 new TN/facial pain patients were seen in the Pain Management Centre from the Trigeminal pathway or other referrals. Of these 143 patients had TN including with 15 having Multiple Sclerosis and TN

From 143 patient 68 patients subsequently progressed to Trigeminal ganglion treatments. Of these, none of their demographic data was statistically different (Pearson’s correlation, T tests) from published series. In addition 19 patients had MVD surgery

Sex, age: n=41 women mean 71.7, n=27 men mean 68.9yrs
Neuralgic side: Right - 62%, Left 38%
Distribution: V1 -1.5%, V2- 25%, V3 -40%, V1/2 -16% and V2/3- 16%.
Radiosurgery for TN: n=2
MVD 19 patients: n=12 women mean 55.1 n=7 men (mean 50.1)

During the 3 year study period 89 patients in total had trigeminal ganglion, microvascular decompression or radiosurgery. This is equivalent to a surgical incidence rate of 1: 18,500 population.

Conclusion

In this study 90 patients in Devon & Cornwall had significant surgical procedures or radiosurgery for TN over a three year period with a calculated surgical incidence rate of 1:18,500 population.
The surgical incidence rate may be a useful calculation and allow comparison and planning for provision of these specialised services for TN.
Limitations of study:
1. Up to 20% of patients may have been referred out of area for treatment which would increase the surgical incidence rate to 1: 15,400
2. Minor surgical peripheral nerve blocks are excluded from this study but are rarely useful for longterm TN management.

029 Prevalence of neuropathic pain in patients with diabetes using arabic leeds assessment of neuropathic sign and symptoms in derna, libya

Category: Epidemiology

Raga Elzahaf

Faculty of Medical Technology, Derna, Libya

Background

Neuropathic pain among diabetics is one of the most frequent complications of diabetes. There is a need to obtain data about the prevalence of neuropathic pain among diabetes patients in Libya to plan appropriate national pain management strategies. There have been no estimates of the prevalence of neuropathic pain among diabetes patients in Libya. The aim of this survey was to estimate the prevalence of neuropathic pain in patients with Diabetes (type 1 and 2) attending outpatient clinics and to determine the demographic factors associated with these patients.

Methods

The Arabic version of the Self-complete Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire was given to patients with diabetes from 1 Sept - 02 Dec 2013 in the Diabetic Unit in Derna. Pain intensity was measured using a visual analogue scale.

Results

A total of 223 patients agreed to participate in the survey. More women (n=126, 56.5 %) fill the questionnaire and took part in the survey than men (n=97, 43.4%) and the mean ± SD age of the sample was 54.2±12 years. The overall prevalence of neuropathic pain among diabetes patients was estimated to be 43.04% (96 of 223 respondents), (36.54% to 49.54%) (95% confidence interval) in this population. The proportion of females with NeuP was 54.8%. The mean pain intensity±SD was 7.7±1.8.

The prevalence of neuropathic pain increased with age, from 6% in the 20-29 year age group to 45.2% in the 70-79 year age group. Neuropathy was associated with the duration of diabetes, and was present in 28.9% of patients with diabetes duration less than 5 years and in 38.8% of those with diabetes duration greater than 10 years.

Conclusion

Neuropathic pain is a common complication associated with diabetes. It increases with both age and duration of diabetes. There is a need to improve management of neuropathic pain with increased use of neuropathic pain drugs.

Evidence & Guidelines

030 Service Provision for Patients with Chronic Post-Surgical Pain after Total Knee Replacement: A Qualitative Study Of Healthcare Provider Perspectives

Category: Evidence & Guidelines

Fiona MacKichan, Vikki Wylde, Rachael Gooberman-Hill

University of Bristol, Bristol, UK

Background

Total knee replacement is one of the most commonly performed elective surgical procedures. The operation is often considered an effective intervention for pain, but recent studies indicate that up to 20% of patients experience chronic post-surgical pain (CPSP) after total knee replacement; this equates to around 16,000 new cases of CPSP in the UK each year. Despite the high number of patients with CPSP after knee replacement, ongoing work within our Unit suggests that there is little standardisation in service provision, with a lack of clear clinical pathways for the identification, assessment and management of patients with CPSP. The aim of this qualitative study was to explore healthcare professionals’ views about service provision for patients with CPSP after total knee replacement to identify ways in which improvements could be designed.

Methods

Healthcare professionals in a major acute care NHS Trust with clinical experience of working with patients experiencing CPSP after total knee replacement were eligible to participate in the study. Study information was disseminated to potential participants through direct e-mails, a local professional organisation and at clinical meetings. Four focus groups with a total of 18 healthcare professionals were held. Participants included seven physiotherapists, three surgical registrars, two consultant orthopaedic surgeons, two nurses, one occupational therapist, one orthotist, one consultant pain specialist and one clinical psychologist. The focus groups were facilitated by an experienced qualitative researcher and a topic guide was used to help elicit participants’ views and experiences. Focus groups explored referral pathways and service provision for patients with CPSP after total knee replacement. With written consent from participants, focus groups were audio recorded and transcribed. Anonymised transcripts were managed using QSR NVivo 10 and analysed using thematic analysis.

Results

Analysis found that a key narrative was healthcare professionals’ view that service provision should reflect the complex and individual nature of CPSP, but that current provision was not well joined-up. Current access to services was dependent on patients taking a proactive approach and there were no clear entry points to post-surgical pain services. Treatment options were based partly on individual judgements of patients’ context and need, but also influenced by the healthcare professional’s specific specialism or service, and knowledge of available services and treatments. Participants saw management of CPSP as difficult, and there was a tension between their desire to help patients and the concern that keeping patients ‘in the system’ of secondary care might not always be helpful. Identifying ways to improve services, participants described specialist services, specifically multidisciplinary pain clinics and pain management programmes, as having a vital and specific role in helping patients with CPSP.

Conclusion

Despite healthcare professionals’ commitment to helping patients with CPSP, coherent referral pathways and services to manage CPSP were described as lacking, resulting in an unsatisfactory approach. By corollary, better services would provide a joined up pathway that would assist patients and healthcare professionals involved in their care. This small-scale study complements ongoing work that highlights the diversity of services for CPSP after knee replacement across the UK, in which some examples of clear pathways are apparent. Future research is needed to assess the impact of clear referral pathways and integrated service provision for patients with CPSP after total knee replacement.

031 Service provision for patients with chronic pain after knee replacement: an evaluation of current practice in high volume Orthopaedic Centres

Category: Evidence & Guidelines

Vikki Wylde, Fiona MacKichan, Sam Dixon, Rachael Gooberman-Hill

University of Bristol, Bristol, UK

Background

Total knee replacement is one of the most commonly performed elective surgical procedures. The operation is usually conducted to relieve pain and improve function, but recent studies indicate that up to 20% of patients experience chronic post-surgical pain (CPSP) after total knee replacement; this equates to around 16,000 new cases of CPSP in the UK each year. The wider literature on chronic pain indicates that people with chronic pain encounter patchy service provision. People with CPSP after knee replacement have already undergone major surgery for pain, and follow-up after surgery may have a role in care and pain management. However, we do not know what services are on offer to this group, nor whether there is consistency in service provision including identification of need and any associated referral processes. We therefore conducted a survey to scope current UK service provision for patients with CPSP after total knee replacement.

Methods

This ongoing project is funded through a National Institute for Health Research Programme Development Grant on the treatment and management of chronic pain after total knee replacement (the STAR programme). The project was conducted as a service evaluation of services at high volume NHS orthopaedic centres across the UK.

The 23 NHS orthopaedic centres that conduct 500 or more primary total knee replacements per year were identified from the National Joint Registry. Contact was made with a key health professional at each centre who was familiar with the processes of post-operative assessment and follow-up. A structured telephone interview was conducted to obtain information about usual patient pathways at the different centres. Questions focused on identification, triage, treatment, management, and referral of patients with CPSP after total knee replacement. Information was recorded on a standardised proforma and entered into an Access database. Information was then collated and summarised in Excel.

Results

The survey has been completed by 14/23 NHS orthopaedic centres. Data collection is ongoing, with completion by February 2014. All centres routinely follow-up patients at 6 weeks after total knee replacement, although the provision and timing of subsequent appointments vary. The majority of centres do not have a specific time point at which patients are diagnosed with CPSP; in those that do, time points range from 4.5-18 months post-operative. When assessing pain levels, most centres use patient narrative, and there is some use of a standardised tool, most frequently a visual analogue scale. Four centres reported using a standardised protocol for assessment of patients with CPSP, and two centres reported use of a standardised protocol for management and treatment. Treatment and management options offered to patients vary between and within centres, and include further orthopaedic interventions, referral to pain management services, analgesia review, and referral for physiotherapy.

Conclusion

This survey of current service provision for patients with CPSP after total knee replacement identified national variation in the identification, assessment and management of these patients. Although some centres have developed a care pathway for patients with CPSP, the majority of centres lack standardised protocols to guide care provision. This highlights the potential to develop and evaluate standardised referral pathways and integrated service provision for patients with CPSP after total knee replacement.

032 Chronic pain medications in ICU

Category: Evidence & Guidelines

Katrina Dick¹, Gordon Stewart¹, Tara Quasim^1,2

¹Glasgow Royal Infirmary, Glasgow, UK, ²Glasgow University, Glasgow, UK

Background

Chronic pain can be defined as pain lasting longer than 12 weeks, or pain persisting beyond the time that healing would expect to occur after trauma. It has a prevalence of 14% in the Adult population of the UK and accounts for a significant proportion of the UK’s health expenditure. As an ageing population with increasing life expectancy, it can be hypothesised that the prevalence may increase over time and that affected individuals will live longer with chronic pain. In the future, intensive care units are likely to encounter a greater proportion of patients with chronic pain as well as other chronic illness. While the focus of critical care is most often surrounding acute issues, attention to chronic illness also plays an important role. With chronic pain now being recognised as a condition in its own right, it should continue to be managed even during acute illness wherever possible.

Methods

Glasgow Royal Infirmary (GRI) Intensive Care Unit (ICU) is a 20 bedded ward split into east and west areas. It is a mixed level 2 and 3 unit accepting medical, surgical, elective and emergency admissions.

All patients admitted to GRI ICU in 2012 who had a chronic pain diagnosis and as part of their home medications prescribed amitriptyline, gabapentin or pregabalin were identified. CareVue, the electronic patient monitoring and charting system used in GRI ICU allowed extraction of data from patients records. The admission records were reviewed. We collected data on drug discontinuation, if drug was re prescribed, time taken to re prescribe, and any documented reasons for discontinuation.

Results

During 2012 there were 962 patients admitted to GRI ICU. There were 102 (10.6% of all admissions) with a long term prescription for gabapentin, pregabalin or amitriptyline. These drugs were re prescribed in 74 cases (72.5%). The mean time between admission and re-prescription was 48.5 hours (range 0.25 hours to 1608hours). The median time was 3 hours and the mode was 1 hour.

In 28 cases (27.45%) the drugs were not re prescribed. In 20 (19.6%) the drug was not given due to valid documented reasons e.g. reduced coma scale or acute renal failure. In 8 patients (7.8%) there were no identifiable reasons in the case notes.

Conclusion

Mismanagement of pain in ICU may cause long term sequelae including chronic pain and PTSD. Reassuringly, in our unit 92.2% of patients either had their chronic pain medications restarted or appropriately stopped. However, we have identified that some are experiencing long periods without their usual medication, and in some instances the drugs are not being re-prescribed at all.

Management of pain is a fundamental standard of care and we aim to improve pain related prescribing in our unit through education. We propose the inclusion of a protocol for management of chronic pain medications within our department.

033 Consent for chronic post surgical pain - an evaluation of current practise

Category: Evidence & Guidelines

Jessica Williams, Nilu Bhadra

Blackpool Teaching Hospitals NHS Trust, Blackpool, Lancashire, UK

Background

Chronic post surgical pain (CPSP) is pain that develops after surgical intervention and lasts at least two months after surgery, where other causes of the pain have been excluded. It carries significant morbidity, with reduction in quality of life, poor function and interference with work and leisure activities, and its incidence varies widely depending on the type of surgery being performed. The General Medical Council (GMC) gives guidance to doctors on the issues of consent for surgical procedures. The GMC states the need for doctors to tell patients if an intervention might result in a serious adverse outcome, including medium or long term pain, as well as how patients should document their consent, whether that is written, verbal or implied.

Methods

Using computerised theatre records, we retrospectively identified all patients that underwent a surgical procedure with an anaesthetist present at Blackpool Victoria Hospital, between January 1st 2013 and January 31st 2013. This included 1576 patients and from this group we further selected those patients that were undergoing a procedure with a high risk of CPSP. These procedures included operations from general, breast and vascular surgery, trauma and orthopaedics, ENT, gynaecology, and urology. Our sample group was 220 patients and due to availability of notes we were able to look at 211 patient records. We retrospectively looked at consent forms to identify which patients had documented written consent for the serious or frequently occurring risks of surgery including chronic pain, acute pain and nerve damage.

Results

Of the 211 consent forms analysed, 58% were from general surgery, 29% from trauma and orthopaedics, 7% from gynaecology, 3% from ENT and 3% from urology. In the general and breast surgery group 27/122 (22.1%) of patients had documented evidence of consent for risk of chronic pain. In the trauma and orthopaedics group 4/61 (6.6%) had documented evidence of consent for risk of chronic pain. In urology 5/7 (71.4%) had documented evidence of consent for risk of chronic pain. 0/14 gynaecology records and 0/7 ENT records had documented consent for risk of chronic pain. 11/122 (9.0%) general and breast surgery records showed consent for risk of acute and chronic pain as well as nerve damage. All of these were for patients undergoing inguinal hernia repair.

Conclusion

A significant number of patients are undergoing surgical procedures that have a high incidence of CPSP. When looking retrospectively at consent forms for patients undergoing surgery with a high risk of CPSP, only a small proportion of consent forms are confirming that the risk of CPSP has been discussed with patients prior to surgery. CPSP is a serious consequence of surgery and patients undergoing high risk surgery should be informed of the possibility of developing CPSP during the consent procedure, and this should be documented on the surgical consent form, in accordance with nationally approved guidance on the consent process.

034 Chronic pain management service improvement in scotland

Category: Evidence & Guidelines

Steve Gilbert, Lesley Holdsworth, Linda Sparks, Norma Turvill, John McLennan

Healthcare Improvement Scotland, Edinburgh, UK

Background

The structure of the NHS in Scotland is quite different from that in the rest of the United Kingdom. We do not have a ‘commissioning’ model of funding but continue to have a national budget for Health divided between the fourteen Health Boards by the Scottish Government Health and Care Directorate.

The GRIPs report of 2007 found that despite 4 previous reports, provision of Pain Management Services remained patchy with a lack of availability of multidisciplinary care.

Our traditional approach has been from the specialist viewpoint - “we need more pain management programmes” or “we need to educate GP’s”. This has perhaps led to the feeling that pain is “complicated” and has kept the medical focus firmly on the “Bio”, with the attitude that the “psycho” and “social” couldn’t be fitted in to appointment times or that a pain management approach should be a “last resort”.

Methods

The Scottish Chronic Pain Steering Group was set up in 2009 to direct service improvement. A National Lead Clinician coordinated this with support from Healthcare Improvement Scotland and the Scottish Government.

Subgroups were established on education, measurement and research.

We developed a Scottish Service Model for Chronic Pain, recognising that most people with chronic pain are managed in the community and Primary Care

Level 1 - Advice and Information about pain and what to do about it. Anyone can access these services from home or community services.

Level 2 - When help from a GP or therapist is needed.

Level 3 - For those needing more specialist help from a chronic pain management service.

Level 4 - Highly specialised help

Pain Services were encouraged to develop Service Improvement Groups (SIGs) with government funding over an initial 2 year period.

Collaboration with the RCGP, MSK and other services was sought.

Results

All Boards in Scotland have signed up to developing a SIG, tasked with implementing the Scottish Service Model for Chronic Pain.

GPs and pharmacists and patients are involved in SIGs, contributing to the development of pain assessment and management guidelines.

Pain Association Scotland, a voluntary group have been able to establish local groups.

Chronic pain service development will be part of Local Delivery Plans for Boards.

Guidelines are being agreed for referral and management for Level 4 specialised treatments.

The Scottish Intercollegiate Guideline Network have developed a SIGN Guideline for the Management of Chronic Pain, published 12.12.13.

The Scottish Pain Research Community has held three successful ASMs. The Research Sub-group of the Steering group has obtained a CSO grant to research on opiate prescribing.

chronicpainscotland.org has been established as a central resource for patients, healthcare professionals and SIGs. Next steps are to establish an autonomous national network of pain services.

Conclusion

We are fortunate in Scotland to have a pain management community which is proactive and well known to one another. We are working on strengthening networks, on achieving better collaboration, communication and sharing good practice.

A coordinated approach by the Chronic Pain Steering Group, with support from Healthcare Improvement Scotland and the Scottish Government, has resulted in the establishment of improvement groups in every Scottish Health Board, with action plans to establish the service model.

The SIGN Guideline sets out current evidence and monitoring by the steering group and inclusion of pain in Boards’ Local Delivery Plans will ensure implementation.

Experimental (Basic) Science

035 Gender differences in pain anxiety do not affect experimental heat pain sensitivity response

Category: Experimental (Basic) Science

Claudia Poynton, Mark I Johnson, Osama A Tashani

Centre for Pain Research, Leeds Metropolitan University, Leeds, UK

Background

Sex and gender differences in sensitivity to experimentally-induced pain are well documented with men having higher pain thresholds and tolerances and reporting less intensity of pain than women. Anxiety has been associated with the experience of pain, especially in women although there are few studies that investigated the relationship between anxiety and gender differences on response to experimentally-induced heat pain. The aim of this study was to investigate whether there are differences in anxiety toward pain between male and female university students and whether this affects response to experimentally-induced heat pain.

Methods

Warm detection, heat pain threshold and heat pain tolerance were measured in 20 (10 females) healthy university students (mean±SD age =21±1.4 years). A thermode linked to a ThermoSensory analyser II (Medoc) was placed on the skin over the thenar eminence to deliver heat stimuli. Anxiety toward pain was measured by The Pain Anxiety Symptoms Scale (PASS-20), originally developed to measure four dimensions of attitude toward pain; Cognitive anxiety, Escape/avoidance, Fear, Physiological anxiety (McCracken and Dhingra, 2002).

Results

Women scored higher than men in all PASS 20 dimensions: Cognitive anxiety (men=9.8±4.8, women=14.5±3.4, p=0.022, t-test), Escape/avoidance (men=6.7±3.0, women=12.7±2.7, p=0.0001), Fear (men=4.7±3.0, women=8.5±23.4, p=0.016) and Physiological anxiety (men=5.2±2.9, women=9.6±1.5, p=0.02). There were no differences between women and men in warm detection threshold (difference from baseline of 32°C: men = 1.8±0.7°C, 2.6±1.5°C), heat pain threshold (men=43.7±3.8°C, women=44.1±3.1°C) or heat pain tolerance (men=49.3±0.9°C, women=48.6±1.1°C). Moreover, correlation between anxiety score and heat pain responses were not statistically significant (p>0.05).

Conclusion

Gender differences in anxiety as measured by PASS 20 had no effect on experimental heat pain sensitivity response under the current experimental conditions.

036 Reproducible placebo analgesic responses across different modalities

Category: Experimental (Basic) Science

Matthew Leung^1,3, Andrea Power², Manuela Hunter¹, Timothy Rainey², Ann Lenton², Anthony Jones²

¹School of Medicine, University of Manchester, Manchester, UK, ²Human Pain Research Group, Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK, ³National Institute of Academic Anaesthesia, London, UK

Background

The magnitude of the placebo effect in many clinical conditions has been disputed; however its effect on pain remains consistently significant¹. Significant placebo responses have previously complicated the interpretation of clinical trial Results², leading to attempts to reliably identify placebo responders in clinical trials³, ⁴. To do this in clinical trials involving pain, a better understanding of the consistency of placebo analgesia is needed.

Placebo analgesic response has been shown to be reproducible, when experimental conditions and placebo modality are kept stable⁵. However, a slight change in the context of the placebo (i.e. a change in name) can disrupt the consistency of repeated responses⁶. Furthermore, different placebo modalities can induce different magnitudes of responses, suggesting that placebo responses may be contextual, rather than subject dependent⁷.

We investigated whether a change of placebo modality in a repeat experimental session, would affect the reproducibility of placebo analgesic response.

Methods

The study consisted of two experimental sessions separated by a minimum of two weeks. 30 participants were randomized into a placebo (n=19) or a control group (n=11). Participants received either a cream (10 in placebo group, 6 in control group) or a tablet in the first session, which was then swapped in the second session.

A CO₂ laser was used to induce experimental pain on the back of the participant’s non-dominant hand and subjective pain ratings on a scale of 0-10 were recorded.

Both placebo and control groups underwent the same experimental procedure; however the verbal instructions between them differed. Experimental placebo analgesia was induced in the placebo groups using an established protocol⁵, in which a sham analgesic treatment was paired with a conditioning phase of lower intensity laser stimuli. The placebo group were told the treatment “may contain an analgesic” whereas the control group were told it was inert.

Results

The average pain reduction, the difference between pre and post treatment, was significantly greater (p<0.01) in the placebo group (mean 0.96, SD: 1.38), than the control group (mean: 0.15, SD: 0.73) over the two sessions. This indicates that pain reduction was due to placebo analgesia and not habituation to the laser, in accordance with previous studies⁵.

The placebo group demonstrated a significant positive correlation between pain reduction in the first session and pain reduction in the second session (r=0.5, p=0.02), indicating that the magnitude of placebo response over the two sessions was consistent in subjects. No such correlation was seen in the control group (r=0.07, p=0.8).

We defined a placebo responder as a subject in the placebo group, with a pain reduction greater than the mean of the control group. There were 10 placebo responders in the first session, 80% of whom were also placebo responders in the second session.

Conclusion

This study demonstrates that placebo analgesic response is consistent in individuals across different experimental sessions and modalities. In contrast to previous findings⁶, these Results provide evidence that the magnitude of placebo analgesic response is partly subject dependent and can therefore be predicted.

This evidence further contributes to the theory of “placebo responders”⁵. This has important implications for clinical trial design involving analgesics, as it provides evidence for the use of placebo screening before a trial, assisting the interpretation of Results. It also provides the possible basis for identifying the genetic foundations of placebo analgesia, directing new fields of pharmacological research.

037 Visual Alpha Entrainment Reduces Behavioural And Electrophysiological Responses To Pain

Category: Experimental (Basic) Science

Katharina Ecsy, Christopher Brown, Anthony Jones

University of Manchester, Manchester, UK

Background

It has previously been well established that our brain oscillatory alpha power (8-12Hz) is reduced when we experience pain. There appears to be a negative correlation between alpha power, and both the behavioural and electrophysiological responses to acute pain. Increasing alpha power could hence decrease pain ratings and the amplitude of laser-evoked potentials, measurable through electroencephalography (EEG). Oscillatory frequencies can be modulated by visual entrainment, where brainwave frequencies adapt to the rhythm at which they are being stimulated.

The aim of this study was to determine whether 10 minutes of auditory entrainment at 8 Hz, 10Hz and 12Hz will affect the volunteers’ pain perception of the acute heat laser stimulus, compared to the 1Hz control.

Methods

We recruited 32 healthy (16 male), right handed subjects with a mean age of 22.25 ± 2.00. A CO_⊠ heat laser stimulus was applied to the right forearm. The intensity of the stimulus was slowly increased from a level 0 to a level 7 on a 1-10 pain scale Laser intensity was kept constant, at baseline level 7, for the rest of the experiment. After rating 20 baseline laser pulses, volunteers were subjected to four different visual stimulations: 1 Hz (control), 8Hz (low-alpha), 10Hz (mid-alpha), 12Hz (high-alpha). Each visual stimulation lasted 10 minutes and was delivered in the form of flashing LED goggles. The order of stimulations was randomised. After every visual stimulation session, volunteers were asked to rate 20 heat laser pulses at their pre-determined level 7.

Results

Ten minutes of visual alpha stimulation was enough to increase alpha power, with the largest effect at 10Hz. After visual entrainment ERPs and behavioural pain ratings reduced significantly with the largest effect at 10Hz, followed by 8Hz.

Conclusion

Both the behavioural pain ratings and laser evoked responses were significantly reduced compared to control after the 8Hz and 10Hz entrainment. No significant difference was found after the 12Hz entrainment. These Results are in line with previous findings demonstrating opposite effects of low and high alpha frequencies on pain perception

038 Characterisation of delayed onset of muscle soreness (doms) in the hand, wrist and forearm using a finger dynamometer. A pilot study

Category: Experimental (Basic) Science

Kristina Grancharska^1,2, Gareth Jones^1,3, Osama Tashani^1,3, Mark Johnson^1,3

¹Faculty of Health and Social Sciences, Leeds Metropolitan University, Leeds, UK, ²Faculty of Public Health and Sports, South - West University ‘‘Neofit Rilski’’, Blagoevgrad, Bulgaria, ³Leeds Pallium Research Group, Leeds, UK

Background

Delayed onset of muscle soreness (DOMS) is an acute myogenic condition classified as a type I muscle strain that Results from unaccustomed or strenuous exercise. Both concentric and eccentric contractions may produce DOMS with exercise intensity a key dependent factor. DOMS may present in the first 24 hours as pain, stiffness, muscle tenderness, decreased strength and swelling with intensity peaking between 24 to 72 hours post exercise. DOMS usually resolves in 5-7 days post-exercise. DOMS is used to induce experimental pain although induction techniques result in considerable discomfort and disability in large muscle groups of the upper arms and legs. We have developed an induction- technique to localise DOMS to the hand and forearm using a ‘finger-trigger’ dynamometer. The aim of this pilot study was to characterize sensory and motor changes of DOMS using this induction- technique over a 48 hour period post exercise.

Methods

DOMS was induced in the non-dominant hand of six pain-free participants (mean±SD age = 38.3±8.7years, 3 women) using a ‘finger-trigger’ dynamometer device designed in-house by the investigators. Each participant squeezed a trigger in time with a metronome (flexion=1s, extension=2s) until exhaustion or for a maximum of 15 minutes. This was repeated following a 30 second rest. Measurements were taken on both arms before, immediately after, 24 hours after and 48 hours after the induction of DOMS of: pain location, quality and intensity (VAS) at rest and on movement; forearm circumference; grip strength; detection threshold to von Frey monofilaments on skin over the flexor digitorum profundus muscle; and pressure pain threshold at six points on the anterior forearm using an algometer (probe1 cm²; 50 kPa/s). Differences between affected and unaffected arms were calculated for each participant at each time point and analysed using paired t-tests (mean±SD, p≤0.05).

Results

All but one male participant reached exhaustion within the 15 minute exercise ceiling (time to exhaustion run 1=178.0±109.5s; run 2=87.8±39.7s, n=5). All participants reported pain in the affected arm immediately after exercise (VAS at rest=33.0±25.1mm, VAS on finger flexion no resistance=31.3±16.2mm). After 24 hours all participants reported pain on finger flexion (VAS=10.8±14.7mm) but only 3 participants reported pain at rest (VAS=27.7±24.1mm, n=3). After 48 hours 2 participants reported pain on finger flexion (VAS=2.5±1.5mm, n=2) but only 1 participant reported pain at rest (VAS=10.0mm). Pain location varied between participants and included the index finder, thumb, palm, wrist, middle of forearm, upper arm (m.biceps brachii) and shoulder with “aching” and “heavy” being the most common pain descriptors. PPT was significantly lower in the affected arm immediately after exercise 1cm above the medial epicondyle and 1cm under the medial epicondyle and after 24 hours at the flexor digitorum profundus muscle belly (medial).

Conclusion

DOMS presented as localised sensory and motor changes in the arm, including pain at rest and on movement with lower thresholds to stimuli generating pressure pain. The site(s) of pain varied between participants. A larger sample is needed to statistically validate putative changes grip strength, skin sensitivity and forearm circumference. The ‘finger-trigger’ dynamometer may be suitable to induce experimental DOMS in sporting populations where repeated finger flexion activity is vital, e.g. rock climbing. Therefore, we plan to conduct a follow-up study using a larger sample size to characterise DOMS more fully as part of the development of an analgesic assay.

Interventional Pain Management

039 Evaluating Efficacy and Feasibility of Transcutaneous Electrical Nerve Stimulation for Postoperative Pain After Video-Assisted Thoracoscopic Surgery: A Pilot Study

Category: Interventional Pain Management

Deborah Engen, Paul Carns, Mark Allen, Brent Bauer, Laura Loehrer, Stephen Cha, Christine Chartran, Eric Eggler, Susanne Cutshall, Dietlind Wahner-Roedler

Mayo Clinic, Rochester, MN, USA

Background

Transcutaneous electrical nerve stimulation (TENS) has been applied for pain relief after various surgical procedures, including cardiac operations, cholecystectomy, caesarean section, and thoracotomy. The purpose of the present study was to evaluate the efficacy of TENS applied during the postoperative period after Video-Assisted Thoracoscopic Surgery (VATS), in addition to opioids, for pain management. Secondary outcome included evaluation of the feasibility of having postoperative care nurses who underwent a training session in TENS prior to the study apply TENS rather than a physical therapist.

Methods

Seventy patients scheduled to undergo VATS were invited to participate in this controlled trial consisting of randomization between TENS plus opioids (Group 1) or opioids alone (Group 2) for 48 hours. Select TENS Pain Management System (Empi Inc) was used. Nurses placed 4 electrodes on or around the area of maximum pain. One of 5 preset quick select program buttons was chosen and intensity adjusted until the patient was comfortable. Outcome measures were pain scores taken hourly (visual analogue scale, 0-10), pain medication name and amount in oral morphine equivalents (OME) (mg) used for 48 hours, and satisfaction with pain control (visual analogue scale, 0-10). Level of opioid treatment and pain scores were compared between Group 1 and Group 2 using Fisher exact test, or mixed model method where appropriate. Since this study represents an early-phase trial with a small sample size, we also used the Aickin separation test.

Results

Fifty-six patients were enrolled, 40 completed the study. Age, sex preoperative home pain medication and physical status were similar in both groups. Pain scores and use of OME were not significantly different between the 2 groups during the first and second 24 hours. The decrease in OME use between the first and second 24 hours was significant for Group 1 (P=.005) but not for Group 2 (P=.11); however, the decrease in use of OME between groups was not significant (P=.35). Statistical analysis using the separation test described by Aickin showed that further research is worthwhile to evaluate the use of TENS in postoperative pain control for patients undergoing VATS.

At study completion, 65 nurses who applied TENS at some time during the study were mailed a satisfaction survey; 44 rated the level of ease or difficulty in using TENS, with a median of 5.0 (0, easy; 10, very difficult).

Conclusion

The present study indicates that TENS used in addition to opioid treatment is a feasible approach and may be of benefit for postoperative pain reduction in patients undergoing VATS. A larger, well-powered clinical trial is indicated to further evaluate the effects of TENS in the control of both postoperative VATS pain and opioid use.

Because delivering TENS therapy was a new skill for the nurses, their lack of familiarity with this technology may have diminished its efficacy. In future studies, we plan to extend the number of training sessions to ensure optimal utilization of the device.

040 Effectiveness and Cost-Effectiveness of A Group-Based Pain Self-Management Intervention For Patients Undergoing Total Hip Replacement: Feasibility Study For A Randomised Controlled Trial

Category: Interventional Pain Management

Vikki Wylde, Elsa Marques, Neil Artz, Ashley Blom, Rachael Gooberman-Hill

University of Bristol, Bristol, UK

Background

Total hip replacement (THR) is a common elective surgical procedure and can be effective for reducing chronic pain. However, waiting times for THR can be considerable, and patients often experience significant pain during this time. A pain self-management intervention may provide patients with the skills to enable them to manage their pain and its impact more effectively during the wait for surgery. However, studies of arthritis self-management programmes have faced challenges because of low recruitment rates, poor intervention uptake, and high attrition rates. Therefore, this study aimed to evaluate the feasibility of a randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of a group-based pain self-management course for patients undergoing THR and assess the acceptability of the intervention. Specific objectives were to assess trial design, ascertain recruitment and retention rates, identify barriers to participation, refine data collection Methods, and evaluate uptake and patient satisfaction with the course.

Methods

Patients listed for a THR at the Avon Orthopaedic Centre in Bristol were sent a postal invitation about the study. After recruitment, participants were randomised to attend a pain self-management course plus standard care or standard care only using a computer-generated randomisation system (Minim). The pain self-management course was delivered by Arthritis Care and consisted of two half-day group sessions prior to surgery and one full-day group session 2-4 months after surgery. A structured course evaluation questionnaire was completed by participants after the sessions.

Outcomes assessment was by postal questionnaire prior to surgery and 1-month, 3-months and 6-months after surgery. Self-report resource use data were collected using a diary prior to surgery and inclusion of resource use questions in the 3-month and 6-month post-operative questionnaires. Brief telephone interviews were conducted with consenting non-participants to explore barriers to participation.

NHS ethics approval was obtained (11/SW/0056) and participants provided informed, written consent.

Results

Postal invitations were sent to 385 eligible patients and 88 patients consented to participate (23% recruitment rate). Participants had a mean age of 66 years and 65% were female. Brief interviews with 57 non-participants revealed the most common reasons for non-participation were perceptions about the intervention and difficulties in getting to the hospital to attend the course.

Of the 43 patients randomised to the intervention group, 28 attended the pre-operative pain self-management sessions and 11 attended the post-operative sessions. Participant satisfaction with the course was high, and patients enjoyed the group format of the course.

Retention of participants was acceptable, with 83% completing follow-up. Questionnaire return rates were high at all assessment times (76-93%), with the exception of the pre-operative resource use diary (35%). Completion rates for the resource use questions varied by category and allowed for an economic perspective from the health and social care payer to be taken.

Conclusion

Undertaking feasibility work for a RCT is labour-intensive; however this study highlights the importance of conducting such work. Postal recruitment resulted in a low recruitment rate and brief interviews with non-participants provided valuable information on barriers to participation. Embedding collection of resource use data within questionnaires resulted in higher completion rates than using resource use diaries. While patients who attended the course gave positive feedback, attendance was low. Findings from this feasibility study enable us to design successful definitive group-based RCTs in the future, ensuring the delivery of effectiveness and cost-effectiveness evidence to inform service provision for patients undergoing THR.

041 Compliance on the Use Of Analgesia In Surgical Patients

Category: Interventional Pain Management

Annie Lehmann, Julien Al-Shakarchi

Sandwell Hospital, West Midlands, UK

Background

Pain management has been shown to be integral in the successful and prompt recovery from surgical hospital admissions. The World Health Organisation (WHO) has set out clear guidelines in pain management with the analgesic ladder. The NHS enhanced recovery pathway also recommends the use of NSAIDs post-operatively. The aim of the study was to assess compliance with WHO guidelines in pain management of surgical patients and to assess the use of NSAIDs as adjuvant analgesics.

Methods

Data was collected from 50 patients (23M:27F) on surgical wards. The data collected was for age, sex, surgical speciality, analgesia prescribed during inpatient stay and any contra-indications. We compared the analgesia prescribed with the current WHO guidelines in pain management to assess whether the surgical department adheres to this. We also assessed the use of adjuvant analgesia in surgical patients.

Results

14% of the surgical patients (n=7) included in this study were not compliant with the WHO guidelines. Only a small number of patients (24%, n=12) were prescribed adjuvant analgesia, whilst 12% of patients (n=6) had a caution/contraindication to NSAID use.

These Results suggest that surgical doctors are not fully complying with the WHO pain ladder guidelines, and that a large proportion of patients are not being prescribed adjuvant analgesia despite having no contraindications to their use. There are two possible reasons for this finding. Firstly the notion that some surgeons are not enthusiastic about using certain types of analgesia due to the known side effects, such as the use of NSAIDs and their association with upper gastrointestinal bleeds.

Secondly, it seems that doctors are unwilling to try weaker analgesia in fear of it not being effective, or not having enough time to adequately follow up the patient’s pain management.

Conclusion

Although compliance with the WHO pain ladder is improving, pain management in surgical patients might be further improved by better compliance to WHO guidelines and by greater use of adjuvant analgesia as per the enhanced recovery pathway. Our study would suggest that further research is required to evaluate whether complying with these guidelines would hasten recovery, shorten hospital stay and enhance patient satisfaction.

042 The Impact of Cortical Remapping Interventions on Pain And Disability In Chronic Low Back Pain: A Systematic Review

Category: Interventional Pain Management

Pete Daffada^1,2, Nicola Walsh³, Candy McCabe³, Shea Palmer³

¹Cardiff & Vale United Health Board, Cardiff, UK, ²North Somerset Community Partnership (NSCP), North Somerset, UK, ³University of West of the England (UWE), Bristol, UK

Background

Chronic Low back pain (CLBP) constitutes a major public health problem in Westernized societies. Many CLBP management strategies have been proposed and trialled, but have at best achieved moderate success. Cortical remapping is a common feature of and potential driver for CLBP, with extensive cortical reorganisation demonstrated in areas known to be involved in pain processing (‘the pain neuromatrix’), somatosensation and motor planning. Novel interventions such as graded motor imagery (GMI), mirror visual feedback (MVF) and sensory discrimination retraining (SDR) have been shown to facilitate correction of pathological cortical changes and improve symptoms in other chronic pain states. However, little is known regarding the effectiveness of these treatment approaches in CLBP.

Objective: The aim of this systematic review was to identify and assess the current evidence regarding the effectiveness of interventions which target cortical remapping in the management of CLBP.

Methods

Data Sources: The electronic databases Medline, Embase, CINAHL, AMED, OVID, PEDro, BNI, PsycINFO, HMIC, and the Cochrane library were systematically searched from their individual inception dates to September 2013. Search strategies and eligibility criteria were developed using the standard PICO format. All multiple participant study designs were considered and no language restrictions applied to maximise article retrieval.

Study Selection: Ten potential citations were identified electronically, with the addition of a 11^th via manual screening of the bibliography of relevant publications. Their abstracts were subsequently screened for eligibility, and 5 articles ultimately identified for inclusion. These comprised 3 randomised controlled trials (RCTs), 1 randomised cross-over study, and a multiple case study design. A qualitative synthesis of the methodological quality of each article was performed using the Critical Appraisals Skills Programme (CASP) criteria. Article suitability for inclusion and their subsequent methodological analysis were both corroborated by a second, independent assessor.

Results

The findings of this review suggest that interventions which specifically target cortical remapping (such as GMI, MVF and SDR) have potential for application in the management of CLBP. Real-time visualisation of lumbar movements using mirrors significantly reduced the duration and severity of movement-associated low back pain (p=0.007 and p=0.003 respectively). Specific motor control retraining facilitated remapping within the primary motor cortex (M1) (p<0.016), with concurrent, earlier postural muscle recruitment (r²<0.12, p<0.044) and an improvement in pain (p<0.018). Increasing lumbar tactile acuity using SDR produced significant short-term improvements in both CLBP and disability (both p<0.001), although notable methodological limitations were identified in this study. A combined protocol, including components of all 3 interventions in combination with motor control retraining demonstrated clinically significant short-term benefits, and may represent the greatest potential. However, these Results need to be replicated in a larger trial to confirm statistical significance.

Conclusion

There is a paucity of robust literature which has examined the efficacy of these novel interventions in the management of CLBP. The findings of the few studies which are currently available are encouraging. GMI, MVF and SDR have been shown to be individually effective in reducing pain and improving function in CLBP. Furthermore, a combined protocol, incorporating specific motor control retraining with components of all 3 treatment modalities may provide the best potential outcomes. Further, robust research is needed to optimise treatment protocols and establish the cost-effectiveness and long-term efficacy of these interventions in CLBP.

043 Prospective Evaluation Of The Effectiveness Of Percutaneous Radiofrequency Nerotomy Of The Suprascapular Nerve In Improvement In Pain And Function In Refractory Shoulder Pain Using The Shoulder Pain And Disability Index (Spadi) Questionnaire

Category: Interventional Pain Management

Yehia Kamel¹, Paul Mathers¹, Allen Pinto², Nicholas Plunkett¹

¹Sheffield Teaching Hospitals, Sheffield, UK, ²Doncaster Royal Infirmary, Doncaster, UK

Background

Chronic shoulder pain is a common clinical problem causing considerable pain and disability to sufferers. Most commonly caused by rotator cuff tears, glenohumeral osteoarthritis and trauma, the pain is often prohibitively severe to allow compliance with physiotherapy, especially that pharmacotherapy frequently proves either ineffective or intolerable due to side effects.

As the Suprascapular nerve (a branch of the upper trunk of the brachial plexus derived from C5 and C6 spinal nerves) supplies 70% of the of the shoulder joint, blockade of the nerve by local anaesthetics or radiofrequency neurotomy has been an accepted treatment of shoulder pain, particularly in cases deemed inoperable due to surgical or medical reasons. ⁽¹⁾

We undertook this prospective study in shoulder pain patients referred to us by orthopaedic surgeons to assess the efficacy of radiofrequency neurotomy of the suprascapular nerve in pain reduction and functional improvement using the Shoulder Pain and Disability Index (SPADI) questionnaire

Methods

Prior to the procedure, patients’ degree of pain and level of function were assessed using (SPADI) questionnaire. Self- administered, it consists of five questions assessing the pain severity and scored out of fifty, and eight for the limitation of function affecting upper extremity use scored out of eighty. The higher the score the worse the pain and functional disability respectively.

After explanation and consent, the procedure was performed using continuous Rf for all patients. Adopting the Gauchi landmark technique, the nerve was located as it winds around the scapular spine. 22 Gauge 10 cm RF needles were used.

After successful sensory stimulation at <= 0.5 Volts at 100 Hz and motor stimulation at 2 Hz, lesioning was performed for 120 seconds at a temperature of 80° C. (2)

The SPADI assessment is repeated at three, six, and twelve monthly intervals to assess success and degree of sustained benefit.

Results

There were eight males and six females aged 43 to 92 years with a mean age of 74.35 (SD=13.38). On their pre-procedure SPADI their pain score range was 30-50 with a mean of 37. 14 (SD=9.82) and functional disability range was 20-80 with a mean of 54.14 (SD=17.6).

At 3 months, 5 patients did not return their questionnaire (yet 4 out of them showed improvement in pain and function scores at six month). Of the remaining, despite 3 not showing improvement, the mean pain score was 28 (SD=13.2) and the mean function score was 44.9 (SD=22.18)

At 6 months, all questionnaires were returned. Mean pain score was 28.33 (SD=13.3) and mean function score 39.61 (SD=21.51)

So far, only five patients have reached their 12 months follow up. Mean Pain score 20.8 (SD=16.97) and mean function score 31.8 (SD=28.49).

None of the patients suffered any complications

Conclusion

Radiofrequency neurotomy of the suprascapular nerve, when assessed by a robust tool such as the SPADI questionnaire, proves to be an effective method in reduction of pain and improvement of function in patients complaining of chronic shoulder pain who are deemed unfit for surgery. More important, its effects seem to be sustained over time. Even in a subgroup of patients who did not derive any benefit initially at three months, their pain and disability scores improved at six months.

044 Efficacy of Interventional Procedures in Chronic Pain

Category: Interventional Pain Management

Maria K Stasiowska, Rahul Seewal

Chelsea Pain Centre, Chelsea & Westminster Hospital, London, UK

Background

Evidence for the use of therapeutic interventions in chronic pain is variable (1). At present there are only guidelines for interventional techniques in the management of some aspects of chronic pain (2). The aim of this audit was to look at current practice in a tertiary pain medicine unit, determine which interventional procedures are performed and assess their efficacy.

We also assessed the time scale to follow up after intervention, as there are no current, standardised national guidelines for post procedure follow up (3).

Methods

107 patients underwent therapeutic interventions for chronic pain by a single pain medicine consultant, between March 2012 and 2013, at Chelsea and Westminster Pain Centre.

Patients were divided into six categories that included: mechanical low back pain (MLBP), low back pain with neuropathy (MLBPn), low back pain with radiculopathy (MLBPr), pure radiculopathy and myofascial pain. All other chronic pain was collectively classified as ‘other’.

Time to follow-up conducted by a pain nurse or doctor was calculated as a mean in months.

Intervention outcomes were classified into:

Good – sufficient relief to be discharged from clinic, or >/= 50% pain relief for >/= 3 months.
Partial – less than 3 months and/or < 50% pain relief.
None – worsening pain or no pain relief.

The efficacy of each intervention was assessed overall and within each pain category. A two-tailed Fishers Exact test compared good versus partial/none outcome groups.

Results

Patient categories are summarised in Graph1.

Mean time to follow-up was 3.5 months (range 0.25 – 15).

The intervention most performed was FJI (Graph 2). Of those, 59% (n=63) had a good outcome, whilst 21% (n=23) and 20% (n=21) had partial or none respectively. This was similar across all pain types (Table 1), except in MLBn, where the majority had only a partial response.

None of the three main interventions showed significant association with good therapeutic outcome: FJI (p=0.8444), MBB (p=0.192) or TFES (p=0.5455).

MLBP received the most interventions (n=48), mainly FJI (Graph 3) and no procedure was significantly associated with good outcome (Table 2).

All patients with MLBPn and 80% (n=19) with MLBPr had FJI. The majority were partially effective 83%) requiring a repeat or alternative procedure after follow- up. Again, none were associated with good therapeutic outcome (Table3).

All patients with myofascial pain received TPI.

Conclusion

Low back pain remains the most common cause for undergoing an interventional procedure. The multifactorial aetiology means, no single intervention alone is of significant clinical benefit

The efficacy of an intervention may be affected by the delay in timely post procedure follow up (e.g. MBB).

We suggest implementing the BPS guideline for managing axial, mechanical low back pain (4). The pathway suggests performing diagnostic medial branch blocks, with response assessed on the day of procedure, leading to a 2^nd diagnostic injection and ultimately a therapeutic radiofrequency denervation.

045 Pain Relief and Related Outcomes Following Injection Therapy: A Service Evaluation

Category: Interventional Pain Management

Susan Yeung Ngok Kao, June Corrigan, Sameer Gupta

Northern General Hospital, Sheffield, UK

Background

In the current economic climate the efficacy of many interventions in chronic pain, including injection therapy is coming under increasing scrutiny. Current evidence pertaining to injection therapy is very limited. Research outcomes may not translate into real-life clinical practice. It was felt that the collection of specific data at consistent follow up intervals would provide valuable, and as accurate as possible information to demonstrate the effectiveness of these treatments.

The Results were entered onto a computer database, thus allowing for effective and accurate collation of the information gathered.

Methods

The target sampling population was all patients undergoing injection therapy for the year 2012-13. This was a change in practice for the clinicians involved, therefore patient entry into the database was staggered. This may not reflect the total activity of the clinic.

Data was collected at 6 and 12 weeks via a telephone call. Depending on the outcome of the information collected at 6 weeks, (namely if any pain relief is present), then a further telephone call was made at 12 weeks post treatment. Data was collected prospectively by a named specialist pain nurse.

The primary outcome measure was pain relief. Secondary outcomes were measured, consisting of - physical activity level, sleep quality, analgesia requirement and global perception of change as a result of the treatment. Any adverse effects were also noted in the outcomes.

The data was then entered into our hospital database.

Results

In terms of primary outcome, our Results show that 65% of patients experienced analgesia for more than 6 weeks, with 53% of the total patient cohort still benefiting after 12 weeks.

Secondary outcomes showed that a third of patients were able to increase their physical activity. There was an improvement in reported sleep quality in almost 40% of our patients as well as reduction in analgesia required. Overall, 51% of patients felt that their situation had improved as a result of the intervention.

Conclusion

Injection therapy has a fundamental role within the multi-modal treatment of chronic pain. This data supports the benefits of injection therapy within our service. Collecting the data at different time intervals (as stated in our methodology above) may not reflect the full effects of injection therapy. Ongoing data collection may potentially help identify the patient group most likely to benefit from injection therapy in the future.

046 Development and Evaluation of A Guided Self-Help Intervention For Chronic Oro-Facial Pain

Category: Interventional Pain Management

Vishal Aggarwal¹, Joanna Goldthorpe¹, Sarah Peters¹, Karina Lovell¹, Christopher Roberts¹, Imola Nemeth¹, Linda McGowan²

¹University of Manchester, Manchester, UK, ²University of Leeds, Leeds, UK

Background

Chronic oro-facial pain (COFP) is a common presentation to medical and dental services. Current management continues to follow a biomedical model even when there is no underlying medical pathology to explain symptoms. Treatment typically involves removal of tooth tissue to adjust patients’ bite, mouth-guards / splints and even surgery. However these mechanistic approaches are ineffective and can be iatrogenic. A growing evidence-base recognises the potential effectiveness of psychological interventions for COFP. We sought to understand the processes involved in the experience of COFP and to develop a feasible and acceptable evidence-based intervention for managing COFP.

Methods

We followed the Medical Research Council guidelines for development of complex interventions. This involved a mixed method approach to gather quantitative and qualitative evidence to inform the development of the intervention. Four main studies were conducted: (1) Cochrane systematic review of psychosocial interventions for COFP, (2) qualitative studies explored patient, GP and dentists’ experience of COFP, (3) a national quantitative survey used case scenarios to establish dentists’ preference and ability to diagnose, manage and refer patients with COFP, (4) The evidence from these three studies was synthesized to inform the development of the guided self-help intervention. The intervention was manualised and the manual followed the format of a previous intervention developed for chronic widespread pain. A feasibility randomised controlled trial was conducted to compare the guided self-help intervention with treatment as usual (n= 37 patients).

Results

Seventeen trials were included in the review. CBT either alone or in combination with biofeedback improved long-term pain intensity, activity interference and depression compared with usual care. The strength of evidence was weak and it was unclear which components of the interventions were effective.
GPs, dentists and patients recognised the role of psychological factors in COFP. However management was limited to biomedical interventions. Diagnosis was problematic but functional for all parties. COFP was viewed as a non-dental problem and practitioners felt ill-equipped to manage it. Current inadequacy in management led to frustration and disengagement from the clinician-patient relationship.
Whilst dentists could diagnose COFP, management was not evidence based and included several biomedical modalities. Referral was common and services chosen were rarely available.
The intervention was acceptable and feasible; however the pilot study was not powered to draw Conclusions about the effectiveness of the intervention.

Conclusion

Current management of COFP is ineffective and unsatisfactory for both patients and practitioners. Our intervention was acceptable to patients and allowed them to better understand and self-manage COFP. In addition it could be feasibly delivered by both dental and non-dental professionals either face to face or over the telephone. Further research is needed to understand the most cost-effective ways to implement psychological interventions for COFP within current medical and dental services.

047 Discitis as a Complication Of Lumbar Selective Nerve Root Injection- A Case Report

Category: Interventional Pain Management

John Muthiah¹, Hannah Critchlow¹, John Macleod²

¹Dumfries and Galloway Royal Infirmary, Dumfries, Dumfrieshire, UK, ²Caithness General Hospital, Wick, UK

Background

Whilst therapeutic epidural injections have been practiced for over fifty years, technological advances have brought about contrast guided selective nerve root injections (SNRI). These have the advantage of directly targeting the involved spinal nerve. Infectious complications following selective nerve root injections although rare have been reported in the literature . This is the case report of a 78 year old woman who unfortunately developed discitis following a selective nerve root injection. She was referred to the chronic pain services in 2010 with low back pain and right sided lower limb pain after review by an orthopaedic surgeon. Surgical decompression was not offered as it was felt too risky.

The MRI of her lumbosacral spine showed disc bulge at L3/4, impinging the right L3 nerve root consistent with her symptoms. At chronic pain clinic, a L3 selective nerve root injection and lumbar facet joint injections were proposed.

Methods

A case study was written, using case notes of the patient as the source of information. Contemporary literature pertinent to the case was also studied by doing a MEDLINE search using the terms “discitis”, “selective nerve root injections” and “lumbar transforaminal epidural injections”.

Results

An uneventful lumbar facet injection was carried out at L5/S1. During an attempted right sided L3 nerve root injection the initial needle position was recognised to be intradiscal at L2-3 level. The needle was repositioned and a L3 nerve root injection was performed uneventfully. Intravenous antibiotics were administered immediately post procedure. The patient was readmitted two weeks later with worsening low back pain and CRP of 103. Sensation and bladder and bowel function were intact. Urgent MRI showed vertebral osteomyelitis at L2 and L3, and intervertebral disc desiccation. Follow up MRI scans confirmed the diagnosis of discitis. Blood cultures revealed a coagulase negative staphylococcus. She was started on IV flucloxacillin for six weeks, and IV rifampicin, and then changed to oral antibiotics. Her hospital stay was complicated by Hickman line infection, and pain management challenges. She was finally discharged home seven months later.

Conclusion

Infection (including meningitis, osteomyelitis, epidural abscess and discitis) is a serious but rare complication of spinal injections. Goodman et al, in a comprehensive literature review of lumbar, interlaminar and transforaminal epidural injections, reported the incidence of serious infections to be 0.1-0.01% whereas other studies have not reported any major complications. We discuss the management of a patient who developed discitis following an inadvertent intradiscal needle entry. We also discuss the incidence, predisposing factors, presenting features and management of discitis as described in the relevant literature

048 Radiofrequency Denervation For Coccydynia

Category: Interventional Pain Management

Christine Cleary, Yaroslav Stefak, Enrique Collantes, David Pang

Pain Management and Neuromodulation Centre, Guy’s and St Thomas’ Hospital, London, UK

Background

Coccydynia is pain in the region of the coccyx, usually exacerbated by pressure in the area and on sitting. The onset of symptoms follows trauma in 50% of cases, however other possible aetiologies include coccygeal nerve entrapment, coccygeal intervertebral disc pathology and abnormal coccygeal mobility. Recognised treatments for coccydynia include NSAIDs, physical therapy, pericoccygeal infiltration with local anaesthetic and steroids and ganglion of impar block. In patients with chronic coccydynia these treatments may not result in prolonged pain relief.

Methods

We present the case of a 47-year-old man who experienced the sudden onset of pain in the coccygeal region on bending. The pain had a significant impact on his quality of life as he was unable to sit for any duration, to pursue training to be a HGV driver and as a result he became unemployed. On clinical examination no pain was elicited on stressing the sacroiliac joints, but there was marked tenderness of the coccygeal region on palpation. MRI imaging revealed pronounced anterior angulation of the coccyx.

Results

Initial treatment of pericoccygeal infiltration of local anaesthetic and steroid provided 80% pain relief for a period of 1 week. Due to the short lived pain relief and failure of other conservative treatments we proceeded to radiofrequency denervation of coccygeal nerves at the sacral hiatus. The procedure was conducted in day surgery under local anaesthesia without any adverse events. A 22G radiofrequency needle with a 5mm active tip was placed at the entrance of the sacral hiatus and three lesions at 80°C for 90 seconds made. This treatment resulted in a reduction pain intensity of 80% for a period of 6 months without any adverse effects.

Conclusion

Radiofrequency denervation of the coccygeal nerves should be considered as a treatment for coccyx pain following a diagnostic block.

049 Is specialised opioid clinic management of patients with chronic pain syndromes associated with reduced emergency department attendance?

Category: Interventional Pain Management

John Lankester, Louise Jeynes

West Suffolk Hospital, Suffolk, UK

Background

Emergency Department (ED) management of patients with chronic pain is poorly studied, yet their attendance at EDs is common, and often frustrating for staff and patients alike. At the West Suffolk Hospital patients with long term opiate use for chronic pain are managed in a designated clinic with a specific pathway incorporating opioid screening and monitoring tools, standardised patient information, consent, agreement documentation and goal setting. This study aims to examine whether chronic opioid use is associated with high levels of ED utilisation and whether routine outpatient management of these patients in a designated opioid clinic reduces attendance at the ED.

Methods

Patients under the care of the opioid clinic who attended the ED more than twice a year were retrospectively identified. All ED attendances, regardless of presenting complaint, were identified for these patients over a four year period between October 2009 and October 2013. Monthly rates of ED attendance before and after commencement of opioid clinic attendance were then calculated. The mean length of time spent in the ED was also analysed with regard to the four hour wait target currently in place in UK emergency departments.

Results

Of 56 patients who have attended the chronic opioid use clinic, 17 attended the ED more than twice per year (30%), whilst only 0.06% of unselected ED patients did so over a similar time course. This cohort had a total of 340 ED attendances over the 4 year data set. The mean length of time spent in the ED was 188 minutes with 21 visits lasting four hours or more (6.2 %). Mean ED attendance was 0.464 ED visits per month before clinic review and 0.188 after clinic review.

Conclusion

Patients with long term opioid use were more likely to frequently attend the ED. The rate of ED attendance was reduced following attendance at the designated opioid clinic, suggesting that structured, standardised and monitored opioid prescription may reduce the need for unscheduled care.

Management (Audit)

050 Analysis of Satisfaction Questionnaires Completed By Patients Discharged From One-To-One Work with An Exercise Professional Within A Pain Management Service

Category: Management (Audit)

Linda Knott, John Clare, Emma Downie, Rob Handley

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

Background

The pain management service in South Devon comprises consultant in pain medicine, physiotherapists, nurses and psychologists, with the physiotherapists working across primary and secondary care. In 2005 a new post was created for a fitness instructor/exercise professional (EP) to work with patients on a one-to-one basis and also to contribute to existing groups. A new applicant came into this part-time post in February 2011 (JC) providing an opportunity to be more rigorous in data collection for outcomes and patient satisfaction. This presentation focuses on the development and Results of a new satisfaction questionnaire for patients who have been discharged from individual work with JC. It explores satisfaction in the context of the aims of the job role: confidence and motivation, and the provision of appropriate information, to develop or continue with regular exercise in the home or community setting.

Methods

LK and JC reviewed the job role and aims of the EP and developed initial questions to explore patients’ perceptions of these being fulfilled by asking “How much did the exercise instructor help you with”: confidence in undertaking regular exercise, going to the gym/classes, undertaking daily activities; motivation to do regular exercise; improvement in general mobility, aerobic fitness, fitness for work; help with weight control, returning to specific sports/classes, developing new exercise approaches; information about classes/facilities. Care was taken to address issues pertaining readability, avoiding ambiguity and relevance and included a 0-5 scale. Anonymised demographic information was collected. Patients and staff were asked to trial the questionnaire and amendments made. Between December 2011 and November 2013, JC distributed satisfaction questionnaires at discharge. These were returned by post or to reception. JC entered anonymised data onto an Excel spreadsheet which has been analysed using descriptive statistics and thematic analysis.

Results

232 patients were discharged with 105 questionnaires being distributed. Reasons for non-distribution for the 127 questionnaires included: not opting-in for treatment; failing to attend; referred back to referrer for clinical reasons. 90(85.7%) forms were returned (68.9% females), representing the 10-20 and 81-90 age categories with a skew towards the 40-80 age groups. 64% described having between 2-5 appointments. At assessment, 25.6% stated they were exercising regularly: this increased to 94.4% at discharge. Confidence to undertake a regular exercise programme and gain more information/ideas were the most endorsed questions, with 94.3% and 92.8% rating these at 4/5 or 5/5. The least endorsed was help with weight management (58.7%). Themes were developed for the questions: what was most useful (106 comments; 5 themes); least useful (5 individual comments); what would you improve (5 individual comments); further comments (38 positive, 1 neutral, 1 negative comment). The poster presents these Results in more detail.

Conclusion

This audit indicates that a fitness instructor, integrated within a pain management service, can have an important role for providing education and knowledge, enhancing confidence, reassurance, and motivation to exercise (themes from comments section). Of particular note was the improvement in the percentage of patients undertaking regular exercise (eg going for a brisk walk, cycling, doing a circuit of exercises swimming - at least twice a week). Suggestions for service improvements related to logistical issues. It is acknowledged that feedback was not received from all patients, and data entry was undertaken by the clinician seeking feedback.

051 An Audit of Pain Following Fractured Neck of Femur at York Hospital

Category: Management (Audit)

Kate Henderson, Maeve Curran, Jonathan Dilley

York Hospital, York, UK

Background

Pain is a major component of the patient experience following a hip fracture. Peri-operative pain and surgical site blood loss constitute the major physiological stresses facing these patients. Fear of pain is a major concern to these individuals and their relatives. The best form of analgesia is surgical repair but this is rarely an immediate option, necessitating a period when appropriate pain relief must be provided.

Prompt and adequate relief of pain has long been identified as a major priority in the management of hip fracture. This must be considered carefully as the characteristics of this patient group mean they are at high risk of renal dysfunction from NSAIDs and also opioid toxicity. Using nerve blockade on presentation and at the time of surgery is now recommended to minimise the use of opioids.

Methods

We carried out a retrospective audit of 50 consecutive patients presenting with fractured neck of femur to York hospital.

Our aims were to compare our current local practise in peri-operative analgesia in this patient group with guidelines produced by the National Institute for Health and Clinical Excellence and the Association of Anaesthetists in Great Britain and Ireland in 2011.

Audit Standards:

Offer immediate analgesia to patients presenting at hospital with suspected hip fracture, including people with cognitive impairment.
Offer paracetamol every 6 hours preoperatively unless contraindicated.
Offer additional opioids if paracetamol alone does not provide sufficient preoperative pain relief.
Consider adding nerve blocks if paracetamol and opioids do not provide sufficient preoperative pain relief, or to limit opioid dosage.
Peripheral nerve blockade should always be considered as an adjunct to spinal or general anaesthesia’
Offer paracetamol every 6 hours postoperatively unless contraindicated

Results

Our Results demonstrated areas for improvement with regards to initial assessment of pain. 70% of patients had a numerical pain score recorded on initial presentation; however in 18% no pain score was recorded. 94% of those who reported pain received some form of analgesia with 42% requiring intravenous morphine.

The provision of simple regular analgesia was in keeping with guidelines; 100% were prescribed regular paracetamol pre and post operatively and 91% were prescribed codeine. No patients were prescribed NSAIDs.

Nerve blocks were underused; no patients received a pre-operative nerve block in Accident and Emergency and only 56% received a nerve block at the time of surgery.

Conclusion

Changes in practise:

- A Hip Fracture Specialist Nurse has now been appointed in York. They will aim to improve initial assessment of pain and ensure adequate analgesia is provided, especially in patients with cognitive dysfunction.
- A pre-operative nerve blockade service is under development; offering fascia iliaca blocks in A&E to limit opioid usage in these patients.
- Local presentation has educated Anaesthetists, highlighting recommendations regarding nerve blockade and encouraging them to implement when appropriate.
- A dedicated slot for hip fracture surgery has been created on the Emergency theatre list on a Sunday morning to decrease the wait for surgery at the weekend.

052 Inpatient Pain Referrals - A Hidden Problem in Our Hospitals

Category: Management (Audit)

Cathy Price, Jacquie Trim

University Hospital of Southampton, Southampton, UK

Background

People with long term pain comprise a significant proportion of the UK population. The National Pain Audit found that 20% of people attending pain services (i.e. with complex needs) attended hospital services in an emergency. Still more may never attend an outpatient pain service at all. The profile and needs of this population remain poorly understood. The National Pain Audit has called for an inpatient audit in its future workplan.

Methods

All inpatient referrals to the pain management service that did not require immediate attention were made on an electronic system as part of a No Delays internal hospital project. These were triaged by a co-ordinator for the day to a pain review associated with trauma or peri-operative care that could be physician or nurse lead, to a non complex persistent pain review and to a complex pain review where a specialist pain consultant reviewed the case. All immediate referrals were made to a bleep and were not included in the data. Source of the referral and outcome were noted. A standard of 24 hours to be seen was set as part of the No Delays project.

Results

191 referrals were made in 10 weeks - this amounted to 161 referrals. 25 patients were repeatedly referred as frequent attenders. 5 were inappropriate and 5 required referral to the palliative care team. 43 (27%) of patients had trauma or peri-operative pain that was deemed to be complex. 91 (56%) had persistent pain of which 71 (44%) needed assessment by the specialist pain consultant due to complexity. a significant proportion of these required case conferencing and liaison psychiatry input. Due to lack of capacity very few of these complex patients could be seen within the time frame of 24 hours. 13 (14% of complex referrals) could not be seen at all. A significant proportion had unrecognised mental health pathology and required in hospital psychiatric assessment. Case conferences were needed on average once a fortnight.

Conclusion

The number of referrals was surprising. An electronic system allowed accurate logging and identified the need. It was not possible to see these patients within a timely fashion meaning delays in discharge in an already over stretched hospital system may occur. These patients comprise a significant workload. Mental health needs go unrecognised and undiagnosed meaning patients that may be highly vulnerable may miss out on help. A National Inpatient Pain Audit seems a highly appropriate way forwards.

053 Pain clinic correspondence - what do patients think?

Category: Management (Audit)

Leigh-James Spurling, Karin Cannons, Anne Fish, Mohjir Baloch

Frimley Park Hospital, Frimley, Surrey, UK

Background

Patients seen in our Outpatient Pain Clinic are routinely sent a copy of the post-clinic letter. This details clinic discussion, treatment and any follow-up arrangements. It is a Department of Health recommendation that patients receive such letters. Additionally, patients attending pain clinics rate the explanation of their problem to be as important as its treatment.

With this in mind, we sought to establish timeliness of patient receipt of their letters and how helpful it was to them. Patients should receive correspondence within four weeks and we aimed to establish how to improve our communication with patients through this medium.

Methods

A sample of 100 patients was selected from pain clinic attendees over a two month period (May-June 2013). New and follow-up patients from all clinicians were selected. A questionnaire pro forma with cover letter and stamped addressed envelope was sent to each patient identified.

Focussing on timeliness, we asked how long it took for patients to receive their letters. Regarding content, patients were asked to rate aspects of the clinic letters on a five point scale from ‘strongly disagree’ to ‘strongly agree’. These included clarity, accuracy, usefulness as a reminder of clinic discussions and for understanding management of the condition. We also asked whether patients felt more involved in their treatment.

Included in the questionnaire was a free text section for general comments.

Results

42 (42%) of the 100 patients surveyed responded. Of these, 38 (90%) received a copy of their letter, the majority (28, 76%) within 4 weeks.

Of those patients who recall receiving a letter (38 individuals), 34 (89%) felt more involvement in their treatment as a result. It helped 17 of 26 (65%) better manage their drug treatment, 18 of 25 (72%) understand their injection treatment, 6 of 12 (50%) understand their physiotherapy and 10 of 16 (63%) understand psychological interventions.

The majority of patients (36, 93%) thought the letters were clear and easily to understand, while 35 (89%) agreed that it was a useful reminder of the clinic discussion.

Conclusion

A clinic letter sent to the patient is an effective means of involving a patient in their treatment. However, a better understanding of their various treatments, rationale, efficacy and practical aspects could be achieved through a structured style.

Additional administrative support for the clinic has been secured to improve time to dispatch of letters. We have implemented a hand written summary sheet for urgent communications, such as medication changes, that is handwritten and sent with the patient to pass to their GP.

We are also undertaking a review of GP’s opinions of these letters.

054 Opioid Prescription in Chronic Non Cancer Pain Patients- Are We Following the Guidelines

Category: Management (Audit)

Chaitanya Kumar Hosahalli Vasappa, Arif Hasan, Arasu Rayen

City Hospital, Birmingham, UK

Background

Use of Opioids in chronic non cancer pain patients is associated with a significant number of complications and side-effects .British Pain Society has published clear guidelines for prescribing opioids in this group of patients. The guidelines state that all patients with opioids prescription should be reviewed at least bi-annually. The regular reviews are also important to assess the need to continue opioids. We undertook an audit to review our opioid prescription practice and compliance with guideline.

Methods

All patients attending our multidisciplinary pain clinic during the month of November 2013 were included in the audit. A standard questionnaire was used to collect the data. It included questions to find out the type of opioid, duration of use, person prescribing, frequency of reviews and effectiveness of opioid in controlling pain.

Results

Audit data was collected from 152 patients in one month. Out of this, 37% (57 patients) were on strong opioids. Of the 57 patients, 38% were on morphine compared to 47% who were on tramadol.

Audit also showed that more than half (52%) of opioid prescriptions were started in primary care.

Of the 57 patients who were on opioids, 3 were having repeat prescriptions without any reviews. But majority had their reviews at least every 6 months (52% or 30 patients).Some of the patients (18) were not sure whether they had any reviews or not.

Even though some of the patients (24/57) claimed to have some benefit, 10 patients found no benefit with their opioids.

Conclusion

Our audit clearly shows that significant number of patients having opioids prescribed were not having regular reviews. Several patients lacked awareness regarding their reviews and thereby its importance.We really have to question whether it is appropriate to continue opioids for patients who do not find benefit from them.

We plan to educate both patients and health professionals regarding the importance of regular reviews. The Results of this Audit would be used to make amendments to the opioid prescription practice in primary care and Pain clinics so that we would avoid any inappropriate opioid prescriptions and follow BPS guidelines.

055 Opioid Pathway in Chronic Non-Malignant Pain - Reducing the Risk And Improving The Benefit

Category: Management (Audit)

Christine Waters, Heather Riggs, Alison Morris, Dawn Pretty, Rajesh Munglani, Marcia Schofield, Louise Jeynes

West Suffolk NHS Foundation Trust, Bury St Edmunds, UK

Background

In 2005 universal recommendations in opioid prescribing for chronic non-malignant pain (CNMP) were suggested (Gourlay 2005). In 2010 the British Pain Society published revised guidance on prescribing of opioids in persistent pain. These recommendations and guidelines provided a useful framework to establish and incorporate locally agreed standards for clinical practice within a pathway for chronic opioid therapy (COT).

Key components of the pathway include the use of opioid screening and monitoring tools, standardised patient information, both written consent and agreement documentation alongside goal setting. The pathway is led by pain clinicians and co-ordinated by clinical nurse specialists.

The aim of this retrospective audit was to review electronic records of patients who have attended the opioid clinic at the West Suffolk Hospital (WSH) to i) review standards for documented clinical practice and ii) to identify any aspect of care that could be improved upon.

Methods

An audit was undertaken after the introduction of an opioid pathway to determine compliance with the following audit indicators:

All patients will have a diagnosis or an appropriate differential diagnosis.
Screening for risk of addictive disorders undertaken prior to initiation.
Written and signed informed consent to the use of opioids obtained prior to initiation.
Written and signed treatment agreement to the use of opioids obtained prior to initiation.
Pain level and function are assessed and documented before the start of treatment.
Patients are provided with an appropriate trial of opioid therapy.
Pain level and function are regularly assessed.
The four As of pain medicine regularly assessed (analgesia, activities, adverse effects and aberrant drug-related behaviours).
Periodically pain diagnoses and comorbid condition reviewed.
Careful monitoring of prescribing evident.
For high risk patients secondary monitoring in place.

Results

70 electronic records of patients who had attended the opioid clinic at the WSH were reviewed. For all the above indicators the required locally agreed standard was 100%. Results demonstrated mainly excellent compliance for audit indictors with all Results varying between 96-100%.

Conclusion

Early Results demonstrate excellent compliance with the locally agreed standards.

These findings suggest that an agreed opioid pathway influences good clinical practice in relation to opioid prescribing in CNMP. Following the implementation of a pathway for COT we have observed an improvement in risk assessment and risk stratification, informed consent and agreement as well as improved monitoring. We feel that a pathway offers an opportunity to reduce risks whilst maximising the benefit of opioid therapy.

056 The Impact of Pain Service on Pain in Chelsea and Westminster Hospital

Category: Management (Audit)

Izabella Fabri¹, Maya Sussman², Jessica Borrowman², Elizabeth Goodier², Carsten Bantel², Sarah Thomas², Miss Charlotte Halmshaw²

¹Medical Faculty, University of Novi Sad, Novi Sad, Vojvodina, Serbia, ²Chelsea and Westminster Hospital, NHS Foundation Trust, London, UK

Background

The in-patient pain team in Chelsea and Westminster Hospital is a nurse-led, anaesthetist-supported, service. It aims to review patients with poor pain control, w and make recommendations on management. It comprises of acute and chronic subspecialists; the former is dedicated to managing post-operative and medical patients for example sickle cell crisis. Whereas the latter deals with patients with complex biopsychosocial health and analgesic needs. The service is available for children and adults.

The goal of the pain team is to improve patient care by providing individualised and specialized pain relief Methods, improve pain control and allow for timely discharge.

Audits have been carried out for pain team for single interventions, however most patients are seen on several occasions, and their complete management from referral to discharge has never been audited.

Methods

We carried out a retrospective database analysis of all in-patients seen by the pain team over an 8 month period, from April to November 2013. Pain follow-up documentation used for review and treatment of patients, were analyzed. Demographic, reasons for admission, baseline analgesia and pain team interventions were recorded, as well as total number of visits and time spent. Numerical rating scales (NRS) for pain assessment were used as outcome measures. Data was analyzed with descriptive Methods, correlations and regression analysis to determine which pain team variables influenced the outcomes. Data was analyzed in IBM SPSS 22.0. P<0.05 was considered significant.

Results

N=124 paediatric patients (Acute 97%, Chronic 3%), and n=249 adult patients (Acute 83%, Chronic 35%) were identified. Mean age was 53.8 (range 17-99) in adults and 6.3 (range 0-17) in children. Mean pain scores at discharge (Adults=3.1 SD2.74, Children=1.3 SD 1.95) were significantly lower (Adults P=0.003, Children P=0.000) compared to scores at admission (Adults=5.2 SD2.95, Children=3.3 SD 3.06) . N=89 (35.7%) of all adult referrals had pain scores available at referral and discharge. Of these, 44% had more than 50% resolution in NRS. Similarly, n=50 of paediatric referrals (40.3%) had complete NRS scores, of which 76% had pain relief greater than 50%. Descriptive data analysis showed there was a greater number of total pain team interventions within those patients with more than 50% pain resolution in the paediatric group. Whereas adults were likely to benefit from the introduction of new medications. The correlations in both groups were not statistically significant.

Conclusion

The reduction in pain scores suggests the pain team has a positive impact on in-patient pain management. However, there are too many variables affecting pain scores, which we were unable to control. For example, one would expect time itself to improve pain scores in an acute situation. Furthermore, the large amount of missing data may be poorly representative of the sample. Future audits should aim for clearer and more complete data collection with fewer numbers of variables. As well as including patient perspectives and cost-benefit analyses.

057 What does multimodal analgesia mean? - Results of a Multi-Centre survey

Category: Management (Audit)

Matthew Poynton, Christian Sawicki, Helen Laycock, William Wynn-Jones, Emma Casely, Ping-Yi Kuo, Jane Quinlan, Miriam Kadry, Alice Fung Wah Man, Ashwin Kalbag, Jeyakumari Anandanesan, Carsten Bantel

Imperial College London, London, UK

Background

Multimodal analgesia currently is the gold-standard approach for treatment of pain in hospitals. The goal of this strategy is to address different pain pathways with different medications to improve quality of analgesia and to reduce opioid consumption¹. The latter is especially important as opioid-related adverse effects are often bothersome (drowsiness, itchiness, constipation, nausea and vomiting) and sometimes even life threatening (respiratory depression). The so far most widely used multi-modal regimen is prescribing according to the World Health Organization (WHO) analgesic ladder, which initially included three steps². Recently a fourth step has been introduced including adjuncts like ketamine or gabapentin³.

However, to what degree this modified WHO ladder is employed is completely elusive at present. Hence an audit was conducted to evaluate analgesic prescribing according to the modified analgesic ladder.

Methods

Between March and April 2012 a multi-centre survey involving six London and Oxford teaching Hospitals was conducted. Included were all patients admitted to normal surgical and medical wards, excluding specialist areas (A&E, labour ward, psychiatric wards, day surgery units, critical care units). Patients were exposed to short questionnaire-based interviews, asking about their current pain intensity and co-morbidities. Drug charts were reviewed to obtain information about opioid consumption and co-analgesic prescribing and administration. Descriptive statistics were employed for data analysis. Data were presented as n (%) for the entire cohort, for medical and for surgical patients, respectively.

Results

902 patients (507 medical and 395 surgical) were included in the analysis. Common analgesic regimens coincide with WHO analgesic ladder use, increasing in steps as pain increases. N=247 (27%) patients received WHO1 analgesia only (n=178 (35%) medical and n=69 (17%) surgical). N=173 (19%) patients also received additional WHO2 analgesia (n=101 (20%) medical and n=72 (18%) surgical) whilst n=304 (34%) had WHO1, WHO2 and WHO3 analgesia (n=88 (17%) medical and n=216 (55%) surgical). Paracetamol was most commonly used in the WHO1 analgesic group, with tramadol being the most frequent WHO2 analgesic and short acting morphine the most common strong analgesic (WHO3). In general, the most often prescribed drugs were WHO1 analgesics (n=692; 77%), with WHO2 and WHO3 further behind (n=366; 41% and n=306, 34% respectively). Adjuncts (ketamine, gabapentenoids, antidepressants) were prescribed in n=67 (7%) cases (n=27, 5% medical; n=40; 10% surgical). However, n=178 (20%) patients did not receive any analgesics.

Conclusion

Across London and Oxford hospitals, analgesic prescribing often followed the WHO analgesic ladder. However, pain management still heavily relies on opioid based analgesics with adjuncts at present only playing a side role. Certain drug combinations are favoured moving up the ‘pain ladder’, which may be due to increased clinical pain management efficacy, or perhaps to reduce drug interactions. Further studies needed to determine the efficacy of these, and other, analgesic combinations.

058 Do patients actually take their pills? An audit on patient compliance with prescribed analgesics from pain clinic

Category: Management (Audit)

James Wilson, Adam Woo

Kings College Hospital, London, UK

Background

In Pain Clinics, we prescribe many medications for analgesia and assume these will be continued. These all have potential side effects and financial implications. Patient compliance is often poor, leading to drug discontinuation. Frequently patients in follow up or drug titration clinics are unaware of the drugs and doses they are taking leading to wasted appointments. General Practitioners may also stop expensive anti-neuropathic medications and switch them to cheaper alternatives.

In the current financial situation we need to avoid wasted appointments so we set out to design an audit to look at how common this problem actually is and how we could improve patient compliance and improve the efficient use of resources.

Methods

A prospective audit was performed on 100 follow-up patients in Kings College Hospital Pain Clinic. They were all asked the same standardised questions to see if they were compliant with the medication regime prescribed by the Pain clinic, if they were non-compliant or if it was impossible to assess compliance as they did not know what they were taking.

If they were non-compliant, we looked at whether they were taking a different dose to that prescribed or not taking the medication at all. We then looked at the causes of non-compliance; whether that was because of side effects, lack of efficacy, GP not happy to continue the medication, language and communication difficulties or not known.

Results

We analysed data on 100 outpatients. Of these; 53% were taking the medication at the dosage prescribed by the pain clinic. 35% were not taking the medication as prescribed and in 12% we were unable to assess what medication they were taking.

Of the patients who were not taking the medication prescribed; 54% were taking the same medication at a different dose and 46% were no longer taking the prescribe medication at all. Reasons for non-compliance were; side effects 46%, lack of efficacy 26%, GP not re-prescribing 31%, language barriers 3% and unknown 23%.

Conclusion

We found that 12% of our pain outpatients did not know what medication they were taking at all, representing a significant waste of clinic time. A significant percentage of patients non compliant with prescribed medication were due to lack of efficacy or side-effects but nearly a third were due to GPs discontinuing medication prescribed in clinic.

In order to enhance efficient use of Pain Clinics, efforts must be made to ensure that patients bring accurate records of any drugs taken to clinic and further collaboration with GPs is essential to determine what drugs will actually be continued in Primary Care.

Management (Research)

059 Outcomes Comparison: Carpal Tunnel Surgery and Mechanized Therapeutic Massage

Category: Management (Research)

Maik Zannakis, John Baird

500 patients completed baseline survey; 493 (99%) met OIC criteria. Overall, mean age was 52.6 years; 62% were female; 85% were Caucasian. Back and joint pain most commonly reported (77% and 52% respectively). 19% were fulltime employed and 35% were unable to work. Average pain severity (0-10 scale) in past 7 days was 6.3 and mean patient opioid use was 6.4 years. Overall, 97% patients reported at least one symptom of OIC, the commonest being ‘straining to pass BM’, ‘BMs too hard’ and ‘bloating’. 84% subjects were using ‘natural therapies’ and exercise. 60% used at least 1 OTC laxative medication. 19% overall were using at least 1 prescription laxative. 33% had no benefit from constipation treatment and 56% were not satisfied with their treatment. 66% of physicians had knowledge of patients’ experiencing OIC. 31% of physicians were unaware patients experienced OIC; and only 53% were aware of patients taking laxatives.

Conclusion

OIC is associated with significant burden of symptoms that compromise activities of daily living. The prevalence of these symptoms suggests under treatment and/or ineffective treatment. The majority of patients were not satisfied with their OIC treatment and only a third felt they benefited from laxative treatment. Physicians have a poor knowledge of how much constipation their patients are experiencing and had little insight into their medication. More research is needed to better understand treatment goals with chronic pain and OIC and to identify more efficacious treatments.

Neuropathic Pain

062 “What i really needed was the truth”. Exploring the information needs of people with complex regional pain syndrome

Category: Neuropathic Pain

Sharon Grieve^1,2, Jo Adams², Candida McCabe^1,3

¹Royal National Hospital for Rheumatic Diseases, Bath, UK, ²University of Southampton, Southampton, UK, ³University of the West of England, Bristol, UK

Background

United Kingdom guidelines indicate individuals with Complex Regional Pain Syndrome (CRPS) require information and education to support self management (Goebel et al. 2012). However, there is little evidence regarding the specific information needs of this patient group. Research indicates individuals with CRPS recognise the importance of being informed; to increase knowledge, normalise their experience and learn new coping strategies (Rodham et al. 2012). However when investigated, patients actual knowledge of the condition may be limited potentially undermining their ability to successfully self manage CRPS (Brunner et al. 2010). The opportunity for individuals with CRPS to access information from health professionals or other sources is crucial to facilitate diagnosis and to initiate and engage with therapies early in the onset of the condition. This qualitative study explored the specific information requirements of patients with CRPS and provides insight into how health professionals can best provide this.

Methods

Following ethical approval, study information was placed on three websites for those with an interest in CRPS. Eight adults living with CRPS in the United Kingdom were recruited and semi-structured telephone interviews were conducted following informed consent. They were asked about their experience of receiving information since diagnosis and what information they would choose to receive and in what form. The interviews were audio recorded, transcribed verbatim and analysed using thematic analysis (Braun and Clarke 2006). A summary of the interview was returned to each participant for respondent validation adding credibility to the data. To offset researcher bias, a random sample of the data was coded independently by a peer researcher. The findings were then taken back to the participants using a questionnaire, asking what information they perceived to be the most important to receive and in what form.

Results

Five themes emerged from the data. Two related to the individuals’ experience of receiving information; ‘Facing the unknown’ illustrates how little information participants felt was available and the impact of this, including the difficulty accessing clinical expertise. ‘The need to be an expert’ describes how the individual was required to be proactive to seek this information themselves, often needing to educate health professionals who lacked awareness of CRPS. Three themes related to what information the individual would choose to receive: ‘Seeking the truth’ describes the need for knowledge, in particular accurate, honest information and information about possible outcomes. ‘The shared experience’ describes the positive and negative aspects of sharing information with others experiencing the same condition. ‘Access to expertise’ describes the need for access to reliable information and resources, and improved access to expertise.

Conclusion

Participants described receiving little information from many health professionals at diagnosis and beyond. The internet was the most frequently used resource and information was found to be inconsistent and difficult to access. Consequently there was a struggle for participants to understand the condition, access expertise and appropriate treatment. Participants identified a need for accurate, truthful information from initial diagnosis to address questions such as risk of spread, fear of making the condition worse and how to live with CRPS. They preferred to access this from health professionals directly. Easily accessible patient resources to facilitate early referral for expertise are required.

063 Qutenza® (Topical Capsaicin 8%) For The Treatment of Neuropathic Pain from Critical Ischaemia and Digital Ulceration In Patients With End-Stage Renal Disease: A Case Series

Category: Neuropathic Pain

Emma Aitken, Gillian McColl, Mick Serpell, David Kingsmore

Western Infirmary, Glasgow, UK

Background

Peripheral vascular disease (PVD) is common in end-stage renal disease (ESRD). Advanced disease and extensive co-morbidities limit surgical revascularisation options in this patient group. Often the only treatment option is symptomatic relief. Effective analgesia can be difficult to achieve, limited by side effects e.g. confusion and drowsiness. A drug which is not renally excreted, has minimal systemic absorption and does not require dose adjustment in renal failure, is an attractive alternative.

Qutenza® (topical capsaicin 8%) is a dermal application system for the rapid delivery of capsaicin into the skin. High concentration capsaicin causes reversible desensitisation of TRPV-1 expressing cutaneous sensory nerve endings and reduction in nerve fibre density in the epidermis (Noto et al., 2009). Qutenza® is licensed for the treatment of neuropathic pain in non-diabetic patients. We present a case-series of patients with ESRD, critical ischaemia and digital ulceration treated for neuropathic pain with Qutenza

Methods

A case series of 6 patients with ESRD with neuropathic pain from critical ischaemia with digital ulceration is presented. All adult patients (including diabetics) receiving renal replacement therapy with neuropathic pain resulting from critical ischaemia (most days for >3 months) which was unresponsive to standard analgesics and digital ulceration were eligible to participate. Patients were excluded if they had active ulceration at the site of intended treatment.

A single treatment of topical Qutenza® was applied to the painful area for 30-60 minutes in line with manufacturer’s guidelines.

Response was assessed used Visual Analogue Pain Score (VAS), Brief Pain Inventory (BPI) and EQ-5D quality of life score at week 1, 6 and 12. Concomitant analgesics, side effects and complications were also recorded. Primary efficacy outcome was change in VAS from baseline to week 12.

Results

5 patients were diabetic. All had digital ulceration proximal to the site of treatment. All but one patients required strong opiate analgesia prior to treatment; all 6 were taking gabapentin or amitriptyline. All experienced side effects of these.

Median baseline VAS was 8 (IQR 7,10). Median VAS at 12 weeks was 4 (IQR 2,10). 4 patients had a reduction in VAS at 12 weeks >30% compared to baseline. 3 of 6 (50%) had a reduction in their opiate analgesic requirements. There were also improvements in EQ-5D quality of life scores in pain and mood domains. One patient experienced mild self-limiting superficial blisters at the application site. No other issues with tolerance or complications were observed.

Ulceration resolved completely in two patients (one following arterial bypass and one following ligation of arteriovenous fistula), remained static in two patients and necessitated below knee amputation for wet gangrene (unrelated to treatment) in another.

Conclusion

Treatment of neuropathic pain from critical ischaemia is a novel application of Qutenza® (topical capsaicin 8%). We demonstrate safety and efficacy in a small case series of high-risk comorbid patients. Concern has been raised previously regarding the safety of Qutenza® in diabetics and those with vulnerable skin. We have not seen evidence to support these concerns in this small cohort. Lack of systemic side effects makes Qutenza® an attractive analgesic for patients with ESRD.

064 Local Experience of Running a Nurse-Led Qutenza® (Capsaicin) 8% Patch For The Treatment Of Neuropathic Pain

Category: Neuropathic Pain

Suzanne Blowey

Plymouth Pain Management Centre, Plymouth, UK

Background

Burden of neuropathic pain. Neuropathic pain is an unpleasant sensory and emotional experience that can have a significant impact on a person’s quality of life. Patients with neuropathic pain have higher than average pain scores and lower HRQOL, they require more medications for pain and report less pain relief with treatment. In RCTs typically ≤50% of patients experience satisfactory pain relief. Patients may continue to have pain of moderate severity despite taking medications for their condition. Many patients require treatment with combinations of medicines which may provide greater analgesia but can be associated with increased side effects, inconvenience, risk of drug-drug interactions and increased costs

QUTENZA® is a high concentration capsaicin (8% w/w) patch. A single dermal application provides patients with significant pain relief that can be maintained for at least 12 weeks QUTENZA® targets the source of peripheral neuropathic pain with transient low levels of systemic absorption

Methods

We collected data from bi-weekly clinics between September 2010 - 2013. We received 33 referrals - male n=21, female n=22 age range 32-90 years. Types of neuropathic pain PHN n=23, Peripheral neuropathy n=6, Neuropathic pain n=6, Post radiotherapy / chemotherapy related pain n=3, Scar pain n=2. VAS ranges from 2-10, average 6.7, symptoms - allodynia 45%, unable tolerate clothing 30%, burning 25%.

From 33 referrals n=25 patients were actively treated and n=8 patients did not fulfil local criteria. Of 25 patients we undertook 46 treatment episodes with and without prior application of EMLA.

Results

We collected post treatment data from n=11 patients, VAS range 0-9, average 4.0. n=2 patients experienced 90% relief, n=5 patients reported that their area of neuropathic pain changed considerably. n=1 patient commented ‘I can’t believe the difference’

In our local experience n=3 had 6 week benefit only, n=2 treatment efficacy diminished over time, n=2 difficulty in tolerating mapping, n=1 plaster effective but suffered significant rash, n=3 could not cope with the distance travelled

Conclusion

It appears that Qutenza® is effective in treating neuropathic pain and can be delivered as a nurse-led service. For some patients the difference it appears to make to their quality of life is considerable.

065 Improving the Understanding and Treatment Of Neuropathic Pain

Category: Neuropathic Pain

David Buckley¹, Helen Radford², Mark Johnson², Dave Finn³, Patrick McHugh¹

Since made available, it was standard to use local anaesthetic pre-treatment in conjunction with capsaicin 8% applications. A recent study (LIFT¹) challenged this practice prompting the European Commission to liberalize their recommendations.² However, this proposed change in practice is still contentious amongst clinicians.

In our institution, we have undertaken Qutenza® 8% patch applications without local anaesthetic preparation since June 2012. Our clinical observations suggest, that the experience of discomfort of patients pre-treated without topical local anaesthetic is comparable to those who received pre-treatment. This study therefore aimed to shed light into the confusion about whether or not to pre-treat. Through analysis of a recently created database we aimed to elucidate the need for local anaesthetic pre-treatment in our patient population. Further, we wanted to explore co-factors that predicted the need for rescue analgesics.

Methods

In October 2010 a clinical database was created that aimed to monitor treatment related outcomes of capsaicin 8% therapy. Information were entered on the day of procedure and on follow-up.

Between October 2010 to August 2013 a total of n=115 patients were entered into the database. However, n=214 single applications of the Qutenza® 8% patch were identified and further analyzed for this study. Patients included suffered from a wide range of peripheral neuropathic pain conditions.

The requirement of rescue analgesia during or after patch application was defined as primary outcome. Co-variables thought to change this outcome were included in the analysis. These were; aetiology of pain, location of patch application, number of patches applied and applications with and without topical local anaesthetic preparation.

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

Results

59% (n=127) of applications were carried out with pre-application of topical local anaesthetic and 41% (n=87) without. There was no statistical difference between the two groups in reporting clinically meaningful treatment related discomfort. Hence pre-treatment with topical local anaesthetic made no difference in our patient population.

However, 20% (n=42) of applications were associated with treatment related discomfort across both groups warranting rescue medications. Just over half of these applications 11% (n=23) required a strong opioid administration during or following treatment, whilst the remaining 9% (n=19) were managed using with WHO step I and II analgesics.

The total number of patches applied in one single application was positively correlated to treatment related discomfort, revealing a 1.2 times increased likelihood to experience discomfort with an increasing number of patches applied. Chest wall, legs, feet and hands, were associated with the highest levels of discomfort and this finding was statistically significant (P=0.02).

Conclusion

The Qutenza® 8% patch appears to be well tolerated in terms of clinically meaningful treatment related discomfort even without pre-treatment with topical local anaesthetic. This reflects the findings of the LIFT study.¹

The threshold for rescue analgesia appeared to be high in our patient population, which represented a wide range of peripheral neuropathic pain conditions.

The greater the treatment area the more demand there was for multiple patch application. We have demonstrated that areas of the body where the surface area of pain is generally greater, clinically meaningful treatment related discomfort becomes significant.

070 An Investigation into the Use Of Capsaicin Patches For Post-Surgical Neuropathic Pain

Category: Neuropathic Pain

Stephen Hickey, Kathyrn Hill, Joanne Wood

NHS Forth Valley, Larbert, Scotland, UK

Background

Neuropathic pain affects 1-2% of UK population. A concentrated capsaicin (8% w/w) patch has been introduced as a novel therapy for neuropathic pain. In Scotland, these patches are limited for use in the treatment of adults with post-herpetic neuralgia (PHN).

In our practice we see more post-surgical neuropathic pain (PSN) than PHN and we hypothesized that capsaicin patches would be beneficial in this group and our aim was to see if this was the case.

Methods

We collected data on patients treated with patches through our pain clinic for one year. For those who did not have PHN, we applied on a case by case basis for permission to use the patches on these patients. All patients had tried a number of different therapies including opiates first. We documented the size of area to be treated and VAS scores before and after treatment. We used an improvement in VAS score and/or reduction in size of area treated as an improvement.

Results

Table to show summary of Results

Aetiology PSN PHN
Improved 9 1
No difference 11 4
Worse 1 0
Outcome awaited 1 0

Conclusion

Our Results show that less than 1 in 3 patients with PSN have to be treated for 1 patient to show an improvement. This is compared to 1 in 5 patients for PHN. Although the numbers are small, this could make a case for extending the use of capsaicin patches to PSN patients in Scotland.

071 Qutenza® (8% Capsaicin Transdermal Patch) In the Treatment of Crps (Complex Regional Pain Syndrome): A Case Study

Category: Neuropathic Pain

Nishi Patel, Claire Walder, Carol Hunter, Jonathan Francis

Cheltenham and Gloucestershire NHS Trust, Gloucester, UK

Background

The 8% capsaicin (Qutenza®) transdermal patch is designed to deliver up to 12 weeks pain relief from peripheral neuropathic pain. Qutenza is indicated for the treatment of peripheral neuropathic pain in non-diabetic adults. The role of Qutenza® in Chronic Regional Pain Syndrome (CRPS) is yet to be fully elucidated. This case study evaluates the effectiveness of Qutenza treatment on a patient with CRPS of the ankle.

The patient concerned is a 44 year old male, who was first diagnosed with CRPS following an avulsion injury of his left malleolus in 2006. His symptoms included a continuous burning pain, extending from his toes up to his knee. He had unilateral temperature and colour changes and altered hair and nail growth. Since being referred to the chronic pain team in 2007, he has tried a myriad of medications, physiotherapy, a desensitisation programme and injections, all of which have offered no improvement.

Methods

Prior to initiation of treatment with Qutenza® in July 2012, a ‘Pain and Quality of Life Service Evaluation’ was performed to try and quantify the severity of pain and its effects on his everyday life. Pain severity at various times was scored out of 10 as was the degree of interference of pain on general activity, sleep, mood and work. The patient was also asked to select statements best describing his health in relation to mobility, self-care and mood. Finally he was asked to indicate on a scale of 0-100 how good he perceived his general health to be.

He was treated in clinic with two 8% capsaicin patches applied for 1 hour to his ankle after an initial application of local anaesthetic cream. This treatment regimen was repeated every 6 weeks. A pain and quality of life questionnaire was completed at every treatment session to monitor progress.

Results

Prior to his Qutenza® treatment, the patient was requiring slow release tramadol 100mg four times daily, 100mg twice daily of pregabalin, 5% Versatis® (lidocaine patch), 12mcg fentanyl patch and 25mg of amitriptyline. Despite this his daily average pain score was 9 out of 10 and he reported that the pain severely interfered with his sleep (9/10), walking, work and relationships resulting in very low mood. He marked his general health at only 35/100 where 0 is the worst imaginable health state and 100 the best.

Fortunately the patient reported an improvement in his symptoms with each treatment and by November 2013 he ‘felt a great deal better and that a considerable improvement had been made’. He had halved his tramadol dose, and stopped his Versarti®s. His average pain was reduced to 4/10. The interference of pain on his life was markedly improved and his ‘health state score’ improved to 80.

Conclusion

This case demonstrates a significant improvement in reported pain scores as well as function and quality of life following treatment of CRPS with capsaicin cream (Qutenza®). Whilst the treatment of CRPS requires a multi-disciplinary approach this case shows us that there may be a role for capsacin in its management and that further study is warranted.

072 Topical Delivery of Gabapentin for Neuropathic Pain: A ‘Proof of Concept’ Analysis

Category: Neuropathic Pain

Sharmila Khot^1,2, Sarah Hiom¹, Susan Mogford¹, Catherine Hart¹, Robert Newcombe²

¹University Hospital of Wales, Cardiff, UK, ²Cardiff University, Cardiff, UK

Background

Some patients cannot tolerate oral gabapentin for neuropathic pain. Topical gabapentin, manufactured as a pharmaceutical ‘special’, has been used as a treatment alternative in chronic pain clinics. These preparations are limited in that they lack robust evidence to support safety, efficacy and quality. We performed a pilot study to assess the effectiveness and tolerability of 6% w/w gabapentin gel, manufactured by a local NHS pharmacy manufacturing unit (SMPU, Cardiff), for the treatment of a variety of peripheral and localized neuropathic pain conditions. The wider collaborative research group also explored mechanisms of action using human tissue and animal studies and quality aspects of formulation development. We conducted a proof of concept study to investigate safety and efficacy of topical gabapentin for peripheral neuropathic pain.

Methods

We present a single centre consecutive series of case studies (n=23) where pain (NRS 1-10) QOL and sleep scores pre/post treatment were assessed. A clinically significant reduction in pain score = 2. Data was collected monthly from notes of patients being treated with gabapentin gel. The case mix included PHN, DPN, CPSP, CRPS and vulvodynia. Patient treatment regimens followed local neuropathic pain guidelines (NICE 2013). Patients were only offered topical gabapentin if proven refractory or suffering intolerable side effects to standard treatments.

In order to assess long-term efficacy of medication, a six-month data set was reviewed which included data sheet collected outcome measures from individual patients. Pain relief at the end of the 6-month period was the same as that at the 2^nd month.

Some patients had additional treatments and this data was not included in the final analysis presented. However a separate analysis for all patients demonstrates similar Results.

Results

Data analysis demonstrates statistically and clinically significant reduction in pain scores after one-month treatment (n=20) with remaining patients (n=3) reporting unaltered pain scores. Mean pain, sleep and QOL scores at baseline and 1 month after treatment changed from 8.1 (SD 1.5) to 5.3 (SD 1.6), 5.8 to 7.1 and 4.2 to 5.5 respectively with Wilcoxon signed rank test indicating strong tendency for the pain score to decrease after 1 month (p<0.001). Individual patients reported between 30-80% pain relief. All patients with vulvovaginal pain (4/4), PDPN (1/1) and 2/3 patients with PHN responded positively to topical gabapentin gel. Tolerance was not demonstrated where improvement seen in all one month after treatment. Individual analysis of each case indicated the gel was effective for burning pain, autonomic hyperactivity and post surgical NeP and was ineffective with dysaesthesias. However this study is limited by small sample size and absence of specific neuropathic pain measures.

Conclusion

Our study suggests that topical delivery of gabapentin can elicit a therapeutic response. A reduction in any experienced central side effects and a lower delivery dose were observed when compared to oral delivery. Topical gabapentin resulted in rapid improvement of symptoms (<1month) when compared to the gradual titration required with oral administration (< 8 weeks), with the associated patient and institution benefits.

Results support anecdotal evidence that topical gabapentin is safe and efficacious for use in refractory focal peripheral neuropathic pain. Further controlled trials will be required to validate these Results.

Non-Pharmacological Pain Management

073 Determinants of self-reported disability in arab patients with low back pain

Category: Non-Pharmacological Pain Management

Dana Maki¹, Paul J. Watson², Duncan J. Critchley¹

Using a solution focused approach, an information morning explores whether the person’s ‘best hopes’ for the programme are roughly in line with its aims. It is an inclusive approach. Patients can be offered a place if they are still hoping for a fix / cure, provided they also wish to explore living the best life they can in the meantime (the professional invites the patient to explore this with them).

The eight week community programme aims to facilitate sustainable behaviour change, long-term well-being within local networks. It includes twice weekly exercise sessions in a community gym, two hydrotherapy sessions and weekly education/discussion sessions. Discussion sessions are led by different MDT members and topics are facilitated using a solution focused approach (Sharry, 2007). Outcome measures are administered at pre-PMP, post-PMP, 10-week follow-up, 6- and 12-month follow up. The one minute sit-to-stand test is administered at pre, post and 10-week follow-up.

Results

63 females and 22 males with a range of chronic pain conditions, who attended at least 75% of the PMP sessions, were included in the analysis (ages 28 - 83 years; mean = 54 years). A series of two-tailed, paired sample t-tests investigated mean differences between pre-PMP and post-PMP, 10-week, 6- and 12-month follow up data. Statistically significant improvements were found for self-efficacy immediately post-PMP (p=<.001 - also clinically significant) and at 10-week follow-up (p=.001). Mental well-being showed statistically and clinically significant improvement at all-time points post-PMP: post-PMP (p=<.001), 10-week (p=.008), 6-month (p=.031) and 12-month (p=.038). The sit-to-stand test showed statistically and clinically significant improvement for function at post-PMP (p=<.001) and 10 weeks (p=<.001) - later time points not measured. In regards to pain levels, as measured by the BPI, no significant improvements were observed following the programme. All findings were also limited by internal and external validity.

Conclusion

Locally, a SF, community approach to PMP appears to have a positive impact with maintenance of outcomes. Minimal changes to self-reported pain levels corresponded to a recent Cochrane review (Williams et al, 2012) which also found no effect on pain (as compared to active control) for CBT programmes. The Results suggest that a SF approach is potentially as effective as other Methods, possibly more, with advantages to a community setting and concurrent opportunities for long-term support and social networking. Future evaluation/research should build upon the existing findings to encompass a larger sample and continued collection of long-term data.

077 Southport & Ormskirk Nhs Hospitals Trust Community Pain Service: “Good Vibrations” Choir Evaluation

Category: Non-Pharmacological Pain Management

Rebecca Simm, Hannah Traynor, Karen Moss, Katherine Williams

Southport & Ormskirk Hospital NHS Trust, Southport, UK

Background

An innovative NHS community project was piloted to explore the impact of singing on health and wellbeing, specifically for individuals with chronic pain attending the Community Pain Service. The ethos of the pain service involves noticing and utilising patient strengths and resources, in line with a solution focused psychological approach. Therefore the choir (“Good Vibrations”) was a joint venture between the Community Pain Service and an expert patient volunteer, who utilises singing as part of self-management for pain. It has been recognised that music can promote relaxation, wellbeing, and physical health (Stacy et al, 2002). Furthermore relaxation and improvements to breathing capacity, posture and muscle tension can be helpful in the management of chronic pain. In response to the literature, a 12 week pilot choir was facilitated. Following the success and significant findings of the pilot, the choir continues to meet and a six month evaluation undertaken to monitor effectiveness.

Methods

The pilot choir project took place over 12 weeks (one hour a week) from April to July 2013 at a local community centre, directed by the expert patient volunteer. Initially 12 individuals were recruited from a cohort of patients who had previously attended the services’ Pain Management Programme. Approval was gained from the trust’s Audit and Effectiveness Department to conduct a service evaluation. The following standardised measures were administered at week one and week 12: Pain Self-Efficacy Questionnaire (PESQ, Nicholas, 1989); Warwick Edinburgh Mental Well Being Scale (WEMBS, Tennant et al, 2007); and Brief Pain Inventory Short Form (BPI-SF, Cleeland & Ryan, 1994). A participant evaluation sheet, comprising of qualitative and quantitative items, was administered at week 12. Since the pilot project, the choir has been ongoing and further patients from the Community Pain Service have joined. A six month evaluation, using the same measures, was undertaken.

Results

The data from the 12 week pilot project suggests some improvement in post scores of self-efficacy and mental wellbeing. A series of two-tailed, paired samples t-tests investigated mean differences between pre and post choir scores and found a statistically and clinically significant improvement in mental wellbeing (p=.049). Furthermore analysis of the 6 month data (as compared to pre-choir data) demonstrated maintained improvement in self-efficacy and mental wellbeing (the latter being statistically significant p=.02). In regard to pain levels, no significant improvements were observed following attendance to the choir. An initial look at the participant evaluations suggest that overall individuals had a very positive experience of attending the choir. A common theme emerged that participants found attending the choir helped them to put pain more in the Background, with some individuals indicating that they took less pain medication on days they attended.

Conclusion

Overall the Results suggest an improvement in mental wellbeing and self-efficacy following attendance at the choir. Although there were minimal changes to self-reported pain levels, the primary aim of the choir was not to reduce the pain for individuals but to increase “living well”. Additionally it has been resource minimal. It is hoped that the choir service will be expanded for patients with other long term conditions, gaining further support from expert patient volunteers.

078 Changing the Impact of Pain: Outcomes of A Different Care Pathway

Category: Non-Pharmacological Pain Management

Luke Mordecai, Frances Cole

Bradford Teaching Hospital, Bradford, UK

Background

Evidence from recent reports show the impact of pain on health and its direct and indirect economic cost. Additionally the long term debilitating nature of chronic pain is increasingly recognised with only two thirds of the five million people diagnosed annually recovering.

Pain care pathways are largely neglected within the NHS commissioning and insufficient community CBT based rehabilitation leads to a “revolving door” patient experience in fragmented specialist services.

There are few structured, person centred community services that address both pain and health function loss, indeed only 40% of specialist pain services are truly multidisciplinary. This poster presents a commissioning solution through integrating health and self care which not only improve health outcomes but also reduces unnecessary use of primary and specialist care.

Methods

The clinic is a Tier 2, community based, multidisciplinary specialist pain self-management service. Referral is from GP’s guided by criteria. It provides a holistic approach concentrating on patient led health needs assessment, associated symptoms, fatigue, sleep, reduced physical function, and stressful life issues simultaneously and coherently.

Individuals referred had two-part assessments involving a health trainer, GPwSI in pain, physiotherapist, CBT therapist and community leisure service officer. The first with a health trainer, focused on goals for living well with pain, information on skills to self manage chronic pain and emphasising management rather than cure. The second with the clinical team addressed patient action plans and concentrated on reducing the impact of pain and improving health through application of self-management skills and other interventions. This entailed up to six, half hour sessions over 26 weeks.

On completion the patient could self-refer to the service should a setback occur.

Results

Data was recorded between November 2008 and March 2010 during which 115 patients were referred to the service.

86% stated they strongly agreed or agreed they had a better understanding of their pain and how to manage it and 84% found service very helpful. Self efficacy score change was significant.

Impact on service use in the clinic’s catchment area found lower referral rates to secondary care services. From 2009 to 2010, this was 3.5/1000 as compared to 4.9/1000 in the adjacent region. In the same regions, this corresponded to fewer hospital interventional pain procedures and less MRI imaging referrals. There was a reduction in GP consultations by 50% in six months following discharge.

Only 0.9% of the GP’s referred were subsequently referred to pain medicine clinics. GP’s shared they would have referred 50% patients to hospital care had the service not been available. No one re-referred following discharge.

Conclusion

Patients with chronic pain have significant health related consequences that rely mainly on poly-pharmacy and a significant chance of never regaining full function. The “revolving door” alluded to earlier often does little to improve consistently their health and self care. The PSM is a potential paradigm shift away from usual secondary care with efficient community access, improved health outcomes and self efficacy, confidence to cope and reduces reliance on specialist and primary care services significantly. It provides a simple, viable pain management pathway option with savings through reducing hospital referral rates and releases primary care consultation time.

079 Transcutaneous Electrical Nerve Stimulation Using a Conducting Sock In Chronic Foot Pain

Category: Non-Pharmacological Pain Management

Enrique Collantes, Erin Wynne, Christine Cleary, Stefak Yaroslav, David Pang

Guys & St Thomas NHS Trust, London, UK

Background

Transcutaneous electrical nerve stimulation (TENS) is a well established and non-invasive therapy for both acute and chronic pain conditions. The mechanism of the analgesia produced by TENS was originally explained by the gate-control theory proposed by Melzack and Wall in 1965¹.

Coverage of the painful area is usually delivered via adhesive pads but certain areas are not easily stimulated. The use of a conducting sock that can be attached to a standard TENS machine allows this treatment modality to be used in painful foot conditions.

The aim of this study is to assess the effectiveness of the TENS socks in patients with chronic painful conditions affecting the foot.

Methods

We recruited 11 patients with chronic pain affecting the foot that attended to our pain management unit over 6 months. Age range was 28 to 58 years (mean 44 years). The underlying cause was neuropathic pain (2), peripheral neuropathy (4 caused by alcohol (1), sickle cell disease (1) and diabetes (2)), complex regional syndrome (1), traumatic injury (2) and patients after undergoing orthopaedic surgery (2).

All the patients attended to a nurse led TENS clinic where they received education on TENS socks including its mechanism of action, how to operate the device and their questions were answered. Subsequently patients were followed up by telephone to review the effectiveness of the TENS socks.

The parameters used on the TENS sock were:

Continues Mode
Pulse Intensity: adjustable 0-80mA peak into 500 ohm load in each channel, constant current
Pulse Width: adjustable 30-260µs
Pulse Rate: adjustable 2-150Hz

Results

Nine patients reported a good result from the TENS socks. 55% (n=6) of the patients reported >70% pain relief. All the patients found that trying this treatment modality and the education received useful.

Conclusion

TENS using a conducting sock is useful, safe and non-invasive treatment for chronic painful conditions of the foot.

080 Perspectives of Patients, Health Professionals And Service Providers On Self-Management In Chronic Low Back Pain: A Q-Methodology Study

Category: Non-Pharmacological Pain Management

Carol McCrum^1,2, Janet McGowan², Paul Stenner³, Viny Cross¹, Emmanuel Defever¹, Phil Lloyd⁴, Robert Poole⁴, Ann Moore¹

¹Clinical Research Centre for Health Professions, University of Brighton, Eastbourne, UK, ²East Sussex Healthcare NHS Trust, Eastbourne, UK, ³Faculty of Social Sciences, The Open University, Milton Keynes, UK, 4Service User, Eastbourne, UK

Background

Chronic low back pain (CLBP) is highly prevalent and costly in terms of personal impacts, disability, work loss and health care expenditure. National guidelines and commissioning strategies encourage ‘self-management’ as an important strategy in reducing these widespread impacts. However, it is evident in research and clinical contexts that achieving effective self-management is challenging, with outcomes much less successful than expected. Despite being a strongly encouraged strategy and in contrast to other long term conditions, there is a lack of research into the concept and meaning of self-management or how it is best achieved and supported in patients with CLBP. The purpose of this study was to explore the range of viewpoints held amongst stakeholders in back care provision to inform service developments and enable more effective self-management for patients experiencing chronic low back pain.

Methods

Using a combined qualitative/quantitative approach called Q-methodology, the viewpoints on self-management of CLBP were explored through a review of related literature and four stakeholder focus groups. The viewpoints expressed were distilled into a set of 60 statements. A wider group of stakeholders including 60 patients with CLBP and 60 multidisciplinary health professionals and other stakeholders (clinicians, service providers, voluntary sector agencies) ranked the statement set onto a continuum from strongly agree to strongly disagree(a Qsort). Comments on ranking decisions for each statement were also collected. Participant questionnaires provided biographical information, demographics, levels of chronicity/disability and professional roles. Data was analysed using SPSS and PCQ to identify correlations between the stakeholders’ Q-sorts and statement rankings. Four highly intercorrelated groups of Q sorts (called ‘factors’) were evident. The particular statements encompassed within each factors were subjected to further analysis and interpretation.

Results

Four distinct viewpoints on self-management of chronic low back pain were found and described by the following themes: 1) “Changing myself” -A strongly psychological approach, needing a lifestyle/mind-set change. This was the largest perspective, expressed mainly by health professionals but also shared by patients. It could be taken as the ‘normative/authorative’ view; 2) “Changing what I do”- A strongly pragmatic approach guided by accurate information and practical strategies, shared mostly by patients and some professionals; 3) “Not sure what to change”- Managing the medical uncertainty, with the need for ongoing access to healthcare resources and assistance, expressed mostly by patients and few professionals; 4) “The others must change”- a concern with the stigmatic perception of being in chronic pain, with reliance on health professionals to acknowledge and validate their problem. This view was voiced only by patients. These perspectives appear to be independent of any obvious biographical characteristics.

Conclusion

The study provides valuable insights into the diversity, complexity and tensions in viewpoints on self-management of CLBP amongst stakeholders. Addressing these issues and the resulting differences in expectations on the nature and delivery of care seems essential for more successful engagement in and accomplishment of self-management. There is a need for achieving greater consensus amongst all stakeholders on how self-management is conceived, conveyed and supported in CLBP. Further research and education is needed both for those experiencing problems and those providing health care services to help support more effective self-management of CLBP.

081 Long-Term Results from a Randomised Controlled Trial (Rct) Of Telephone Delivered Cognitive Behaviour Therapy (tcbt) And Exercise In The Management Of Chronic Widespread Pain (Cwp), And Predictors Of Treatment-Effectiveness

Category: Non-Pharmacological Pain Management

Marcus Beasley¹, Gordon Prescott¹, Graham Scotland¹, John McBeth², Philip Keeley², Karina Lovell², Philip Hannaford², Paul McNamee¹, Deborah Symmons², Steve Woby³, Gary Macfarlane¹

¹University of Aberdeen, Aberdeen, UK, ²University of Manchester, Manchester, UK, ³Pennine Acute Hospital NHS Trust, Manchester, UK

Background

Chronic Widespread Pain (CWP), the primary symptom associated with fibromyalgia, has been shown to persist over time. It is challenging to manage and can have impacts on functioning and quality of life. Recent reviews have, however, suggested that non-pharmacological treatments such as behaviour therapy and exercise may be effective, at least for short-term management. The MUSICIAN study was a trial of 6-month courses of treatment by telephone-delivered cognitive behavioural therapy (tCBT), exercise, or a combination of both for the management of CWP that have previously shown short-term improvements in patient-reported health compared to treatment as usual (TAU). The aim of the current study is to determine whether these improvements are maintained long-term (2 years after the end of treatment), to determine if any of the active treatments were cost-effective in relation to TAU, and to determine if pre-treatment characteristics identify patients who are more likely to benefit from these treatments.

Methods

Population survey was used to identify patients who: met the American College of Rheumatology (ACR) definition of CWP, consulted a GP for pain in the last year, and had no contraindications for exercise. Random assignation was to: a) 8 weekly sessions of tCBT, with refreshers at 3 and 6 months; b) an individually tailored exercise programme with monthly review over 6 months; c) both active treatments, or d) TAU. Follow-ups were at end of treatment, and 3 and 24 months later. Primary outcome was self-reported change in health since before the trial. Positive outcomes were ‘Much better’ or ‘Very much better’, on a 7-point scale from ‘Very much worse’ to ‘Very much better’. Analysis was by longitudinal logistic regression. Results are presented as odds ratios (OR) with 95% Confidence Intervals (CI). Additional models were run to assess cost-effectiveness, and the influence of baseline characteristics on the effectiveness of each treatment.

Results

442 persons (median age 57 years, 57% female) were randomised of which 361 (82%) provided information 24 months post-treatment. The percentage of patients reporting positive outcome at the final follow-up was: TAU 12.8%, tCBT 35.4%, exercise 29.4%, and combined treatment 31.2%. At 24 months, positive outcome after adjustment for baseline characteristics was more likely for tCBT (OR 3.6; 95% CI 1.7, 7.6), exercise (2.5; 1.2, 5.4), and combined treatment (2.9; 1.4, 6.0) compared to TAU. Of all four groups, tCBT had highest probability of being cost-effective at a ceiling willingness to pay ratio of £20,000 per Quality Adjusted Life Year gained. Baseline characteristics associated with greater response to tCBT at any time-point were high psychological distress (treatment-predictor interaction OR 5.6; 1.5, 21.2), and high kinesiophobia (4.7; 1.1, 20.5). High Chronic Pain Grade at baseline was significantly associated with a greater response to Combined Treatment (8.3; 1.6, 43.4).

Conclusion

A six-month programme of exercise or tCBT is associated with improvements in health in CWP patients which are maintained two years after treatment has finished. The size of effect is similar for both treatments, and there is no advantage in receiving both treatments together. Characteristics were identified associated with response to the treatments which could allow future targeting of such interventions to those likely to benefit.

Other (Audit)

082 Efficacy of the 5% Lidocaine Patch In the Treatment Of Chronic Pain

Category: Other (Audit)

Maria K Stasiowska, Bianca Kuehler

Chelsea Pain Centre, Chelsea and Westminster Hospital, London, UK

Background

The 5% Lidocaine patch (5LP) has been well established as an effective treatment for localized neuropathic pain e.g. post herpetic neuralgia (1). However evidence for its use in other chronic pain conditions such as low back and widespread pain is not clear (2 & 3).

Topical Lidocaine has very few systemic side effects and is versatile to apply and use (4). It can be applied to treat specific and multiple sites of pain simultaneously. As such, it can be an ideal agent for patients who are unable to tolerate systemic analgesics (5) or as a safe additive in a wide variety of chronic pain conditions.

The aim of this audit was to determine the impact of the 5LP as a targeted peripheral analgesic in a variety of chronic pain conditions, assess patient satisfaction and determine its adverse effect profile.

Methods

Retrospective data was collected between 1 January 2012 - 1 January 2013. 60 patients were prescribed 5LP for a wide range of chronic pain conditions, located throughout the body.

The patch was used as first line treatment or added to an established medication regime that was not achieving adequate pain relief. Patients were instructed to apply up to 3 patches to the most painful areas for a maximum of 12 hours of continuous skin contact per application.

Patch efficacy was assessed by comparing mean NRS scores at the start of treatment and at 3 - 4 month follow up, using a paired T-test. In addition, overall satisfaction, percentage of pain relief, adverse effects and problems with patch application, were assessed on follow up.

The effect of co-analgesics on patch efficacy was explored further by performing a two tailed Fishers exact test.

Results

Data analysis revealed a population with a mean age of 55.3 years (20 - 88), with more female (66.7%) and Caucasian (58%) patients. Median duration of pain was 5.5 years (0.5 - 40).

There was a statistically significant (p = 0.0001) reduction in the mean NRS scores recorded from baseline 8 (+/- SD 1.74) to follow-up 6 (+/- SD2.19).This represented a 35% reduction in overall pain scores. 42% (n=25) reported >/=50% pain relief. Patch efficacy was not affected by co-analgesics such as opiates (p = 0.1959).70% (n=42) of patients were satisfied overall with the 5LP.

Sub analysis of specific pain conditions revealed that low back pain with radiculopathy and abdominal pain were the only conditions that did not improve with 5LP use. Adverse effects such as: numbness, itch, rash and dizziness was present in n=5 cases. 73% (n= 43) patients found the 5LP easy to use and apply.

Conclusion

5LP significantly reduced NRS pain scores by more than 30% and offered =/> 50% pain relief in 42% of patients. This was not statistically affected by other co-analgesics used at the time.

Although it did not achieve complete pain relief in the majority of patients, 70% were satisfied with its use. There were minimal adverse effects and no significant problems with patch application that caused its early discontinuation.

This data hence suggest 5LP can be safely used as an effective mono or adjuvant treatment in a wide range of chronic pain conditions.

083 Audit on Tapentadol: an efficacy survey

Category: Other (Audit)

Lorraine Stevens, Arindam De, Margaret Bone

University Hospitals of Leicester, Leicester, UK

Background

Tapentadol is a centrally acting analgesic with dual mode of action, as an agonist of μ-opioid receptor and as a norepinephrine reuptake inhibitor. It is licensed for the management of moderate to severe pain of both nociceptive and neuropathic origin. Tapentadol provides analgesia comparable to other opioid analgesics, with a potency considered somewhere between tramadol and morphine in effectiveness, but with more tolerable side effect profile.

At University Hospitals of Leicester (UHL), we elected to prospectively assess the efficacy of tapentadol in patients with moderate to severe nociceptive pain, with or without a neuropathic element, refractory to other opioid medication and/or pain modifying treatment.

Methods

Thirty patients with moderate to severe nociceptive pain with or without a neuropathic element, whose pain had failed to respond to opioids and/or pain modifying treatment, were assessed. Patients with history of epilepsy were excluded. All patients were taking opiates and at least one neuropathic pain modifying medication. Patients invited to enter the trial were provided with information about tapentadol.

Demographic data was recorded together with baseline self assessments of: visual analogue score; verbal pain rating score; mobility score; self care score; level of day to day activities; sleep and mood levels. Previous medications and adverse effects were noted. The outcome data was mapped against baseline levels before treatment at 1, 4 and 12 weeks.

Patients stopped their existing opioids and tapentadol was prescribed at an equipotent dose i.e.: 24 hour morphine dose of 40 mg = 24 hour tapentadol dose of 100 mg. All prescriptions were issued from UHL.

Results

Thirty patients entered the trial. Seventeen patients had tapentadol 50 mg b.d. and thirteen patients received doses up to 200 mg b.d.

The mean VAS for all patients before treatment was 9.0 (7 -10). Following treatment the mean VAS were 3.7 (0 - 7) at 1 week, 3.7 (0-7) at 4 week and 3.6 (0 -7) at 12 weeks. Eighteen out of thirty patients reported pain reduction.

There were improvements in quality of life. Over 3 months 18 patients had improved sleep pattern; 7 patients, improvement in self-care activities; 6 patients, a reduction in anxiety and depression; 6 patients, an improvement in day-to-day activities; and mobility improved in 3 patients.

There were no serious adverse events. 18 patients had minor side effects - drowsiness, nausea and bowel disturbance. Of the 18, 9 patients elected to stop treatment. Two patients stopped tapentadol before 3 months due to lack of efficacy.

Conclusion

Tapentadol is a balanced analgesic for the management of moderate to severe chronic pain. In our small series of patients whose pain had failed to be controlled adequately with standard opioid and/or pain modifying treatment, 60% reported an improvement from extreme/moderate to mild / no pain.

There were no serious adverse effects, although 9 patients elected to stop the medication due to minor adverse effects.

We consider that tapentadol has a place in the management of carefully selected chronic pain conditions but acknowledge that further research is needed to benchmark the efficacy of tapentadol.

084 Improving the Value of Discharge Summaries Sent Out To General Practitioners after A Multidisciplinary Pain Management Programme

Category: Other (Audit)

Gill Thurlow, Thea Claxton, Cara Lovell, Andrew Lucas, Victoria Tidman, Roxaneh Zarnegar

Royal National Orthopaedic Hospital, Stanmore, UK

Background

A detailed multidisciplinary discharge summary is sent out to general practitioners (GPs) after patients have attended the residential pain management rehabilitation programme (PMP) at the Royal National Orthopaedic Hospital. These summaries have free text sections for each of the disciplines involved in the patient’s rehabilitation therapy. Our first audit aimed to determine whether these documents aided GPs in reinforcing self-management principles post discharge.

Improvements were made to the structure and content of the summaries towards this objective; more detailed information was given with different sections clearly demarcated. Goals on discharge were included with every summary.

Methods

Twenty patients who had attended the PMP in 2011 were selected randomly. GPs were sent a questionnaire with a reminder copy of the discharge summary. The questions explored whether this document was helpful to the management of the patient and if it helped understand the aims and components of the PMP. Free text was allowed for GP’s suggestions for improvement.

A group with representatives from all disciplines involved in the PMP reviewed the format of the summaries and re-designed them. A re-audit was done using the same questionnaire after a year, selecting the discharge summaries of 20 patients who had completed the programme in 2013. Data was analysed using Fisher’s exact test.

Results

Sixteen completed questionnaires were received in 2011 and eleven in 2013.

The number of GPs who had read the summary when it arrived dropped between the two audits (16/16 to 9/11) but this difference was not significant. The proportion of GPs who returned to it in future consultations was also unchanged. There were no significant differences in proportions of GPs who found the document useful or realised from reading it that patients should behave differently in terms of their pain after the programme.

A small number of questionnaires (3/40) had an entry in the free text section. Comments included “too long”, “too wordy” and that inclusion of the flare up plan would be useful for subsequent consultations with the patient.

Conclusion

Changes made to our unit’s discharge summaries included clearer formatting, more in-depth description of treatments and details of patient’s discharge goals and self management plan. The changes made no difference to how useful the summaries were to GPs.

Our experience demonstrates that GP’s ideas of improving the quality of information that we give them is not the same as ours. GPs are increasingly pushed for time both during consultations and for administrative clinical work. To improve clinical effectiveness, information should be presented to them in a succinct and streamlined form.

085 An Audit to Investigate the Impact Of Back Pain On A&E Services Within An Acute Hospital Trust

Category: Other (Audit)

Lynsey McKay

Southport and Ormskirk Hospital Trust, Southport, UK

Background

With rising pressures on A&E departments in the NHS avoidable admissions could help to reduce stress on services. Patients with back pain are sometimes admitted to A&E with little change or impact on their care.

The aim of this audit was to investigate A&E attendances with back pain. It was hypothesised that a high proportion of these patients would have been admitted unnecessarily and utilised resources inappropriately. It was also proposed that, should this be the case, that the Community Pain Service could have a role in ensuring the more suitable management of this patient group.

Methods

By liaising with the Clinical Audit Team and using clinical coding patients who had been admitted to A&E with back pain could be identified. In a six month period starting January 2013, 58 patients were recognised as fitting these criteria.

A pro forma was designed to draw out appropriate information from case notes in a consistent manner. A random selection of 15 patient notes was analysed, with admissions spread over 6 months. Common themes were extracted from these which we felt were representative of the patient group and therefore to expedite the audit they formed the group for analysis.

Results

Of the 15 patients 3 were excluded from the audit due to the admission being associated with other medical issues that would impact on length of stay.

Necessary Admissions; From the remaining 12 patient notes it was found that 4 patients were admitted appropriately to undergo investigation.

Unnecessary Admissions; There were 8 cases patients being admitted to A&E due to back pain which could have been avoided.

No patient was arranged any follow up care on discharge.

Presuming that the 15 patients analysed in this audit are representative of the remaining 58 patients from the 6 months, then some figures to propose how costly it is to the trust can be generated.

Based on these figures 62 patients will have avoidable admissions to A&E with back pain in 12 months.This would equate to 39 nights spent in hospital unnecessarily and 70 days spent in hospital.

Conclusion

Unplanned bed stays and cost £264 per night (NHS reference costs 2011-12 www.gov.uk) giving a predicted total avoidable spend of 39x264=£10,296

This is a significant and avoidable cost. Change in practice may reduce expenditure and improve patient experience.

Recommendations

Avoid bed waits for non-urgent investigations

Develop audited direct referral care pathway from AED to Community Pain Clinic service (underway)

Train AED staff in use of appropriate analgesia (underway via CPC)

Train AED staff in delivery of trigger point injections (underway CPC)

Closer liaison between Acute pain team and AED

Improve physio/OT input into assessment and management

086 The Prevalence of Polypharmacy Cyp2d6 Inhibition in Patients Referred For Specialist Pain Management: A Single Site Audit

Category: Other (Audit)

Helen Radford^1,2, Karen Simpson^1,3, Pauline Fitzgerald², Steve Martin², Mark Johnson^2,3

¹Leeds Teaching Hospitals NHS Trust, Leeds, UK, ²Leeds Metropolitan University, Leeds, UK, ³Leeds Pallium Research Group, Leeds, UK

Background

Chronic pain patients that report suboptimal analgesia often receive several drugs in a trial and error approach^{1, ²}. Ultimately referral to a specialist secondary care Pain Service is often initiated when pain becomes unmanageable. Once referred, assessment begins with the information provided in the General Practitioner (GP) referral letter. These patients are complex and often established on concomitant medication for co-morbities such as depression, diabetes, hypotension and cardiovascular disease. CYP2D6 enzyme is responsible for phase one hepatic metabolism and the bioactivation of analgesic pro-drugs in approximately 30% of marketed drugs³ such as tramadol. CYP2D6 function can be affected by genetic polymorphisms and drugs that act as inhibitors such as fluoxetine. Drug inhibition of CYP2D6 may result in suboptimal analgesia, potential drug-drug interactions (pDDIs) or adverse drug reactions (ADRs). This audit investigates the prevalence of polypharmacy CYP2D6 inhibition and the potential clinical implications in this patient population.

Methods

Consecutive referrals to a large NHS hospital Pain Service over a three month period were analysed for gender, origin of referral, and current and past analgesics including concomitant medications. Data was collected from the letters of GP referrals using an extraction sheet and transferred to a dedicated database. Analyses using descriptive statistics were conducted on demographics and medication history (i.e. analgesics, pain adjuvants and medication history), and clinical implications of potential CYP2D6 inhibition including pDDis and ADRs^6,7,8,9. Potential CYP2D6 inhibitors were identified from literature including the UK Medicines and Healthcare products Regulatory Agency (MHRA⁴) and the US Food and Drug Administration (FDA⁵). Drug inhibition was classified as strong, moderate and weak using criteria developed by the FDA⁵ through clinical testing. Additional inhibitors were identified from published work by Flockhart⁶ and Stockley on Drug Interactions⁷.

Results

There were 250 GP referrals (127 females). There was information about current pain medication for 92% (230/250) of referrals, information about previous pain medication and treatment for 51.7% (119/230) of referrals, information from 76.5% (176/230) of referrals to analyse concomitant medications for CYP2D6 inhibition. Prescribing trends at referral were 52.2% (120/230) strong opioids, 36% (83/230) weak opioids, 25.2% (58/230) NSAIDS, 25.7% (59/230) TCA’s, 32.6% (75/230) anti-epileptics, and 38.3% (88/230) other analgesics. Pro-drug analgesics reliant on CYP2D6 function were prescribed for 60% (137/230) of referrals, with 21% (29/137) affected by polypharmacy inhibition. A CYP2D6 inhibitor was prescribed for 29% (51/176) these cases with 57% (29/51) experiencing suboptimal response to analgesic pro-drugs. A risk of pDDI and/or aADR due to CYP2D6 inhibition was identified in 69% (35/51) of these referrals with SSRI’s being co-prescribed in 39% (20/51) of cases and 22% (11/51) identified as being at high risk of Serotonin Syndrome.

Conclusion

Referral standards were acceptable but of poor quality with 63% (144/230) of referrals lacking information on analgesic drugs or concomitant medication. Prescribing trends were in-line with national guidelines with tramadol being the most commonly prescribed opioid and amitriptyline and diclofenac the most commonly prescribed adjuvants. Prescribers need to be aware that suboptimal analgesia with common pro-drug analgesics such as codeine, co-codamol and tramadol could be related to CYP2D6 inhibition. By having an awareness of CYP2D6 polypharmacy inhibition, especially when co-prescribing tramadol with SSRI’s, practitioners may reduce the incidence of serious DDIs and ADRs.

Other (Research)

087 Exercise Prescription for Patients with Non-Specific Chronic Low Back Pain: A Qualitative Exploration Of Physiotherapy Practice

Category: Other (Research)

Rob Stenner^1,2, Theresa Mitchell¹, Shea Palmer¹, Annette Swinkels¹

¹University of the West of England, Bristol, UK, ²Somerset Partnership NHS Foundation Trust, Somerset, UK

Background

Non-specific chronic low back pain (NSCLBP) is a long term condition commonly encountered by physiotherapists and for which exercise is consistently recommended in treatment guidelines. Non-compliance with exercise programmes is a significant problem in clinical practice which could indicate a failure by physiotherapists to attend to patients’ beliefs, values and/or preferences, and a possible lack of patient involvement in the decision making process.

Current health policies promote the involvement of patients in decisions about their treatment and care. The call for a shift from a pathoanatomical-based therapist-orientated framework to a patient-orientated biopsychosocial framework has challenged physiotherapists to rethink their approach to practice.

The aim of this study was to investigate the approaches used by physiotherapists in the prescription of exercise for patients with NSCLBP, and to explore how shared decision making and patient partnership are addressed by physiotherapists in this process.

Methods

This study was informed by a philosophical hermeneutic approach which seeks to describe, understand and interpret participants’ experiences. Purposive sampling recruited eight physiotherapists working in a musculoskeletal physiotherapy service across seven different practice settings.

Each physiotherapist was observed undertaking their usual clinical activities on three separate occasions. They participated in brief interviews after each observation and a later in depth semi-structured interview. A greater depth of understanding of the phenomenon of exercise prescription was achieved by directly observing the physiotherapists, and by using interviews to define how they gave meaning to and interpreted their clinical practices

Before data collection the researcher acknowledged and identified their pre-understandings and kept a reflective diary for the duration of the study. Iterative hermeneutic strategies based on a thematic analysis were used to interpret the texts and identify the characteristics and processes of exercise prescription for patients with NSCLBP.

Results

Four main themes were formed from the texts:

‘Exercise as the mainstay of treatment’ - focuses on the physiotherapists’ reliance on exercise as a key management strategy and their concerns over their competence to deliver it effectively.

‘I want them to exercise’ - deals with some of the elements therapists talked about and were observed doing that underpinned the way decisions were reached.

‘Which exercise? - the tension between evidence and everyday practice’ - encapsulates the struggle to balance competing priorities of research evidence, patients’ preferences, as well as therapists’ attributions and perceived professional role.

‘Compliance-orientated more than concordance based’ - physiotherapists talked about solutions to factors impacting on a patient’s ability to engage with an exercise programme. This could be interpreted as a form of ‘bargaining’ to obtain compliance with their suggestions, rather than concordance in which decision making is shared equally between the patient and physiotherapist.

Conclusion

The findings provide a complex understanding of how physiotherapists regard and apply exercise based management strategies to patients with NSCLBP. They support the suggestion that physiotherapists experience difficulty in accommodating to the patient-centred agenda in which patients are viewed as active participants in therapy, and the framework physiotherapists use has not kept up with the literature on shared decision making. The attitudes, practices and skills of clinicians are likely to be the most significant factors influencing the degree to which patients feel involved in decisions about their care.

088 Chronic Pain Service Provision in Wales 5 Years after the Launch of Design For Pain

Category: Other (Research)

Christian Egeler¹, Carolyn Middleton², Gareth Parsons³

¹ABM University HB, Swansea, Wales, UK, ²Aneurin Bevan HB, Newport, Wales, UK, ³FLSE University, South Wales, UK

Background

In 2008 Welsh Assembly Government (WAG) published the Design for Pain Document outlining the necessary developments for Chronic Pain Services (CPS) in Wales. At the time service provision was patchy and missing in large parts of South Wales. Pain Management Programmes (PMP) were centralised, multidisciplinary teams varied considerably. WAG aimed to redress this imbalance and to establish consistent, patient centred service provision across primary and secondary care.

This survey, commissioned by the Welsh Pain Society and NSAG Pain, was designed to provide an up to date overview of the current status of service provision in all 7 Health Boards in 2012/2013.

Methods

A detailed questionnaire was developed to capture: chronic pain team members, nature and location of services, monthly service sessions, availability of PMPs and any specialised services offered. Completed questionnaires were analysed and follow up clarification sought where necessary. The Results were presented at the WPS annual meeting and NSAG meeting in October 2013 and forms the basis for future service development in consultation with WAG.

Results

11 independent services exist covering all 7 Health Boards. Teams consist of Anaesthetic Consultant (100%), Nurse Specialist (91%), Physiotherapist (91%), Psychologist (54 %), GPwSI (27%), Staff grade (27%), Occupational therapist (27 %), Neurorehab Consultant (9 %), HCSW (9 %). All services remain in part secondary care based, 3 utilise day centres, 2 GP practices.

2 services are funded for 20 sessions per month, 6 between 55 and 100 sessions, 3 between 136 and 182 sessions. 9 of 11 services provide a PMP, provided by Psychologist in 7, Physiotherapists in 9, CNS in 8, OT in 4, Consultant in 3.

Between 2-12 Programmes are run per year for 24 - 182 patients. Most programmes take 10 patients and run for 8 sessions.

Other services offered are Acupuncture clinic (7), TENS (6), medicine review (8), Telephone F/U (6), specialised pain Physiotherapy (1).

10 services offer interventions, between 3-21 sessions per month, 1 service offers PMP only.

Conclusion

Since ‘Design for Pain’ was published there has been a considerable move towards multimodal and multidisciplinary services. In particular PMPs run by Psychologists have been developed widely. Some services remain underfunded which needs addressing. There is considerable variation in interventional strategies offered and an all Wales outcome audit will be beneficial to inform a sustainable approach.

To fulfil the 2008 document for patient centred services the remaining imbalances across Wales need to be addressed, in particular expanding multidisciplinary teams and PMPs. Further work needs to assess the feasibility and limitations to moving services further into primary care.

Peadiatric

089 The Use of Peri-Operative Gabapentin to Reduce Acute Post-Operative And Chronic Pain After Pectus Excavatum Repair

Category: Peadiatric

Rajiv Malhotra¹, Rishi Diwan²

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

Background

Pectus excavatum is the most common congenital chest wall abnormality, with an incidence of 1 in 1000 children. Pectus repair is a cosmetic procedure that is associated with significant and difficult to manage post-operative pain. Gabapentin is an anti-epileptic that has been used for neuropathic pain. A recent study has shown that pre-operative gabapentin in adults undergoing hernia repair reduces post-operative pain scores and analgesic requirements, as well as chronic post-surgical pain. Two systematic reviews have confirmed the benefits of perioperative gabapentin in reducing acute and chronic pain after surgery. Evidence is emerging of similar benefits in the paediatric surgical population. Recently, we have used gabapentin peri-operatively to reduce pain after pectus surgery. This retrospective review investigates the effect of gabapentin on post-operative pain scores and analgesic requirements, as well as chronic post-surgical pain.

Methods

A review was performed on all paediatric patients who underwent pectus surgery between 2012 and 2013 at a single tertiary referral hospital. Patients were divided into those who received gabapentin for 5 days post-operatively (300mg on the day of surgery, 300mg BD for the next day, then 300mg TDS) and those who did not. All patients received paravertebral blockade as part of their intra-operative analgesic management, with post-operative opioid (fentanyl or morphine) patient controlled analgesia and intravenous ketamine infusions. Pain scores, use and duration of intravenous analgesia, as well as the use of other analgesic adjuncts (e.g. paracetamol, NSAIDS) were noted. Time to discharge and analgesic requirements at the follow-up clinic appointment (8-12 weeks post discharge) were documented.

Results

Ten patients received gabapentin as part of their anaesthetic management (7 male, 3 female, average age 15 years), with 25 patients (21 male, 4 female, average age 15 years) not doing so. The gabapentin group had lower daily pain scores (2.1 vs. 3.5/10), reduced duration of ketamine infusions (2.5 vs. 4 days) and an earlier discharge from hospital (4.4 vs. 5.8 days). Patients in the gabapentin group were less likely to have nausea and vomiting (0% vs. 32%), possibly due to decreased post-operative opioid requirements (102 vs. 116 presses of PCA). The gabapentin group were less likely to require regular analgesia at their follow-up in clinic (0% vs. 24%). There were no reported side effects attributed to the use of gabapentin.

Conclusion

Peri-operative gabapentin use in paediatric patients undergoing pectus repair improved post-operative pain scores and reduced analgesic requirements and opioid intake. There was an earlier time to discharge and less pain reported 2-3 months post-operatively. Gabapentin is a useful analgesic adjunct to reduce acute and chronic pain after pectus repair and should be incorporated in the peri-operative analgesic plan. Further work with larger numbers of patients will develop the evidence base for this practice.

090 Chronic Abdominal Pain in Children: Subtype Prevalence and Effects Of Management Results Of A Service Evaluation In Sheffield Children Hospital Nhs Foundation Trust

Category: Peadiatric

Yehia Kamel^2,1, Ayman Eissa¹

¹Sheffield Children’s Hospital, Sheffield, UK, ²Sheffield Teaching Hospital, Sheffield, UK

Background

Although abdominal pain is a relatively common complaint in children and adolescents worldwide, often clinicians fail to identify a structural or biochemical derangement to account for it. Categorically labelled Functional Gastrointestinal Disorders (FGID) according to the Rome III criteria, it includes amongst others, irritable bowel syndrome (IBS) and functional abdominal pain (FAP).⁽¹⁾ Nevertheless, the biopsychosocial impact on a child’s wellbeing and the burden on health resources remain enormous. Recently, up to a third of these patients followed up for several years were found to suffer from chronic abdominal pain, and some researchers have suggested that children complaining of FAP may be more vulnerable to other chronic non-abdominal pain in adulthood. ⁽²⁾ As such, we undertook this service evaluation to assess our management of abdominal pain patients referred to our paediatric pain clinic.

Methods

Following institutional approval, we identified a cohort of patients who were referred to our tertiary paediatric pain clinic over the period from 2008 to the present. Retrospective data was collected for forty of these patients from their medical records. In addition to demographics, we collected information about the cause of pain, either organic or functional, comorbidities, laboratory and imaging investigations performed, previous and current medications, duration of pain prior to referral, period under pain clinic. In addition to that we assessed the impact on school attendance, sleep, sport activity, social interactions, and family relations. Furthermore, we collected data on physical findings on examination, medications and interventions tried, input by psychology or physiotherapy, hospital admissions, and if discharged the reason.

Results

Thirty two (80%) were females. Mean age was 14.4 (SD =0.7). 32 (80%) had FGID, out of which 18 (45%) deemed Functional abdominal Pain (FAP). Time to referral was 1.94 years (SD=1),17 (42.5%) had other pain complaints like headache and dysmenorrhoea and 11 (27.5%) had anxiety.

Thirty seven (92.5%) were already on medication upon presentation. Amongst them, 10 (25%) were on weak opioids (codeine) and 3 (7.5%) on moderate opioids (tramadol), 25(62.5%) on regular paracetamol, 12(30%) on regular NSAID’s, 17 (42.5%) on regular laxatives, and 5 (12.5) on tricyclic antidepressants (amitriptyline).

We started opioids on 9 (22.5%), tricyclic antidepressants (amitriptyline) on further 16 (40%), and gabapentin on 4 (10%).

72.5% lost school days and 23 (57%) hospital admissions related to pain. 28(70%) were discharged, 9(32.1%) because of inability to add anymore interventions, 6(21.4%) transferred to adult services, and 11(27.5%) because of not attending/loss of contact.

Conclusion

Although chronic abdominal pain is a serious condition affecting 0.5%-19% according to some studies, it remains an area of unmet clinical demand.(1) In our experience, escalating pharmacotherapy proved largely disappointing in terms of pain reduction or functional improvement. Also there is a significant prevalence of psychological and other pain complaints on presentation, particularly headache and dysmenorrhoea.

In our opinion a multimodal approach with special emphasis on psychology, physiotherapy and rehabilitative interventions tailored to individual needs is the best treatment that we can offer.

We also recommend earlier recognition and referral to a multidisciplinary pain service where this can be offered.

091 The Co-Morbidity of Musculoskeletal Disorders And Sleep Problems In Adolescents: Associations With Pain-Related And Somatic Factors

Category: Peadiatric

Lee Harrison¹, Sue Wilson², Marcus Munafo¹

Thirty-four articles were assessed for eligibility (from 235 identified). From the initial assessment, a further 27 articles were excluded, with the remaining seven articles deemed appropriate for a full review. Four studies collected data using a questionnaire methodology, one used an interview and written survey methodology, one used a diary study and questionnaire, and one used a telephone interview. Data was extracted from the articles and analysed under three topics: demographics of the child and parent (if parent report), prevalence of medication use and misuse, and correlates of use and misuse. Not all articles included Results for all topics. There was a vast discrepancy of data reported in each study for each topic. Due to the paucity of data available in the articles, it was not possible to perform a meta-analysis as intended. Data is presented descriptively, highlighting areas of focus for future work.

Conclusion

These studies highlight the lack of data available and the need not only for more studies investigating OTC medication use, but for robust methodologies and comprehensive reporting of Results in future studies. The insufficient evidence of OTC use creates a lack of understanding of pain medication use, therefore we are unable to highlight populations at risk of misuse and potential inappropriate pain management and the potential for excess strain on clinical services. This review highlights the need for higher quality future research into prevalence of use.

094 Ongoing Audit of Paediatric Pain Management in the Emergency Department

Category: Peadiatric

Amy-Jo Farrow, Heinrich Hollis

Norfolk and Norwich University Hospital, NHS Foundation Trust, Norwich, Norfolk, UK

Background

In 2013 The College of Emergency Medicine (CEM) revised the guidelines for pain management in children presenting to the emergency department (ED). A retrospective audit of children attending the Norfolk and Norwich University Hospital with fractures from January 2013 was completed and re-audited in June and November 2013.

The audits were measured against the CEM standards:

All children must have their pain assessed and receive appropriate analgesia within 20minutes of arrival in the ED.
Any child with a moderate or severe pain score (>3/10 severity) requires reassessment of their pain within 60minutes of the first dose of analgesia.

Methods

The notes of the first 50 children aged 4-16years diagnosed with long bone fractures from 1st January 2013 were included in the original audit. After the initial findings paediatric pain posters were displayed and teaching was provided in an attempt to improve the management of children in pain. The re-audit period was June 2013. The Results demonstrated little improvement despite these interventions. Subsequently the ED prescription chart was modified to include a pain score column and further education was delivered aiming to increase compliance with the standard. The second re-audit looking at the impact of these interventions took place using notes from attendances beginning 1st November 2013.

The notes were reviewed to see if:

Pain score was assessed at triage.
Analgesia was given.
When analgesia was given: after how many minutes was it provided, and was it appropriate to the pain score?
Pain score was re-assessed.

Results

Jan 19/50(38%), June 29/50(58%), Nov 23/50(46%) Had pain score assessment noted at triage

Jan 22/50(44%), June 20/50(40%), Nov 23/50(46%) Received analgesia

Jan 9/19(47%), June 12/29(41%), Nov 15/23(65%) With pain score noted received analgesia

Jan 13/31(42%), June 8/21(38%), Nov 8/27(30%) Without a recorded pain score received analgesia

Jan 15/19(79%), June 21/29(72%), Nov 19/23(83%) Received analgesia appropriate to their pain score

Jan 8/22(36%), June 10/20(50%), Nov 15/23(65%) Patients who received analgesia did so within 20 minutes of arrival

Conclusion

The Norfolk and Norwich University Hospital ED is not meeting the CEM standards for the management of pain in children with fractures. Modest improvements in all the parameters assessed between January and November have been demonstrated. The amended prescription chart may have contributed to the improvement in analgesia appropriateness, however, pain score reassessment is rarely recorded.

Pain passports for patient and parent completion are soon to be provided at registration to encourage repeated self-assessment of pain and guide its management. The next audit will review the effect the pain passport and further education have on compliance with the CEM guidelines.

Primary Care

095 Clinical and Sociodemographic Characteristics of Patients Referred To A Community-Based Pain Clinic

Category: Primary Care

Muhammad Hadi^1,5, David Alldred², Michelle Briggs³, Kathryn Marczewski⁴, S. José Closs⁵

¹Monash University Malaysia, Petaling Jaya, Selangor, Malaysia, ²University of Bradford, Bradford, West Yorkshire, UK, ³Leeds Metropolitan University, Leeds, West Yorkshire, UK, ⁴Pain Clinic, St. George’s Centre, Leeds, West Yorkshire, UK, ⁵University of Leeds, Leeds, West Yorkshire, UK

Background

The management of chronic pain, given its multidimensional detrimental consequences, is challenging. Timely access to quality pain management services is crucial for effective pain management. In 2005, a community based pain clinic jointly managed by a nurse and a pharmacist was established in Leeds, UK with the aim of improving access and quality of chronic pain services. The aim of this study was to examine the clinical characteristics and referral pattern of patients referred to the pain clinic.

Methods

A prospective cross-sectional survey was conducted. All patients attending the pain clinic between January 2012 and October 2012 were requested to participate in the study. Patients completed the Brief Pain Inventory (BPI), a validated questionnaire for assessing pain intensity and its interference with physical activity, while waiting for their first consultation at the pain clinic, after giving written informed consent. In addition, patients also completed a structured and pilot-tested questionnaire to gather sociodemographic data. Clinical data were collected by reviewing patients’ case records and referral letters, using standardized data collection forms. Ethics and research governance approvals were obtained from relevant authorities. Data were analyzed using SPSS version 18.

Results

Of 146 referrals, 79 patients agreed to participate in the study. The mean (S.D) age of patients was 46.4 (± 14.5). The majority of the patients were female (67.1%) and white (British) (84.6%). Almost half (34; 43.1%) of the patients were unemployed with one quarter (20; 25.3%) citing pain as the reason. The majority (57; 72%) of the referrals were requested by the general practitioners (GPs). Two-thirds of patients (56; 70.9%) reported never having been referred to a pain clinic/pain consultant in the past. Low back (68.4%) followed by lower limb (58.2%) were the most commonly reported pain sites. The median (IQR) values of worst pain, least pain, average pain, and pain ‘right now’ were 8 (7;9), 5 (3;7), 7 (5;8), and 7(5;8), respectively, measured on a 11-point ( 0 to 10) numerical rating scale (NRS). The median overall interference with physical functioning was 7.1 (5.7; 8.3).

Conclusion

The clinical characteristics of patients referred to the pain clinic were quite diverse. The economic implications are significant as the majority of the patients were middle aged (productive age), receiving multiple treatment modalities and unemployed

096 How can web based resources for chronic pain be used to promote self-management?

Category: Primary Care

Ollie Hart¹, Janet Harris², Lucy Gell², John Skinner³

¹Sloan Medical Centre, Sheffield, UK, ²University of Sheffield, Sheffield, UK, ³Sheffield City Council, Sheffield, UK

Background

There is evidence that for approximately 50% of patients presenting to musculoskeletal services a pain management, rather than a curative approach, may be more suitable. Nationally, an estimated 4 to 8 million people could benefit from a self-management approach. Current primary care resources do not meet this need. Providing good information, with appropriate support, will improve individual capacity to self-manage.

Research shows that information is more effective if the person delivering the message is similar to the patient. Sheffield has a well-established chronic musculoskeletal pain care pathway whereby patients seen in clinics by GPs or physiotherapists may be referred to a (non clinical) Health Trainer (HT). The role of the HT is to help patients set goals, self-manage health conditions and ‘sign-post’ them to available resources.This Health Foundation funded project aimed to assess the value of a specific web based information site in supporting self-management of musculoskeletal conditions.

Methods

During clinical consultations with GPs and Physiotherapists, patients meeting selection criteria were given details about an internet site specifically commissioned to provide self-management information about chronic pain. Some patients accessed the site in conjunction with their HTs, others accessed it independently.

In depth qualitative data were collected by telephone interview from 14 patients who agreed to participate by providing their contact details via the website. Additionally, data from HTs involved in service delivery were collected via focus group and individual interviews.

Data were collated and analysed thematically by three researchers who independently identified preliminary themes and met to cross validate findings and produce key themes. Data were collected over a six month period, based on a semi-structured interview schedule through an iterative process whereby themes emerging from the analysis of early interviews informed the topic guide used in subsequent interviews.

Results

Interim Results suggest several factors that influence access and acceptability of web based information. 1) ‘information readiness’: patients being at a stage where they want to look up information to self-manage; 2) Learning style: site usage appears to be greater amongst people who like to read for information rather than discussing information; 3) Information seeking style: use of the site is greater amongst those already accustomed seeking health information via computer.

Some patients preferred other pain information sites they are already use routinely. Client expectations mediate the way in which HTs use the site. Active promotion of the site is best introduced at the stage when clients are motivated to self-manage . HTs bring a specific skill to the pain management pathway by taking these factors into account when signposting clients to the site, and integrating use of information into the process of setting goals for self-management with clients.

Conclusion

Making web-based information available to patients with chronic musculoskeletal pain is in itself insufficient to encourage self management. Instead, Health Trainers play a crucial role in optimising the benefit of web-based information. They add value by applying skills that judge the most appropriate time to introduce and encourage the use of web-based self-management information in a way that makes sense to, and has relevance for, the patient.

097 The Addition Of Tens To Usual Primary Care Management For The Treatment Of Tennis Elbow And The Role Of Patient Adherence: Results From The Tate Randomised Controlled Trial

Category: Primary Care

Linda Chesterton, Martyn Lewis, Julius Sim, Christian Mallen, Elaine Hay, Danielle van der Windt

Keele University, Staffordshire, UK

Background

Tennis elbow is a common and painful condition with considerable impact on daily activities, including work. Whilst it is considered to be a self-limiting condition, common interventions include rest, analgesia, corticosteroid injections and physiotherapy, although there is a lack of consensus as to which is most effective. Whilst corticosteroids injections offer short-term pain relief, the treatment can be unpleasant and is associated with a risk of pain recurrence in the long term. There is a need for an intervention that is acceptable to patients and provides safe and effective pain relief. Transcutaneous electrical nerve stimulation (TENS) is an inexpensive, non-pharmacological analgesic that purportedly promotes self-management and is advocated as an adjunct to other treatments for musculoskeletal pain. This trial investigated the clinical effectiveness of supplementing primary care management with TENS to reduce pain intensity in patients with tennis elbow and recorded patient adherence to the intervention protocols.

Methods

241 adults with a first or new clinical diagnosis of tennis elbow were recruited from 38 General Practices. Participants were randomly allocated to either primary care management (PCM), consisting of a GP consultation followed by information and advice on exercises, or PCM plus TENS to be used at least once per day for 45 minutes over 6 weeks (or until symptom resolution). The primary outcome was pain intensity in the last 24 hours (0-10 numerical rating scale [NRS]). Postal questionnaires were used to collect data at 6 weeks, 6 and 12 months. Process measures were assessed at 6 weeks and included adherence to treatment protocols (frequency of performing exercises and use of TENS) and satisfaction with treatment (0-10 NRS). The main analysis was by intention to treat, and sensitivity analyses taking a per-protocol approach were also undertaken, including only participants adhering to recommendations for exercise and TENS.

Results

The main Results are reported elsewhere but briefly showed large within-group improvements for pain and other outcomes, but no important or statistically significant differences between the groups. The potential influence of treatment adherence and TENS dose was investigated by analysing treatment effects for different levels of adherence. Only a small number of participants (42 for PCM & TENS, 29 for PCM) reported adherence according to our a priori definition of using TENS and performing exercise at least 4 out of 6 weeks, and at least 4 days per week. Results of sensitivity analyses concurred with the ITT analysis, showing little or no difference in pain reduction between the groups at 6 weeks, although significantly better long-term outcomes were found for the small sample adhering to TENS protocols . The reasons for poor adherence were not recorded, but may be related to difficulties when fitting TENS and implementing daily 45-minute sessions.

Conclusion

Our trial was designed to investigate the effectiveness of supplementary TENS being implemented as a patient-controlled intervention in routine primary care. No difference in pain relief was observed and very poor levels of adherence were reported. Supervised applications of TENS could potentially improve adherence to treatment protocols, but this would be impractical and overly expensive in a primary care setting. Future studies might investigate the delivery of TENS and patient adherence within primary care to establish if this can be improved in other ways, and if so whether this is associated with larger effects of TENS.

098 An Economic Evaluation of Tens In Addition To Usual Primary Care Management for The Treatment Of Tennis Elbow: Results From The Tate Randomised Controlled Trial

Category: Primary Care

Martyn Lewis, Linda Chesterton, Julius Sim, Christian Mallen, Elaine Hay, Danielle van der Windt

Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, UK

Background

Tennis elbow is a common and painful condition with an annual incidence of 1–3% in the general population. Tennis elbow has a considerable impact on daily activities, including work absenteeism: 30% of patients report on average 4–5 days absence. Transcutaneous electrical nerve stimulation (TENS) is an inexpensive, non-pharmacological analgesic that promotes self-management and is advocated as an adjunct to other treatments for musculoskeletal pain. However, there is no information on the cost-effectiveness of TENS as an intervention and limited evidence regarding the cost- effectiveness of primary care management of tennis elbow. This multicentre pragmatic randomised controlled trial investigated both the clinical and cost-effectiveness of supplementing primary care management (PCM) consisting of a GP consultation followed by information and advice on exercises, with TENS to reduce pain intensity in patients with tennis elbow. The main clinical Results of this trial have been reported in detail elsewhere.

Methods

241 adults with a first or new diagnosis of tennis elbow were recruited from 38 general practices, and randomly allocated to either PCM alone (n=120) or PCM plus TENS (n=121). The primary clinical outcome was pain intensity in the last 24 hours (0–10 numerical rating scale). The EQ5D and SF6D were used to derive quality-adjusted-life-years (QALYs). Data on clinical outcomes, healthcare resources and time off work were collected using postal questionnaires at 6 weeks, 6 and 12 months. Economic analysis was by intention-to-treat, analysing all participants as randomised and imputing missing data. Two economic perspectives were evaluated: (i) healthcare perspective: inclusive of NHS and private health costs related to tennis elbow; (ii) societal perspective: healthcare costs plus productivity losses through work absenteeism. Mean outcome and cost differences between the groups over 12 months were evaluated through regression analysis, adjusting for baseline covariates and using bootstrapping to derive confidence intervals.

Results

The trial showed large improvements for pain and other outcomes in both intervention groups. Mean pain reduction over the 12 months follow-up was higher for PCM plus TENS compared to PCM only. Similarly, mean difference in QALYs based on SF6D was higher for PCM plus TENS; the converse was true for QALYs based on EQ5D. However, mean differences in clinical outcomes and QALYs were small and not statistically significant: 95% confidence intervals included zero.

Mean healthcare cost was £33 greater for the PCM plus TENS group, which was largely due to the cost of the TENS intervention. Mean productivity cost due to work absenteeism was £98 less for PCM plus TENS group, which resulted in an overall lower societal mean cost of £65 in this group compared to PCM only. None of the cost differences were statistically significant.

Conclusion

Our findings show that adding TENS to primary care management of tennis elbow is likely to be cost-effective in respect of a broad societal perspective that includes health care costs and indirect costs linked to work productivity losses. However, from a healthcare perspective only, the probability of this additional treatment being cost-effective is small. Based on the findings of the primary and secondary clinical outcomes where there was no evidence for additional clinical benefit of TENS, the findings indicate that adding TENS confers little advantage from a purely healthcare driven viewpoint, but may reduce productivity losses.

099 Strong Opioid Utilisation within UK Primary Care: A Longitudinal Cohort Study Of Non-Cancer Strong Opioid Users

Category: Primary Care

Jane Harvey¹, Roger Knaggs^1,2, Li-Chia Chen¹

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

Background

There has been a vast increase in the use of opioids in America, Australia, Canada and some European countries including the U.K. within the past decade, predominantly for patients with chronic non-cancer pain (CNCP). There is a lack of robust evidence to support the long-term use of opioids in CNCP as randomised controlled trials (RCTs) usually lasted less than four months. RCTs also recruit from populations with strict inclusion/exclusion criteria meaning that the study population may differ from the general population. This study aimed to assess the utilisation patterns of strong opioids in non-cancer patients in day to day clinical practice within the UK; to quantify the proportion of patients using strong opioids in the long-term; to determine the frequency with which long-term patients use strong opioids; and to describe the proportion of long-term patients who use multiple strong opioids.

Methods

This cohort study used primary care data extracted from the Clinical Practice Research Datalink (CPRD) from 2000-2011. Adult patients who received a non-parenteral prescription for buprenorphine, fentanyl, morphine or oxycodone and had at least one-year registration prior to their first strong opioid prescription date (index date) were included. Those prescribed sublingual buprenorphine 2mg or 8mg (a marker for patients treated for substance abuse) or who had a cancer diagnosis (identified by cancer-related Read code) were excluded. Patients were followed for four years from index date and excluded from analysis if death, transfer out of practice or end of database records occurred within this period. The proportions of patients using long-term strong opioids were calculated in addition to a sub-group analysis of long-term patients, describing the median minimum number of prescriptions per year per patient and number of different strong opioids used per patient.

Results

In total, 24,906 of the 93,238 patients who received an opioid for non-cancer pain had at least four years of complete data. Patients with less than four years follow-up were excluded from the cohort due to death (n=21,398; 31.31%), transfer from the practice (n=7,931; 11.61%) and end of records (n=39,003; 57.08%).

Of the 24,906 patients, the median age was 59 years (inter-quartile range 46-71) and 16,470 (66.13%) were female. Of these patients 52.69% (n=13,123) only obtained strong opioid prescriptions within the first patient-year.

Around one quarter of the cohort (n=6,559; 26.34%) received strong opioids in all four follow up years. The median minimum number of prescriptions per year for these patients was 9 (interquartile range 4-12) and 3,540 (53.97%) patients received one opioid (15.81% buprenorphine, 8.49% fentanyl, 23.01% morphine, 6.66% oxycodone), 2,095 (31.94%) two opioids, 758 (11.56 %) three opioids and 166 (2.53%) four opioids.

Conclusion

Although half of non-cancer strong opioid patients used opioids for less than one year one quarter of patients used strong opioids for at least four years with half of these patients receiving a minimum of nine or more prescriptions each year. This is likely to be an underestimation of the numbers of patients who use opioids chronically as only the first four years of strong opioid utilisation are considered. Further research is required to consider additional opioid utilisation measures including analysis of dosages and formulation type used in addition to the evaluation of long-term clinical outcomes.

100 Engaging With Older People and Their Carers to Develop And Deliver Interventions For Self-Management Of Chronic Pain (Epic) - Phase V

Category: Primary Care

Rachael Docking¹, Patricia Schofield¹, Blair Smith², Denis Martin³, Amanda Clarke⁴, Derek Jones⁴, Geraldine Anthony⁵, Paul McNamee⁵, Lisa Anderson³

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

Background

Evidence suggests chronic pain increases with age. It is essential we identify Methods to enable self-management in older adults. Phase V involved working in partnership with a group of older adults and pain clinicians to explore acceptable and feasible ways to communicate self-help materials developed within phases 1-1V, including: the Medikidz comic book designed to help older adults explain their chronic pain to grandchildren; “Living with persistent pain in later life - answers to your questions” booklet, a guide developed to help older adults identify literature around self-management of pain; and “Living with persistent pain in later life - what you can do to help yourself” which is a concise booklet that folds out into a poster detailing key Methods of self-managing pain. It further evaluated children’s perspectives on the Medikidz comic and the knowledge they acquire regarding chronic pain and its impact on the lives of older adults.

Methods

Focus groups with older adults (>65years) with chronic pain & their carers, and also with health care practitioners involved in pain management. Participants were given the tools (detailed above) three weeks in advance to read over and these were then discussed within the group to assess how helpful they are as a tool for self-management of pain. The second aspect of Phase V aimed to evaluate children’s perspectives of the Medikidz comic, which was designed to help children understand why older people, such as their grandparents, experience chronic pain. The participating schools were sent copies of the comic book and were asked questions regarding their knowledge of chronic pain before and after reading the book, and also asked about their opinion on the book in general. The two participating schools differ in terms of socio-demographics to ensure generalisability. Data for Phase V will be analysed using narrative and thematic analysis.

Results

Preliminary Results with three focus groups to-date (one to complete), two with service users (n=19) and two with pain practitioners (n=11). These were conducted in Scotland and London to increase generalisability.

Analysis-to-date suggest there is a contrast between what older adults/pain practitioners expect children to understand about chronic pain from the Medikidz book, and what they actually comprehend. Focus groups with older adults suggested the book was only suitable for “very clever children or a set of older teenagers” and “designed for older but would appeal to younger”. In contrast, children aged 9-10years in the initial school evaluation understood that chronic pain is “long lasting pain” that can make people “feel sad and lonely”.

Preliminary analysis of the living with persistent pain in later life booklet and poster identified these as useful sources of information for chronic pain sufferers and pain practitioners were enthusiastic on research focusing on older adults.

Conclusion

These preliminary Results of this study indicate that the three tools that have been developed could help aid self-management for older adults living with chronic pain in the community. It is envisaged that this will also inform the work of health care professionals and policy makers. With the prevalence and impact of chronic pain increasing with age and an ageing population it is essential we identify ways in which older adults can self-manage their pain to allow them to live independently and within their own home for as long as possible.

101 Survey of Opioid Prescribing Practice in Primary Care

Category: Primary Care

Anneka Varma, Arasu Rayen, Atika Kabeer

Sandwell and West Birmingham NHS Trust, Birmingham, UK

Background

Research suggests that approximately 5 million individuals suffer from chronic pain in the United Kingdom. These patients commonly consult their General Practitioner (GP) who can then act as a gatekeeper to specialist services or manage the pain in the community. The role of opioids in chronic pain is controversial and the benefits should be balanced by the numerous side-effects associated with long term use.

Treatment of chronic non-cancer pain with opioids has reached epidemic level in USA. Even though UK prescription practice is not epidemic there are signs that the use of stronger opioids is on the increase. The British Pain Society with the Royal College of General Practitioners published guidelines on use of opioids in chronic non-cancer pain. This audit aims to investigate the use opioids in the community, adherence of the GP’s to the BPS guidelines and awareness of side effects.

Methods

A questionnaire was distributed among the GP’s attending Protected Learning Time session in Pain Management. The questions included were

·· Whether the GPs used any opioids

·· How often they used it?

·· How often they review the patients who were on opioids?

·· Which opioid was the first choice?

·· Which side effects the GP’s were aware of?

The completed questions were collected immediately analysed using Microsoft Excel.

Results

We had 33 completed questionnaires. 100% GP’s stated that they use opioids for chronic non cancer pain, with 47% use them regularly, 43% occasionally and only 10% claiming rare use. The first choice opioid in practice was tramadol; with 87% of GP’s saying this was their initial drug choice. Next most commonly used drug was Buprenorphine, followed by Morphine and Fentanyl. Interestingly, despite the widespread use of opiates, there appeared to be a relatively poor understanding of the side effects of long-term opioid use. Constipation (25%), Nausea and Vomiting (25%), Respiratory Depression (20%) and itching (15%) were the most highlighted side effects, however very few GP’s were aware of key side-effects such as hyperalgesia, immunosuppression and hormonal problems associated with chronic opioid use. Even though most GP’s review the patients who were on opioids at least every month, 3 GP’s mentioned that they allowed patients to continue on repeat prescriptions.

Conclusion

This audit demonstrates that opioids are widely used by inner practice GP’s in Birmingham for the management of chronic pain. The first choice opioid to be prescribed for the majority of GP’s was the least potent tramadol which is in line with current guidelines. Most interestingly however, there appeared to a deficiency in the understanding of common side effects of long term opioid use and frequency of reviews. For GP’s to be able to correctly prescribe and consent a patient for opioid use, it is key that they are aware of these, highlighting a requirement for further education.

102 Converting Community Expenditure on Analgesic Drugs to Non-Drug Pain Management

Category: Primary Care

Michael Mason¹, David Laird²

¹Northumbria GP Training Scheme, Durham, UK, ²County Durham & Darlington NHS Foundation Trust, Durham, UK

Background

We describe ongoing work in Co Durham & Darlington to improve community pain management. The main method of delivering management of pain in the community is through prescription drugs with little provision for non-drug pain management techniques that are effective and cost effective.

Opioid and Pregabalin analgesic use is being scrutinized for efficacy, safety and cost. New tools to deliver pain management in the community are now available. We sought to marry these two developments to deliver better community pain management, using the first as the financial enabler of the second.

We wanted to identify primary care practices that had patterns of prescribing that were in the upper 25th centile. We have agreement to work with them to understand their prescribing patterns and to modify their prescribing behaviour. Reducing expenditure on medication can fund the development initiatives to deliver earlier and more accessible pain management in the community.

Methods

The first phase was to identify drug expenditure and prescribing patterns.

After false starts because of Primary care changes, we identified analgesic drug expenditure over a 2 year period for the 3 Clinical Commissioning Groups in County Durham & Darlington. Using these data we sought to understand the trends and variance in the data and to identify practices to work with.

The second phase was to approach the practices in the upper 25centile with our proposal to work with them in changing management of pain in their community. This consists of developing non-drug pain management Methods, including the “Kirklees” developed Pain Management Plan, delivered earlier and in the community together with clinical and virtual support for patients and professionals in changing patterns of analgesic use.

The third phase of delivering proven community pain management interventions and supporting prescribing change is being rolled out in 2014.

Results

The analgesic drug budget has been rising 10% each year for the last 4 years. Most of this rise can be accounted for by the increase of expenditure on three drugs: transdermal Fentanyl, oxycodone and Pregabalin. Each of these drugs have safety and misuse issues. Clinically it is appropriate to ensure that they are used when indicated as second or third line medications. Experience in the secondary care pain clinics indicates that they are being used as first line agents. These 3 drugs have a baseline cost 2012-2013 of 4M GBP and an annual increase of 670k. Therefore we have identified 3 drugs that should be reserved in their use, have cheaper alternatives and are used widely so that a target conversion of 20% should yield 10% actual savings allowing investment in non-drug pain management.

Conclusion

We are sharing this work at an early stage to stimulate similar initiatives and allow collaboration and comparison across regions. We note that

The pain population is too large for secondary care services as currently configured;

The levers of cost reduction are being applied in a non-specific way. We seek to demonstrate expenditure conversion from drug management of pain to a balanced management of pain with cost savings;

There are now tools validated in the community, and there is a openness for community colleagues to use new approaches with this significant population.

Psychology

103 Women’s Perspectives on the Impact of Chronic Pelvic Pain on Their Personal Relationships

Category: Psychology

Polly Hardy-Johnson, Cynthia Graham, Christina Liossi

University of Southampton, Southampton, UK

Background

Chronic pelvic pain (CPP) is a highly prevalent (Zondervan et al., 2001), debilitating condition (Shin & Howard, 2011), affecting all aspects of women’s lives (Gordan, Panahian-Jand, McComb, Melecari & Sharp, 2003). Despite the fact that associations have been documented between impaired sexual functioning (Gorden et al, 2003) and CPP, relatively few studies have addressed the effects of CPP on personal relationships. In previous qualitative studies on the effects of CPP on personal relationships women have described feelings of anxiety, inadequecy, resentment, shame and isolation, along with tension and conflict with partners (Ayling & Ussher, 2008; Butt & Chesla, 2013). However, previous studies limited recruitment to participants with specific CPP aetiologies (Denny & Mann, 2007) and relationship length (Butt & Chesla, 2013). The current study aimed to explore the effects of CPP of different aetiologies on all aspects of personal relationships among women in relationships of varying lengths.

Methods

Ethical approval was obtained from the Ethics Committee of the University of Southampton and 29 women, aged 22 to 67 (M=38.93, SD= 13.38), experiencing CPP (>6 months) (M=8.18 years; SD=9.00) were recruited via CPP societies, and advertisements in the local newspaper. Participants were diagnosed with vulvodynia (N=16), endometriosis (N=11), interstitial cystitis (N=1) and three had not received a diagnosis. Participants were in short (<1 year) (N=6) or longer-term (>1 year) (N=19) relationships and four were single. Sampling was purposive, in that we aimed to interview women who were likely to have a wide range of experiences and views. We conducted semi-structured audio-taped interviews (27 over the telephone, two face-to-face). Open-ended questions and prompts were used to explore participants’ experiences of CPP, focussing on personal relationships. Audiotapes were transcribed verbatim and thematic analysis used (Braun and Clarke, 2006). Subgroup differences were examined across diagnostic categories and relationship length.

Results

Participants reported that CPP affected all aspects of their past, present and future personal relationships. Prominent themes derived from the women’s discourse included feelings of loss for sexual aspects of their relationships, perceived partner distress, feeling that partners deserved better and, in some cases, relationship breakdown. Single participants discussed the effect of CPP on decisions to enter into future relationships and concerns about disclosing CPP to potential partners. Some women reported positive effects of CPP on their personal relationships, feeling “closer” to partners and perceiving relationships as “stronger.” Sexual intercourse was often affected, but there were several accounts of re-defining sexual relationships in terms of non-penetrative sexual activities. Subgroup analyses revealed similar themes across diagnostic categories and relationship length, although differences were found in subthemes relating to fertility concerns and symptom reports between diagnostic categories and partner knowledge, feelings that partners deserve better and future planning varied with relationship length.

Conclusion

CPP has a profound effect on all aspects of womens’ personal relationships, suggesting that health care professionals should be aware of, inquire about, and address this. Differences found in subthemes related to diagnosis and relationship length suggests that support should be tailored to each patient based on individual concerns and experiences. Reports that CPP can have positive effects on relationships adds new insights to the CPP literature and is consistent with reports of post traumatic growth after other challenging life experiences. Future research could benefit from further exploration of factors that predict successful coping of individuals and couples with CPP.

104 “Work is a beautiful thing….” exploring attitudes towards employment in chronic pain (cp) patients attending a pain management programme (pmp)

Category: Psychology

Parmpreet Kalsi¹, Wafa Turkstani¹, Catherine Sykes¹, Andrew Lucas², Roxaneh Zarnegar², Cara Lovell²

¹City University, London, UK, ²Royal National Orthopaedic Hospital, Stanmore, UK

Background

Chronic pain (CP) has considerable impact on physical and psychological function (Ebert & Kerns 2010). This can in turn affect the employment status of its sufferers (Breivik 2006). The negative consequences of work-absence on economic status and social life are significant (Krause 2001) and longer periods of sick leave or work inactivity have been associated with reduced psychological wellbeing (Svensson 2006).

Patients who have more negative cognitive representations of their pain are less likely to engage in actions that lead to return to work (Schultz 2004, Busch 2007, Coutu 2010). Conversely recovery expectations have been found to predict RTW in back pain patients (Dionne 2005). The aim of this study was to further explore CP patients’ beliefs and attitudes towards RTW and understand how these may impact on RTW readiness.

Methods

The study was approved by the local Research Ethics Committee. Patients attending a 3-week high intensity pain management rehabilitation programme (PMP) at the Royal National Orthopaedic Hospital were given information about the study and asked to voluntarily participate in focus group discussions about employment. Seventeen patients (M:F 8:9, age range 18-66 years) were recruited. The majority (14/17) were aged 18-34 years. Eight patients had not been working for more than one year (range 14 months - 17 years). Four were in gainful employment.

A semi structured question list was used to explore patients’ attitudes and beliefs towards RTW. Each focus group was planned to comprise 3-5 patients and last 1-1.5 hours. Focus groups were led by psychologists with experience in qualitative research and discussions were digitally recorded. Data was transcribed verbatim to permit a thematic analysis (Braun & Clarke, 2006).

Results

Four superordinate themes emerged from the data: (1) living with CP, (2) the fine balance between CP and RTW, (3) work is a beautiful thing … when you have it and (4) the luck of the draw.

The first two themes provided an insight into patients’ perceptions of the effect of CP on work and the range of coping styles utilised towards returning to or maintaining employment.

The second two themes reflected participant’s cognitions on the positive influence of work on quality of life by fostering psychological wellbeing, social identity, and financial independence. Some participants reported a more positive attitude towards RTW as a result of attending the programme. However, the need for tailored vocational support was identified; not only by health organisations but also by employers backed by government policies.

Conclusion

Patients with CP have a range of psychological and physical needs, which can impact on employment status. This study shows that patients recognise and support the need for vocational elements in chronic pain rehabilitation programmes. However, standardised measures need to be developed to assess the provision of effective interventions. This study has provided a unique insight into work related beliefs and attitudes amongst CP patients; providing the impetus for a readiness to RTW scale to be developed.

105 Pain-Related Guilt in Low Back Pain

Category: Psychology

Danijela Serbic, Tamar Pincus

Empathy is considered an essential prerequisite to successful professional-patient relationships. The Consultation and Relational Empathy (CARE) instrument is a validated measure of patient perceived practitioner empathy in primary care. Whilst practitioner empathy is known to lead to greater patient satisfaction, associations with other patient outcomes remain less clear.

This study therefore sought to explore the associations between perceived practitioner empathy among musculoskeletal physiotherapy attenders and other patient reported outcomes.

Methods

Patients with musculoskeletal conditions were recruited from five community physiotherapy services. Consenting patients completed a questionnaire on their first visit, each subsequent visit and received a three-month follow up postal questionnaire containing the CARE measure. Other patient outcomes included the change in EQ-5D-5L index, global health, the musculoskeletal patient reported outcome measure (MSK-PROM), and satisfaction.

The CARE measure was examined for reliability in terms of item to total correlation and Cronbach’s alpha. Associations between participant characteristics and total CARE score were examined. The relationship between total CARE score and the other patient outcomes of interest was examined using logistic regression (for global health and satisfaction) and linear regression (for EQ-5D-5L and MSK-PROM).

Results

425 patients participated and 225 (53%) completed three-month follow-up. Mean total CARE score was 43.1 (SD 7.8, range 19-50), and 87 (38.7%) scored 50/50 suggesting a significant ceiling effect. The CARE measure had a Cronbach’s alpha of 0.977 suggesting item redundancy. Item 9 ‘helping you to take control’ was most correlated with overall perceived empathy (r=.905, p<.001) and other outcomes. There was no significant difference in empathy compared by gender (p=.313), age (p=.727), site of main problem (p=.766), work status (p=.359), deprivation status (p=.951) or treatment status (p=.812). Greater empathy was correlated with greater treatment expectation (r=.19, p=.005), greater general health (r=.14, p=.04), and less pain catastrophising (r=-.22, p=.001). Perceived empathy was associated with greater change in MSK-PROM score (B=.16, 95% CI: .05,.27), improved global health (Odds Ratio (OR)=1.08, 95% CI: 1.04,1.12), and patients’ overall satisfaction (OR=1.41, 1.27,1.56) but not with change in EQ-5D-5L index (B=.003, 95% CI: .000-.007).

Conclusion

Perceived practitioner empathy, is not influenced by patient age, gender, site of problem, deprivation status, or work status. Perceived empathy is only responsible for a small amount of variability in other outcomes. The aspect of empathy most associated with improvement is ‘helping [the patient] to take control’ and further research to equip physiotherapists to increase patient control is recommended.

110 Impact of Preoperative Psychological Factors On Pain Catastrophizing In Patients Prior To Total Hip Replacement

Category: Psychology

Suwapab Techamahamaneerat¹, Adam Mackridge¹, Charles Morecroft¹, Helen Poole², Philippa Thorpe³

116 A Systematic Review of Experimental Studies on Pain Sensitivity Response Difference between Obese and Non-Obese Healthy Pain-Free Humans

Category: Reviews

Rehab Astita, Osama A. Tashani, Duncan Sharp, Mark I. Johnson

Centre for Pain Research, Leeds Metropolitan University, Leeds, UK

Background

Obesity and pain are major public health problems. It was hypothesised that obesity and pain may be linked through two different mechanisms. The first mechanism is that cytokines which are produced by adipocytes (fat cells) could sensitise nociceptors resulting in a sensitised state of pain. The second mechanism could be that mechanical pressure, because of the increased weight, could aggravate pain in certain parts of the body. However, evidence of the existence of differences between obese and non-obese healthy individuals in experimental pain experience is lacking. The aim of this systematic review was to determine whether there were differences in pain sensitivity response to experimental stimuli between obese and non-obese individuals.

Methods

A search for relevant studies from computerised databases (Science Direct, Web of knowledge, OVID MEDLINE and EMBASE), was conducted on 17 June 2013 using a various combination of key terms: (‘pain’ OR ‘experimental pain’ OR ‘Pain Measurement’) AND (‘obesity’ OR ‘overweight’ OR ‘body mass index’ OR ‘cytokines’ OR ‘lipids’). Two reviewers (RA and OAT) independently screened titles, abstracts and full reports of studies for inclusion using a priori eligibility criteria and extracted data from included studies.

Results

1055 references were identified of which 211 were duplicates. The full published reports of 14 potential studies were retrieved of which 7 were included for review. Two of these studies conducted by the same investigating team found that electrical pain threshold was higher in obese women compared with non-obese or normal weight women, one study found that electrical pain threshold was lower in obese participants and one study found no difference. One study found that experimentally-induced pressure pain threshold and tolerance was lower for obese participants compared with non-obese participants, whereas two studies failed to detect differences in experimentally-induced pressure pain. It was not possible to Meta-analyse data because of significant heterogeneity (Cochran’s Q=76; p=0.0001; I²=93.4%).

Conclusion

It was not possible to determine whether there are differences in pain sensitivity response to experimental stimuli between obese and non-obese individuals, because there were too few studies and those that exist were contradictory and had low methodological quality ratings and poor obesity measures.

117 Pain Outcomes in Patients after Artificial Disc Replacement Versus Fusion In The Cervical Spine: A Systematic Review Of Systematic Reviews

Category: Reviews

Osama A Tashani¹, Hanan G. A EL Tumi¹, Mark I Johnson¹, Khaled Aneiba^1,2

¹Centre for Pain Research, Leeds Metropolitan University., Leeds, UK, ²University Hospital of North Tees, Stockton-on-Tees, UK

Background

Pain is a major complaint for patients with cervical disc disease and is one of the reasons for surgery. Cervical artificial disc replacement (C-ADR) was introduced in 2002 to offer an alternative to anterior cervical discectomy and fusion (ACDF) to treat disk disease in the cervical spine. It is claimed that C-ADR reduces dysphagia, dislodgement or fracture in the affected segment and increases motion at the adjacent levels of the cervical spine. In the last decade there have been several studies that have evaluated whether C-ADR leads to less complications, better clinical outcomes and more patients’ satisfaction than ACDF. Little attention has been paid to pain outcomes in systematic reviews of these studies. The aim of this study was to evaluate effect of C-ADR compared with ACDF on pain outcomes by reviewing evidence presented in systematic reviews of randomized clinical trials

Methods

Combinations of keywords were used to search for systematic reviews in Medline via Ovid, Embase, Cochrane Library, and Google scholar including: (total disk replacement, prosthesis, implantation, discectomy, arthroplasty) AND (cervical vertebrae, cervical spine, spine) AND (pain, disability, quality of life) AND (systematic reviews, reviews, meta-analysis). The initial search was conducted on 18 August 2013 and updated on 02 February 2013. Eligibility criteria were: systematic review and/or meta-analysis of randomised controlled trials (RCTs) that compared C-ADR with ACDF at the cervical region with pain being a primary or a secondary outcome. Screening and data extraction was conducted by two authors (OAT, AK) independently.

Results

The initial search produced 881 citations of which 145 were duplicates. Screening of full reports of 68 relevant abstracts resulted in 10 systematic reviews and/or meta-analyses included for review with 2 to 27 RCTs included in each these systematic reviews. Some of these RCTs failed to report pain outcomes and/or lacked description of randomisation processes. There were discrepancies in the analysis of RCTs studies between the systematic reviews in the length of the follow up period, the outcomes considered and reporting of heterogeneity and publication bias. Eight reviews provided evidence that C-ADR reduced pain in arms and the neck measured by numerical rating or visual analogue scales at 1 to 2 years follow-up, although none of the RCTs described how pain was managed. A Cochrane review found significant superiority of efficacy of C-ADR compared with ACDF in many outcomes, including pain, but the effect size was too small.

Conclusion

C-ADF may be more effective to ACDF in controlling pain in cervical patients after 1 to 2 years of surgery but the effect size of the difference is small to be clinically meaningful.

Translational Pain Research

118 Long Term Effects of Perioperative Epidural Ketamine on Pain Processing After Lower Limb Amputation: Analysis of A Double Blinded Randomized Controlled Trial fMRI Subgroup

Category: Translational Pain Research

Marta Seretny, Liana Romaniuk, Heather Whalley, John Wilson, Alastair Nimmo, Susan Fleetwood-Walker, Marie Fallon, Lesley Colvin

University of Edinburgh, Edinburgh, UK

Background

Phantom limb pain (PLP) is a debilitating chronic pain condition affecting up to 80% of amputees1. Treatment of PLP remains difficult and often ineffective 2. Importantly, recent evidence suggests that in addition to diminished sensory input, the subjective longstanding chronic pain experience itself drives the cortical plasticity underpinning the actual phantom limb phenomenon3. These findings strengthen the impetus for identifying adequate Methods to prevent or minimize PLP.

The cascade underpinning PLP development is postulated to start at the time of nerve injury at amputation4. Central sensitization occurring at spinal cord level and involving N-methyl D-aspartate (NMDA) receptors is likely involved in the development and maintenance of PLP.

We therefore hypothesized that targeted pre-emptive modulation of sensory input at amputation using epidural ketamine, would influence PLP and postoperative sensory processing. In this exploratory study functional magnetic resonance imaging (fMRI) was used to assess long-term ketamine effects.

Methods

This study assessed a subgroup from a previously reported RCT5. Patients received spinal-epidural anaesthesia with bupivacaine for lower limb amputation and were randomized to epidural ketamine(K) or saline(S). After ethical approval and written informed consent, patients underwent pain assessment and fMRI (1.5T GE SigmaScanner) 6 months after amputation. Using a block design, noxious cool, punctate and brush stimuli were applied in random sequence to the stump and healthy leg. Statistical Parametric Mapping (SPM8) was used to preprocess and analyse images. Group level comparisons were conducted using random effects analysis (threshold p=0.05 uncorrected, regions considered significant at p corrected<0.05 FWE). Due to small sample size activated areas not reaching statistical significance were also explored. These included the thalamus, anterior cingulate, and lateral parietal cortex. After confirming the expected differences in activation due to PLP ((i) PLP+S versus PLP-S), the effects of pre-emptive ketamine versus saline where explored ((ii) PLP+K versus PLP+S).

Results

Ten patients underwent assessment and fRMI. One patient was excluded due to scan artifact. Data from the remaining nine patients (4 Ketamine, 5 saline), of which six had PLP, was modelled to assess the impact of pain stimulation administered during scans. Median Pain Rating Index (from the McGill pain questionnaire) at time of fMRI was 35 (Range: 2 to 33) for the PLP group and 2 (Range:0 to 4) for the non PLP group. (i) Statistically significant regions in individuals with PLP versus those without included the left cuneus (pFWE=0.001, KE= 1874, Z=4.14) and the inferior/middle frontal gyrus (IMFG) (pFWE= 0.007, KE= 1461, Z=3.86). (ii) In patients with PLP who had received ketamine, decreased activation was noted in the cuneus (pFWE= 0.032, KE= 113, Z= 3.65). Both analyses were further confirmed by qualitative examination of the within group activation maps.

Conclusion

In this exploratory study inhibition of NMDA receptors with ketamine at the time of amputation, influences pain processing at six months in patients with PLP. Our fMRI findings are strengthened by the Results described in our larger study, showing some sensory changes (using quantitative sensory testing) in the Ketamine group. Importantly, these findings suggest that the impact of central pain modulation at time of surgery affects brain pain regions in PLP patients well beyond the pharmacological effect of ketamine.

PERMALINK

Abstracts

Acute Pain

001 Rectus Sheath Catheters as Part of a Multimodal Analgesic Approach For Enhanced Recovery after Open Cholecystectomy

Background

Methods

Results

Conclusion

002 An audit of pain documentation and prescribing practice in the acute medical setting

Background

Methods

Results

Conclusion

003 The influence of an acute pain service on the quality of postoperative pain management in Jordan: a comparative case study

Background

Methods

Results

Conclusion

004 Catheter Wound Infusion of Local Anaesthetic Is an Effective Alternative to Epidural Analgesia in Vascular Patients Undergoing Lower Limb Amputation for Peripheral Vascular Disease

Background

Methods

Results

Conclusion

005 Ionsys® (Iontophoretic Transdermal Fentanyl) For Post-Operative Pain Control Improved Mobilisation and Resulted In Higher Nurse Ease Of Care And Patient Global Assessment Ratings Compared With Morphine Iv Pca

Background

Methods

Results

Conclusion

006 Peri operative pain management: an audit of patient satisfaction

Background

Methods

Results

Conclusion

007 Patient Compliance with Post-Operative Analgesia

Background

Methods

Results

Conclusion

008 A Snapshot Audit of Pain Assessment and Management In A Tertiary Hospital In Qatar

Background

Methods

Results

Conclusion

009 Does perioperative spinal diamorphine improve patient pain outcomes and satisfaction scores after open midline general surgical laparotomy?

Background

Methods

Results

Conclusion

010 Investigating Pain after Orthopaedic Surgery – The Importance of Asking the Right Question

Background

Methods

Results

Conclusion

011 A Survey of the Peri-Operative Use of Sustained (Prolonged) Release Strong Opioid Analgesics In The UK

Background

Methods

Results

Conclusion

012 Audit of Perioperative Pain Management of Proximal Femoral Fractures at Blackpool Victoria Hospital

Background

Methods

Results

Conclusion

Assessment & Measurement

013 A Cross-Sectional Survey of Chronic Pain-Related Attitudes and Beliefs Among Physiotherapy Students

Background

Methods

Results

Conclusion

014 Distribution of Pelvic Floor Muscle Trigger Points in Vulvodynia

Background

Methods

Results

Conclusion

015 Development and Validation of The Keele Musculoskeletal Patient Reported Outcome Measure (Msk-Prom)

Background

Methods

Results

Conclusion

016 The Role of Pain Catastrophising In The Distorting Effect Of Negative Expectancy On Pain-Positive Cues