The following are the best five Trainee/Student abstracts andinstead of presenting a poster they will be presented during Plenary Session 8 on Friday 5th may.
. 2017 May 3;11(2 Suppl):5–96. doi: 10.1177/2049463717696602
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
It is becoming increasingly clear that more pronounced features of nervous system sensitisation are linked to a more severe symptomatology (Woolf, 2011), including those with knee osteoarthritis (OA) (Fingleton et al., 2015). The question of whether nervous system sensitisation has prognostic implications or implications in terms of treatment response has not been well investigated. In clinical practice an increased understanding of the role of nervous system sensitisation in relation to symptom progression in knee OA would be advantageous. Traditional treatment approaches were typically based on the structural-pathology paradigm, and this does not integrate new findings in relation to sensitisation of the nervous system into the clinical management approach (Pelletier, Higgins and Bourbonnais, 2015). Further evidence is required to demonstrate the prognostic implications of nervous system sensitisation in knee OA.
Aims
To date, the relationship between features of nervous system sensitisation and responder status has not been studied in a cohort of individuals with knee OA referred for physiotherapy management. The aim of this study was to investigate the independent association between features of nervous system sensitisation and clinical outcome (non-response)
Methods
This was a prospective cohort study whereby 156 participants with knee OA were assessed at baseline and followed up on discharge from physiotherapy. The baseline assessment prior to commencing physiotherapy provided a comprehensive description of the somatosensory characteristics of each participant by means of clinical examination, quantitative sensory testing, and validated questionnaires. All participants received usual physiotherapy care. Physiotherapy consisted of between 4 and 6 sessions of which exercise, education and self-management advice were principal components. On discharge from physiotherapy participants were classified as non-responders or responders using the OMERACT-OARSI criteria responder criteria (based on changes in pain, disability or global rating of change). A hierarchical logistic regression model was constructed to investigate if features of nervous system sensitisation (pressure pain thresholds (PPTs), temporal summation (TS), cold hyperalgesia, conditioned pain modulation or Central Sensitisation Inventory) added meaningfully to a model containing other known predictors of poor outcome.
Results
Higher TS and lower PPTs emerged as robust predictors of poor non-response following physiotherapy from a model that controlled for other predictors of poor outcome (comorbidity score, treatment adherence ratio, age, gender, depression). More enhanced TS was associated with a greater likelihood of being a non-responder (OR 2.00, 95% CI 1.23 to 3.27), while an OR of 0.48 (95% CI 0.29 to 0.81) for PPT indicated that higher PPTs were associated with a decreased likelihood of being classified as a non-responder. Cold hyperalgesia, conditioned pain modulation, and the Central Sensitization Inventory were not retained in the main hierarchical model. This model demonstrated high sensitivity (88.9%) but modest specificity (52.3% ) suggesting these factors may not be useful for predicting outcome with sufficient accuracy to justify their clinical use.
Conclusion
Variables representing nervous system sensitisation; lower PPT s and enhanced TS, had the capacity to independently predict non-response following physiotherapy. This independent relationship points to an underlying explanatory association between maladaptive neuroplastic changes in nociceptive processing and maintenance of on-going pain and disability in knee OA. These preliminary results may have implications for developing therapeutic targets related to the nervous system in the future treatment of knee OA. Replication of these results in another cohort is necessary and inclusion of a control group would help understand if features of nervous system sensitisation are general prognostic factors or treatment effect modifiers.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Opioids, like morphine, remain the mainstay of clinical analgesia. However, whilst acute treatment has proved effective, prolonged opioid administration leads to therapeutic desensitization (tolerance). Additionally, in neuropathic pain higher doses of opioids are required to achieve pain relief and tolerance appears rapidly. These phenomenon restrict the clinical usefulness of opioids and consequently there is a pressing need for the identification of new therapeutic regimens and strategies to improve efficacy of opioid-based treatments. Recently, it has become clear that the mammalian target of rapamycin complex 1 (mTORC1), a kinase which controls protein synthesis, regulates nociceptor sensitivity and modulates opioid efficacy. However, direct mTORC1 inhibitors are only used in limited clinical indications due to adverse effects. An alternative approach to inhibit mTORC1 is linked to metformin, a widely clinically available and relatively safe anti-diabetic drug that was shown to negatively regulate mTORC1-mediated translation through activation of the adenosine monophosphate-activated protein kinase (AMPK).
Aims
By extending upon studies on the mTORC1 in chronic pain we explored for the first time the effect of metformin on the modulation of morphine analgesic efficacy in neuropathic mice, thus leading to a novel preclinical approach to define the role of mTORC1 in opioid analgesia and opioid prolonged treatment.
Methods
In adult male C57BL/6J mice (n=5-6/group) neuropathic pain was induced by spared nerve injury (SNI). Tolerance was induced by morphine (40 mg/kg, i.p.) given at 12 h intervals for 10 days. The influence of metformin on tolerance was assessed by repeated injections of metformin (200 mg/kg, i.p.) once daily, 24 h before morning morphine injections. In addition, morphine tolerant SNI mice received a single injection of metformin to determine the effect of metformin on restoring morphine analgesia. Morphine analgesic effect was also assessed in SNI mice treated with morphine alone (3, 10, 20 mg/kg, i.p.) or in combination with metformin (200 mg/kg, i.p.). Pain threshold was assessed by tail-flick, von Frey and acetone tests. mTORC1 activity was measured by Western blotting. Analysis was performed using two-way ANOVA with Bonferroni’s test, and the Home Office regulations and the International Association for the Study of Pain Ethical Guidelines were in place.
Results
Administration of morphine to both naïve and SNI mice resulted in tolerance to its analgesic effect after 6-8 days of morphine treatment. However, the originality of our study showed for the first time that chronic metformin co-administration blocked the development and maintenance of morphine tolerance observed as an elevated withdrawal threshold to all testes stimuli. Also, a single metformin dose injected on day 8-9 in morphine tolerant naïve and SNI mice fully restored the analgesic effect of morphine. In addition, when metformin was injected in combination with morphine in SNI mice it potentiated dose-dependently analgesic effect of morphine in mechanical and cold hypersensitivity tests. Our immunoblotting analysis showed that these behavioural effects were attributed to the inhibition of mTORC1 activity as the phosphorylation level of one of mTORC1 downstream targets P-p70 S6 kinase was significantly decreased in the dorsal spinal cord after metformin treatment.
Conclusion
Since chronic pain and tolerance to antinociceptive effects of morphine share some common pathological mechanisms, our study may suggest that mTORC1 represents a novel and tractable target for the improvement of opioid analgesic efficacy in chronic pain. An important aspect of our observations is related to the use of metformin, a widely clinically available and relatively safe anti-diabetic drug, in contrast to other mTORC1 inhibitors that display numerous side effects (e.g. rapamycin), thus leading to an immediate novel avenue for the improvement of opioid therapy in humans, particularly when prolonged opioid treatment is required.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
A consistent body of literature has found that women experience more frequent and debilitating pain than men, but biological explanations fail to fully account for these differences. Psychosocial constructs, such as gender, are likely to play a role in explaining these male-female differences. However, extant research has not thoroughly considered gender-related factors which could account for some of the variability that biological sex fails to explain. This study focuses on coping strategies, as previous research has often found that women utilise significantly more strategies than men, particularly emotion-focused strategies (Affleck et al., 1999; Keogh & Eccleston, 2006; Unruh et al., 1999), although not without exception (Edwards et al., 2000; Grossi et al., 2000; Racine et al., 2015). It considers whether performance of unobservable, internal pain management such as cognitive and emotional strategies, and external, observable pain relief behaviours varied between men and women in accordance with gender norms and stereotypes.
Aims
The aim of this study was to explore sex and gender differences in internal and external pain relief behaviours. We sought to untangle the independent roles of sex and gender, and identify any gender-related barriers to pain relief. A better understanding of such barriers could improve targeted pain relief interventions.
Methods
The sample comprised 479 participants (211 male, 268 female), with a mean age of 33.42 years (SD= 10.80). Participants were all over the age of 18 and had a good understanding of English. The study utilised a between-participants, cross-sectional design by administering an online questionnaire containing measures of demographic information, pain experiences, pain relief strategies, and gender traits. Participants were recruited through (1) online referral and snowball (opportunistic) sampling, by sharing the questionnaire link across media and social media outlets, and (2) utilising Crowdflower, an online marketplace that allows users to complete tasks in exchange for a small monetary incentive. Two hundred participants were recruited via this second method, and paid $1 each. Ethical committee approval was granted by Department of Psychology Ethics Committee.
Results
This poster presents the key preliminary findings from a multiple linear regression analysis. Age, sex, and pain intensity significantly predicted frequency of use of internal (R2= .058) and external (R2= .079) pain relief strategies. Younger participants, male participants, and participants experiencing more intense pain reported more frequent use of both types of pain relief. The inclusion of masculine and feminine traits improved the prediction of internal pain relief (R2= .086). As masculine traits increase by one standard deviation, frequency of use of internal pain relief increases by .12 (p= .017). The contribution of feminine traits was non-significant (p= .078). The inclusion of masculine and feminine traits to the external pain relief model did not significantly improve the prediction of external pain relief (R2 Change = .000, Sig. F Change = .916).
Conclusion
Sex predicted both internal and external forms of pain relief, although the greater frequency of use in men was surprising given women typically report using more pain coping strategies. In terms of the gender traits, masculinity and femininity, there was a less consistent role; masculine traits were found to predict the use of internal pain relief strategies. This is consistent with views that it may be more ‘masculine’ to use internal, hidden strategies to cope with one’s pain, rather than external, overt strategies which could signal weakness or vulnerability. Further research into both sex and gender in pain is warranted.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Retrospective evaluations of pain not only serve as the basis for medical diagnoses, choice of treatment, and proof of symptom improvement, but they also may affect subsequent pain experience and the willingness to return for painful procedures, and they may even contribute to the development of chronic pain. However, consistent evidence whether recalled pain is accurate, overestimated, or underestimated, is lacking. Among factors that can influence pain memory, such as time, actual or expected pain intensity, anxiety, negative and positive affect, also the context of the painful experience has been associated with over- or underestimation of recalled pain. Furthermore, mood dependent memory, occurring when the congruence between affective states at encoding and retrieval facilitates memory, might account for some inconsistencies in the existing pain memory research. Though several studies have explored factors that potentially influence pain memory, few have attempted to examine broad affective and contextual contributions to this phenomenon.
Aims
To determine the accuracy of postoperative pain recall after a 3-month delay, with respect to the context of the painful event and the congruence of affective states during the initial experience and its recall.
To identify potential sensory, cognitive and affective predictors of remembered pain intensity and unpleasantness.
Methods
This prospective, observational study investigated two groups of elderly patients undergoing painful medical procedures in a positive or negative context, i.e. planned (N = 40; mean age = 71.25+/-6.42; 22 female) or unplanned hip surgery (N = 31; mean age = 78.9+/-9.76; 25 female). Data was collected 24-48 hours pre-surgery (T1) and post-surgery (T2), and 3-months after the procedure (T3). At each time point, participants provided the ratings of experienced pain intensity and unpleasantness and state anxiety on Numeric Rating Scales (NRS). Positive and negative affect was measured with Positive and Negative Affect Schedule (PANAS). Participants reported expected pain intensity and unpleasantness (NRS) and underwent cognitive assessment with Mini-Mental State Examination (MMSE) in the pre-surgical period only. Recalled pain intensity and unpleasantness ratings (NRS) were collected only after 3-month delay, and until that point the participants were not aware that their memory of pain will be tested.
Results
Repeated-measures analyses of covariance (ANCOVAs, with group age and MMSE scores as covariates) followed by planned comparisons (experienced vs recalled measures of postoperative pain intensity and unpleasantness; T2 vs T3 measures of positive and negative affect) revealed no significant interactions and differences. The results suggest that memory of pain was accurate and mood states in the postoperative period and after the delay were congruent, regardless of the context of the surgery, indicating a possible mood dependence effect on pain memory. Stepwise forward multiple regression analyses found that cognitive functioning and T2 experienced pain accounted for significant proportion of the variance in remembered pain intensity (37%) and, together with T3 negative affect and T1 positive affect, also in pain unpleasantness (59%) after planned surgery. Age, T1 anxiety, T2 negative affect and T3 positive affect were found to be significant predictors of remembered pain intensity (52%) and unpleasantness (47%) after unplanned surgery.
Conclusion
Memory of acute postoperative pain appears to remain accurate after a long delay, which may be partly attributable to mood dependent memory. Furthermore, a variety of factors influence pain memory, depending on the context of painful experience. Planned surgery appears to be associated mostly with sensory predictors of remembered pain, whereas memory of pain after unplanned surgery seems to depend not on the actual sensory experience, but on affective factors (especially anxiety), possibly due to the largely negative context of acute trauma. Study findings have implications for future research on pain memory and may facilitate improvements in perioperative hospital care.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Low socio-economic position (SEP) is known to be strongly associated with a wide range of health outcomes including chronic pain (CP). A large number of cross-sectional studies have consistently found associations between different measures of SEP and CP but results from cohort studies have been inconclusive. Additionally, few have examined whether measures of SEP including financial hardship across the life course are associated with CP in older adults.
Aims
The aims of this study are to assess the associations between indicators of SEP including markers of financial hardship over the life course and CP at age 68.
Methods
The MRC National Survey of Health and Development (NSHD) is a cohort study initiated at birth in 1946. At age 68, participants were asked about pain and were classified as having CP (pain of at least 3 months’ duration), ‘other pain’ (pain that has not persisted for 3 months) or no pain. Information on a range of SEP indicators (including father’s occupational class, parental education, household overcrowding and tenure, own occupational class and education, and experience of financial hardship) were collected at different ages across life (childhood; early to mid-adulthood; and old age). Data were also collected on a range of covariates: sex, marital status, symptoms of anxiety and depression, smoking status, alcohol consumption, leisure time physical activity and BMI at age 60-64. Multinomial logistic regression models were used to examine whether measures of SEP at different life stages are associated with CP at age 68.
Results
A total of 2386 NSHD participants provided valid data on pain at age 68. Of these, 37% of men and 45% of women reported CP. Indicators of childhood SEP were not associated with CP at age 68. Of the adulthood SEP indicators, manual (versus non-manual) occupational class (RRR 1.29 [95% CI 1.00, 1.66]), lower educational attainment [RRR no education versus degree level 1.35 [95% CI 1.06, 1.71]) and having experienced financial hardship (RRR most versus no hardship, 2.58 [95% CI 1.20, 4.86)] were associated with increased odds of CP after adjusting for sex. After adjustment for other covariates, only financial hardship remained associated with CP (RRR 2.16 [95% CI 1.11, 4.22]). In later life, not owning one’s home compared with being an owner-occupier was associated with CP after adjustment for sex (RRR 1.51, [95% CI 1.14, 2.01]) and this remained in fully adjusted models (RRR 1.42 [(95% CI 1.04, 1.93]).
Conclusion
These results suggest that experiencing financial hardship during adulthood and not owning one’s home in later life are associated with increased risk of CP in old age. Our data are consistent with two previous life course studies which found associations between adulthood SEP and CP, but not childhood SEP and CP. Other cohort studies have been inconsistent in their findings but this may be due to inappropriate or incomplete SEP ascertainment: the present study by contrast utilised a range of SEP indicators. Our findings also imply that tackling CP in old age requires consideration of SEP from earlier adulthood onwards.
The following are the top five scoring abstracts (where the first author is not a trainee or student) and instead of presenting a poster they will be presented during Plenary Session 6 on Thursday 4th May.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Cordycepin (3’ deoxyadenosine), isolated from Cordyceps fungi that infect caterpillars, is a popular traditional medicine in Asia, taken for conditions associated with ageing. Osteoarthritis (OA) is a common cause of pain and disability in the ageing population. According to the United Nations [1], by 2050, 130 million people will suffer from OA worldwide, and 40 million of these will be severely disabled. Inflammation is a key component of osteoarthritic pain. Current treatments are largely limited to lifestyle changes, non-steroidal anti-inflammatory drugs (NSAIDS), corticosteroids, opioid pain killers and surgery. These treatments are not only associated with problematic side effects but are also ineffective at controlling OA progression and pain in a subset of patients. Cordycepin is thought to act by inhibiting polyadenylation, the last step of mRNA synthesis. This novel mechanism of action of cordycepin can potentially have increased therapeutic benefit in OA (anit-inflammatory and analgesic) with fewer side effects than currently available therapies.
Aims
The aim of this study was to determine whether cordycepin treatment alters osteoarthritic pain and pathology, and to decipher the mechanisms of action by which cordycepin exerts any potential beneficial actions.
Methods
OA was induced in male Sprague Dawley rats by intra-articular injection of mono-sodium iodoacetate (MIA; 1mg/50µl) on day 0. Cordycepin was administered orally (2mg/rat mixed in 1g of wet mash) every other day for 2 weeks (pre-emptive study: day 0 to day 14, therapeutic study: day 14 to day 28). Pain behaviour was measured as hind-limb weight-bearing asymmetry and mechanical paw withdrawal thresholds. Joint tissues were collected at days 14 and 28. Joint changes were quantified using histology and immunohistochemistry techniques. Synovial inflammation was quantified as extent of CD68 positive macrophage and cellular infiltration. Synovial angiogenesis was measured as endothelial cells positive for proliferating cell nuclear antigen (PCNA). Safranin-O staining was used to score cartilage damage and bone changes (osteophytes and channels crossing the osteochondral junction [OCJ]). Tartrate-resistant acid phosphatase (TRAP) positive osteoclasts and ADAMTS-5 and MMP13 positive chondrocytes were quantified as additional markers to detect bone and cartilage changes.
Results
The MIA rodent model of OA pain exhibited significant pain behaviour, synovial inflammation and angiogenesis, cartilage damage, osteophyte formation and subchondral bone changes, compared with non-arthritic controls. A two week pre-emptive and therapeutic treatment with cordycepin reduced MIA-induced pain behaviour and synovial changes (inflammation and angiogenesis). Pre-emptive cordycepin treatment reduced cartilage damage and the level of ADAMTS-5 and MMP13 from the chondrocytes. Pre-emptive and therapeutic cordycepin treatment reduced the number of channels crossing the OCJ and TRAP positive osteoclasts in the subchondral bone, but had no effect on numbers of osteophytes. Therapeutic cordycepin treatment did not alter cartilage damage score or the level of ADAMTS-5 and MMP13 positive chondrocytes.
Conclusion
Our data show that the analgesic effects of orally administered cordycepin in a pre-emptive and therapeutic protocol are associated with synovial changes (inflammation and angiogenesis) and bone remodelling. Administration of cordycepin before the onset of MIA-induced OA reduced cartilage damage and had a chondroprotective effect. Whereas therapeutically administered cordycepin did not alter cartilage damage. Further studies will investigate whether cordycepin mediated reduction in MIA-induced pathology and pain behaviour is as a result of its direct action on polyadenylation inhibition. Polyadenylation inhibitors could therefore be a novel class of drugs for treating OA.
Reference
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Nurse-controlled analgesia (NCA) is a flexible, demand-led technique for providing pain relief available for patients who are too young or otherwise unable to use patient-controlled analgesia. The use of morphine-NCA has a good safety profile but there are concerns about opioid-induced respiratory depression, a rare but potentially serious adverse event, especially in certain patient populations including neonates and those with obstructive sleep apnoea or renal impairment. It has also been suggested that children with neurodevelopmental disability (ND) are more at risk but there are so far only a few small and inconclusive studies examining this question.
Aims
To assess the association between ND and: (1) respiratory depression (RD) and (2) serious adverse events (SAEs).
Methods
A retrospective cohort study of 12,904 postoperative children who received intravenous morphine-NCA was conducted. Subjects were divided into neurodevelopmental disability (NDG) and control groups (CG). Rates of RD and SAEs were obtained as well as data on potential confounding factors. Using R and WinBUGS, we assessed the association between ND and each outcome before and after adjustment in Bayesian multilevel logistic regression models. Posterior distributions are summarised by their mean and 95% credibility interval. As any increase in the risk of either outcome was considered clinically significant, we also calculated the probability from the posterior density that the true odds ratio (OR) was >1.
Results
2,390 of 12,904 patients (19%) had ND. There were 88 cases of RD and 52 SAEs; there were no opioid-related deaths. The majority (92%) of incidents occurred within the first 48 hours. The cumulative incidence of RD in the NDG was 1.09% vs 0.59% in the CG, with an unadjusted OR 1.65 (1.03, 2.63) and a 98% chance that the true odds ratio was >1. This association persisted after adjusting for confounders. The association between ND and SAE was considered statistically insignificant (OR 1.42 [0.77, 2.63]) but there was an 86% chance that the OR was >1. A significant interaction between postoperative morphine dose and ND was observed, with higher risk of RD with increasing dose (within a therapeutic range) in the NDG but not in the CG.
Conclusion
This is the first large-scale study to provide data on the safety profile of morphine-NCA in children with ND. We found that absolute rates of RD and SAEs were very low in both groups. There was, however, an increased risk of RD in the NDG vs the CG, which was possibly explicable on the basis of differential sensitivity to morphine. Nonetheless, morphine-NCA, as used at our institution, is overall a safe technique for this patient population.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Pain present for at least three months after a surgical procedure is described as chronic postsurgical pain (CPSP). CPSP affects between 10% and 50% of patients following common surgeries such as mastectomy, cardiac surgery, hysterectomy, hernia repair, joint replacement, back surgery and also more minor procedures. Possible forms of management for CPSP may focus on the condition that indicated a need for surgery, on the aetiology of the pain, or be multifactorial in recognition of the diverse causes of post-operative pain. While some forms of management may have limited applicability outside of the specific condition for which they were intended, others may be transferrable and of importance more widely, regardless of the surgical procedure. There are systematic reviews of pharmacological and non-pharmacological interventions for the management of chronic pain, but no review has considered management of CPSP.
Aims
The aim of this systematic review was to identify randomised controlled trials of interventions for the management of CPSP and to synthesize data across treatment type to provide an estimate of the effectiveness and safety of treatments.
Methods
The protocol for this systematic review was registered on the international prospective register of systematic reviews (PROSPERO; registration number 15957). MEDLINE, Embase, PsycINFO, CINAHL and The Cochrane Library were searched up to 23rd March 2016. Reference lists were checked, registers inspected and grey literature was searched for in OpenGrey. No language restrictions were applied. Randomised controlled trials of interventions for pain received by patients at a minimum of three months after surgery were eligible for inclusion in the review. Abstracts or full text articles were screened to determine if they met the eligibility criteria. Data from eligible studies were extracted onto a standardised proforma. The primary clinical effectiveness outcome was pain intensity and the primary harm outcome was the occurrence of serious adverse events. Risk of bias was assessed using the Cochrane Risk of Bias tool.
Results
A total of 66 studies with data from 3,149 participants met the inclusion criteria. The majority of trials were conducted with patients who had chronic pain after spinal surgery (23 trials) or phantom limb pain (21 trials). Interventions were predominantly pharmacological, including anti-epileptics, capsaicin, epidural steroid injections, local anaesthetic, neurotoxins, N-methyl-D-aspartate receptor antagonists, opioids, calcitonin, and naloxone as an adjuvant to morphine. Other interventions evaluated included acupuncture/dry needling, exercise, limb cover/liner after amputation, spinal cord stimulation, further surgery, laser therapy, magnetic stimulation, mindfulness-based stress reduction, mirror therapy and sensory discrimination training. Opportunities for meta-analysis were limited by heterogeneity between studies. For all interventions there was insufficient evidence to draw conclusions on clinical effectiveness.
Conclusion
In conclusion, this review has highlighted the need for more evidence regarding interventions for CPSP. It is clear that trials to date have predominantly focused on pharmacological interventions, and no trials have been conducted to evaluate multimodal interventions matched to pain characteristics for the management of CPSP. Given the complexity of pain that extends or emerges after surgery, individualised interventions should be developed and evaluated. High quality trials of these interventions are needed to provide a robust evidence base to guide the management of CPSP and improve care for patients.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Living with chronic non-malignant pain is challenging, and a growing number of people with chronic non-malignant pain (usually back or joint pain) go to see their healthcare professionals for help. There is a large body of qualitative research that aims to explore and further understand the experience of living with pain in order to inform healthcare practice and policy. However, the proliferation of studies can make it difficult to access and utilise this knowledge. Systematic reviews of qualitative research aim to synthesise ideas and make them accessible to stakeholders. We became aware of a growing number of systematic reviews exploring the experience of living with chronic non-malignant pain. The innovation of this study is to systematically search for and bring together these systematic reviews using the methods of meta-ethnography. This is the first mega-ethnography of qualitative systematic reviews.
Aims
To pull together the findings from the systematic reviews of qualitative research exploring the experience of living with non-malignant pain in order to offer a conceptual understanding for healthcare.
Methods
We used the seven stages of meta-ethnography to synthesise findings: (1)’getting started’; (2)‘deciding what is relevant’ (3) ‘reading the studies’; (4) ‘determining how studies are related’; (5) ‘translating studies into each other’; (6)’synthesising translations’; (7) ‘expressing the synthesis’. We searched seven bibliographic databases (Medline, CINAHL, Psychinfor, Embase, AMED, HMIC, BNI) from inception to February 2016 to identify reviews of qualitative research that explored patients experience of living with chronic non-malignant pain. We used the following search terms: (metasynthes* OR meta-synthes* OR “meta synthesis”) OR (metasummar* OR meta-summar* OR “meta summary”) OR (metastud* OR meta-stud* OR “meta study”) OR (metaethnog* OR meta-ethnog OR “meta ethnography”) OR (metanarrative OR meta-narrative OR “meta narrative”) OR “critical interpretive synthesis” OR (qualitative ADJ4 systematic*) OR (qualitative ADJ4 review) combined with (exp PAIN or pain.ti,ab). We utilised an approach to assess confidence in findings from Qualitative Evidence Syntheses (GRADE-CERQual) to consider the quality of included studies.
Results
We identified 81 potential studies from 556 titles. We removed 50 duplicates and screened 31 full text articles. We included 11 separate reviews in the analysis which included a total of 187 primary qualitative studies exploring: chronic back pain (67), non-malignant pain (5) Fibromyalgia (37), chronic low back pain (23), musculoskeletal pain (22), arthritis (1) and chronic pelvic pain (11), endometriosis (21). From these studies we identified 78 ideas and organised them into 7 conceptual categories: (1) my life is impoverished and confined; (2) I am struggling against my body to be me; (3) the quest for the diagnostic ‘holy grail’; (4) lost personal credibility and not being believed; (5) trying to keep up appearances; (6) treat me with dignity; and (7) the challenge of ending the quest for a diagnostic ‘holy grail’. We present a conceptual model to pull together these conceptual categories.
Conclusion
We used the methods of meta-ethnography to bring together findings into the first ‘mega-ethnography’. Qualitative studies consistently demonstrate that people with chronic pain can feel that health care professionals do not believe them. This finding has profound implications for health care practice and education, particularly as this loss of credibility may underpin strategies that do not necessarily facilitate lives of full participation for those in pain. The innovation of this study is to present the first systematic review of qualitative systematic reviews. We present a model that pulls together the findings from the systematic reviews.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The Sacroiliac joint (SIJ) is the largest axial joint in the body and is prone to trauma and degeneration which can eventually lead to chronic, non-radicular pain. It has been suggested that at least 20% of low back pain could be attributed to the SIJ.
Radiofrequency neurotomy (RFN) is an established therapy in clinical practice that has shown to provide sufficient pain relief in subjects with chronic non-radicular pain originating from the zygo-apophyseal joints who have failed conventional treatments. Traditional RFN involves applying a local electrical current to the nerves that produces thermal lesions disrupting the pain signals. Specifically, traditional RFN for SIJ involves multiple injections and individual lesioning to the lateral branches of the L5 and S1, 2, 3nerve roots. Unfortunately, this broad and inconsistent anatomical target field prohibits ease of device placement and proper neuronal targeting leading to the various degrees of therapy success found
Aims
The purpose of this study was to provide evidence that that RFN using Simplicity III is safe and effective for reduction of SIJ pain.
Methods
The study was REC approved, single-center, prospective, double-blinded, randomised, sham- controlled pilot trial evaluating the Simplicity III device for patients suffering from SIJ pain. Enrolled patients at St Bartholomew’s Hospital, London after undergoing double diagnostic test with local anaesthetic to confirm SIJ pain were randomised (2:1) to either a sham (no lesions performed) or an active group (lesions performed). The primary endpoint was improvement of pain using the Numeric Rating Scale at 3-months and was analysed using non-parametric tests. Thereafter, subjects were un-blinded and those in the sham group, with an NRS score of 5 or more or more, had the option of crossing over into the active group. All subjects had additional evaluations at 6 months (post randomisation). Safety, secondary and long term outcomes were also collected and measured against 12-item Short Form Health Survey (SF12), EuroQol (EQ-5D), Hospital and Depression Scale (HADS).
Results
Seventeen patients out of thirty enrollments were randomized to active treatment (n=11) or sham treatment (n=6). At 3-months, the mean NRS score for the active group significantly decreased from 8.1 (±0.8) at baseline to 3.4 (±2.0) (p<0.001). The sham group did not yield a statistical or a clinical meaningful mean NRS decrease from baseline (7.3±0.8) to 3-months (7.0±1.7). On average, patients in the active group went from a category of having borderline anxiety at baseline (9.4 ± 5.9) to no anxiety (6.6 ± 6.3) at 3-months. Results were similar for the 6 months visit for the NRS score. After crossing over to the active group at 6 months, all subjects with RFN treatment reported a mean HAD-Anxiety score of 6.7 + 5.0, mean HAD-Depression score of 8.7 + 6.0, EQ-5D score of 0.43 + 0.33 and mean PCS and MCS score of 34.7 + 10.8 and 49.1 + 9.9 respectively.
Conclusion
Our results demonstrated that RFN using Simplicity III significantly improved pain intensity scores in subjects for up to 6 months of treatment with clinically meaningful improvements in mental health scores. Subjects with RFN therapy achieved a mean NRS decrease of 4.7 (p<0.001) at 3 months and sustained this improvement till 6 months. No major adverse outcome reported.
These are the abstracts accepted for poster presentation at the Annual Scientific Meeting.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Cardiac device implants are a common procedure often undertaken in day-case settings. There is a paucity of data from audit or research and no standardised national guidelines. Very limited patient information is available on pain management following device insertions which are not included in the procedure list of The British Association for Day Surgery (BADS). Thus no national guidance is currently available informing best practice for pain management and analgesia provision following cardiac device procedures.
Despite raised awareness and education following local audit cycles in 2013, 2015 and 2016, a need remains for further exploration of the patient experience and how to improve this. Previous audit cycles have shown that despite raised awareness within our institution amongst clinicians, there remains an under recognition of pain related issues, thus patients report a need for improved communication and periprocedural patient information.
Aims
The primary aim was to collect prospective qualitative periprocedural patient experience data following cardiac device insertion. The secondary aim was to host a patient focus group to inform the development of a patient information leaflet (PIL) on managing pain after cardiac device insertions.
Methods
Following institutional approval a tool was developed to capture qualitative patient experience. Forty patients were approached and consented to participation on admission. A pilot of the tool was undertaken with five patients in March 2016 and subsequently adapted to improve usability. Data were collected from April – September 2016. A written formal invitation to participate in a focus group interview (FGI) was posted to consented patients. A blank semi-structured interview schedule was included for patients to complete and return if unable to attend the FGI.
The FGI was conducted using an identical tool. A scribe recorded responses and discussions during the FGI on flip charts. Data were collated and grouped according to time points (on admission, immediately post procedure and 48 hours post procedure).
The results and a review of procedure specific literature guided the content and development of a PIL on pain after cardiac device insertions.
Results
Qualitative data for 12/40 patients (response rate 30%) were analysed. Nine of these patients attended the FGI. Five key themes emerged from the returned questionnaires and FGI participants:
Need for improved communication between patients, carers and healthcare professionals
Need for formal verbal, written and interactive information on the devices related to admission, postprocedural care and rehabilitation
Need for holistic assessment and approach to patient care
Overuse of medical terms impairing patient and carer understanding of the procedure and its sequelae
Insensitive attitude of healthcare professionals in general (lack of empathy)
Limited literature on pain was found in any current PIL national publications.
A draft institutional PIL was developed and the key themes from the FGI were included. This draft document was posted to FGI participants for comment in December 2016.
Conclusion
The FGI and final respondents for this qualitative project comprised only 30% of the total potential population which may limit the generalisability of our findings. However, this project provided a valuable insight into patient and carer experience and that cardiology healthcare professionals require a greater understanding of patients’ needs.
These findings reinforce the value of qualitative data and how it may enhance patient care and experience. The next step will be an interdisciplinary working party to finalise the content and format of the PIL. The PIL will be circulated to relevant patient and professional groups for comment.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Rib fractures are associated with increased mortality and morbidity, especially in the elderly. The presence of six or more rib fractures significantly increases the risk of death, often due to associated injuries. The development of pneumonia in addition has a huge impact on mortality. The primary goals of management are prevention of respiratory complications through adequate analgesia and pulmonary volume expansion. In a prospective study of patients with >4 rib fractures, a multidisciplinary clinical care pathway was associated with shorter intensive care unit and hospital stays, and lower mortality compared with those who were not in the care pathway. The Salford Royal Foundation Trust is a Level 1 trauma centre that introduced a similar multidisciplinary pathway involving pain clinicians, orthopaedic surgery and critical care. Patients are triaged for appropriate treatment based on a recognised scoring system.
Aims
The purpose of this review is to describe the profile of rib fractures and determine outcomes in terms of 30 day mortality in trauma associated with rib fractures. The review also looks at the different treatments offered.
Methods
A review of prospectively collected data in our trauma unit from November 2015 to October 2016 was undertaken. This collection of data forms part of the trauma audit and research networks (TARN) ongoing study into the epidemiology of trauma in the United Kingdom. Additional data in terms of treatment methods and rib fracture scores that provide suggestions for analgesia, were also collected prospectively by the acute pain team. A score of >15 indicates emergent treatment with epidural, 10-15 suggests aggressive treatment with possibly epidural analgesia, 6-9 suggests progressive treatment with PCA and adjuvants and a score of 2-5 suggests that conservative treatment with oral analgesia would suffice.
Results
137 patients were admitted with trauma associated with rib fractures between November 2015 and October 2016. 27 patients (19.5%) had 6 or more rib fractures and all of them had flail segments. 13 patients had bilateral rib fractures.
The mortality rate was 6.5% (9 patients). A case note review of these patients showed that these deaths could not have been prevented. The mortality rate was 12.9% in a review of similar group of patients in previous 5 years. 67 patients (49%) required patient controlled analgesia. 25 patients (18%) had epidurals. Patients with lower scores who had epidurals inserted had significant respiratory comorbidities. Patients with high scores (>15) who did not have epidurals sited had contraindications or were ventilated.
Patients with scores 11-15 who did not have an epidural generally did not have significant comorbidities. No respiratory complications were seen in this group.
Conclusion
Mortality from trauma associated with rib fractures has reduced significantly 12.9 % to 6.5% since November 2015. This can certainly be attributed to recognition of the need for multidisciplinary working. The rib fracture score provides a helpful system for indicating need for epidural treatment. However, patients without significant comorbidities may not require an epidural even in the presence of significant trauma.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Pain is often difficult to recognise in people with dementia and is therefore often poorly treated. To try and aid with this difficulty there has been development of dementia specific pain scores and pathways for the recognition and management of pain in people with dementia.
Neck of femur (NOF) fracture is usually an acutely painful condition occurring predominantly in the elderly population. Amongst this group of patients there is likely to be a comparable cohort of people with dementia.
AMTS is a 10 question screening tool for the presence of cognitive impairment. In this study we have used an AMTS of less than 8 which correlates to the presence of cognitive impairment as a surrogate marker for dementia.
Aims
To determine the incidence of an AMTS < 8 in patients with NOF fracture, and to investigate whether patients with a low AMTS score received the same analgesic strategy as other patients with NOF fracture.
Methods
Through liaison with the hospital trauma sister and by use of the electronic patient records system we identified 39 patients who had a NOF fracture over a 2 month period. We did a retrospective case note review and collected data on pain scoring and analgesia given in A&E; pre-operative and post-operative pain scores; all analgesics prescribed; anaesthetic technique used. We also collected data on complications and length of stay. Our observations were divided into low AMTS (score < 8) and other/normal AMTS (scores 8 to 10).
Results
12 patients (31%) had AMTS < 8.
8/12 (67%) of low AMTS group compared with just 4/27 (15%) of the normal AMTS group received no analgesia in A&E.
Fascia Iliaca block at diagnosis of fracture was performed for 33% with low AMTS compared with 55% with AMTS.
Everyone in the low AMTS group received a general anaesthetic compared with 77% in the normal AMTS group. Of these 50% received concurrent peripheral nerve blocks in the low AMTS group and 75% in the normal AMTS group.
Post-operatively 14/26 (54%) of the ‘normal’ AMTS group received paracetamol plus twice-daily long acting opiate compared with 2/12 (17%) of the low AMTS group.
The most frequent complication is constipation, occurring 16/26 (62%) in the normal AMTS group and 4/12 (33%) in the low AMTS group.
Conclusion
Patients with a low AMTS score were less likely to receive analgesia in A&E, less likely to get a regional block (as analgesia or as part of their anaesthetic), and are less likely to be prescribed regular strong opiate post-operatively. None of our patients received dementia specific pain scoring. The results reiterate the difficulty in recognising pain in patients with dementia and highlight the need for further education and training in the assessment and treatment of pain in this vulnerable patient group.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
There is a lack of research available that examines the diverse population of frequent users of Urgent and Emergency Healthcare services throughout England. The motivations and decision-making processes which frequent users take into consideration when selecting episodic treatment from: Out of Hours GPs; NHS111; Ambulance Services and Emergency Departments are not full examined. Most research explores this population by focusing on the patient’s demographics or preliminary diagnosis, rather than their unmet needs that has instigated the urgent and emergency contact. Subjective terminology and arbitrary thresholds are employed across these services to identify these individuals, with little standardisation or clinical justification to the reasons why they have been selected. Through understanding the unmet needs of this heterogenous population, improved individualised patient centred support and management options should be achieved.
Aims
The aim was to analyse the underlying reasons why frequent users of Urgent and Emergency Healthcare Services in England, select and request episodic instances of care, rather than the consistent approach provided within primary care.
Methods
A systematic mapping exercise was undertaken to create a comprehensive understanding of how these services are currently working with regard to frequent users. The search produced 5094 articles which were screened against the inclusion criteria, leaving 156 articles to be analysed. Data was extracted and a thematic synthesis was used to analyse this diverse population. From this analysis, a taxonomy of sub-groups of frequent users was formed and their underlying needs identified.
Thirty-two clinical semi-structured interviews throughout these services were undertaken, to gain critical feedback on the robustness and viability of the taxonomy. A purposeful sampling method ensured that clinical practitioners that had substantial experience in supporting and managing these complex and vulnerable individuals participated within the research. The qualitative data received from clinicians with knowledge and skills of working with this population prompted adjustments to the original taxonomy.
Results
The taxonomy sub-divided the main heterogeneous group into 5 main groups: Elderly and Frail; Mental Health; Substance Misuse; Chronic Conditions; and Homeless and Vulnerably Housed. Within each sub-group, unmet needs were identified and further categorised. A hidden population of patients that were accessing urgent and emergency healthcare services due to unresolved pain emerged.
This population was categorised into: persistent or chronic pain; acute episodes of severe pain (crisis) and addiction, opioid-induced hyperalgesia or tolerance factors. The reasons attributed to the patients’ frequent contacts were due to the breakdown of their relationship with their GP, polypharmacy issues, access to primary care treatments, perceptions and judgements from clinicians and lack of adequate clinical training around pain management both in primary and acute settings.
These high intensity users of urgent and emergency healthcare services are often the most vulnerable and complex members of our society.
Conclusion
Repeated episodic instances of care, which are often given in urgent and emergency healthcare settings relating to pain management are not proactively allowing individuals to manage their long-term outcomes. Understanding the patients’ unmet needs and what has instigated their frequent contacts to services, could enable clinicians to signpost into other specialised services which will improve the patients’ quality of care. Furthermore, Improved pain management training in both the primary and acute services relating to high intensity users could diminish the negative experiences faced by these individuals and frustrations felt within day to day practice.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The MRHA issued a statement in June 2013 stopping the use of codeine in all children under 12 and all those under 18 undergoing tonsillectomy for obstructive sleep apnoea. Many trusts were now left with the dichotomy of day case tonsillectomy and limited pain relief options. Our trust followed up the caregivers of children undergoing tonsillectomy or adeno-tonsillectomy. Sixty percent of the respondents in the original audit would have used additional pain relief if some had been available. As a result our trust introduced 3 doses of oral morphine (100mcg/kg if over six months) as part of the discharge medication. We conducted a follow up audit of the caregivers to ascertain whether there had been an improvement in the pain experienced by the patients and the responses of their caregivers.
Aims
To evaluate the improvement in patient experience and caregiver responses to the revised discharge pain relief.
To seek comments from the caregivers to evaluate satisfaction with the current discharge medications.
To ascertain comments from the caregivers to further improve the service provided to our paediatric patients.
Methods
Thirty-one carers of children who had undergone tonsillectomy or adeno-tonsillectomy were contacted by telephone post-operatively. A series of questions were asked and the answers were recorded and analysed in Excel. We ascertained what medication was utilised, further contact with health care professionals and the reason why and allowed time for comments.
Results
All caregivers received written or aural information about medication for discharge although only 29 received specific information about oral morphine. The caregivers of thirty children assessed their pain as moderate or severe at some point post-operatively. The number of oral morphine doses given ranged from 0 to 3, with the majority (12) not giving any doses at all. Fifteen caregivers sought additional health care of which 5 were for pain; of these five caregivers 2 had given all 3 doses of morphine. Fifteen caregivers who had not used all the oral morphine were asked about its disposal and six had disposed of it; four with the pharmacy. Comments from the caregivers ranged from being very satisfied and happy with the experience through to being concerned about the safety of oral morphine.
Conclusion
Overall, comments from the caregivers were far more positive when compared to the original audit despite there being a dominance of moderate-severe pain experienced. Some caregivers sought additional healthcare advice for pain despite not giving their child all the oral morphine prescribed. In addition there appears to be a lack of knowledge on disposal of oral morphine. It has been agreed within the department that we shall provide the patients with better education about the role of oral morphine including disposal. Further research should look at what the optimum dose of oral morphine should be – is 100mcg/kg too cautious?
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
In spite of the recognition that pain and its effective management is a hugely important part of postoperative care and contributes to both quality of patient recovery and outcome, there remain a significant percentage of patients for whom postoperative pain is poorly controlled. Additionally, for a proportion of patients, an acute postoperative pain episode is the precursor to chronic pain. It is unclear as to how common acute neuropathic pain is in this patient group.
A number of risk factors have been identified as being associated with severe acute pain and/or chronic pain after surgery. For chronic pain, this includes high pain scores and/ or opioid consumption in the acute period. Effective identification preoperatively would assist specific targeting of perioperative pain management strategies aiming to improve both short and longer term outcome for these patients.
Aims
To investigate whether preoperative risk factors were predictably associated with severe postoperative acute pain in our colorectal surgical population.
To identify patients who developed features of postoperative neuropathic pain and the relationship with preoperatively assessed factors.
Methods
After ethical committee approval, patients on the surgical waiting list for open colorectal resection were sent a study information pack. When patients attended for preassessment, written informed consent was obtained if they agreed to participate. Baseline questionnaires, were completed to assess different components of the pain experience, as recommended by www.immpact.org:
Brief Pain Inventory: pain intensity and its effect on function.
The Pain Catastrophising Scale (PCS).
Hospital Anxiety and Depression Scale.
A self report version of the Leeds Assessment of Neuropathic Symptoms and Signs pain scale (sLANSS).
Bedside Quantitative sensory testing (QST) was undertaken to examine changes in somatosensory processing. (von frey filaments, calibrated brush, pin prick, warm and cool rollers (Somedic))
Assessments were repeated at 2-5 days postoperatively. Timing depended on patient well being and the duration of epidural analgesia if relevant.
A further set of tests were done around 8 weeks postoperatively when patients attended the surgical clinic.
Results
46 patients (age range 40-88 mean 67; 60% male) were studied. In 38 of those the indication for surgery was cancer.
Preoperatively, 10/46(22%) had pain. No patients were taking potent opioids.
2 patients had a positive sLANSS score (>12) and 12 patients scored highly on the PCS ( > 20).
10 patients had evidence of wind up on QST.
Postoperatively: 35 patients were assessed (9 missed, 1 admitted to intensive care; 1 died).
11 patients had severe acute pain on wakening.
Mean pain intensity ranged from 0 to 6.7 (mean 2.3) and median interference ranged from 0 to 10 (median 4). There was a trend to higher mean pain intensity and median interference scores in patients with a high preoperative PCS or preoperative pain.
No patients had a positive sLANSS score.
15 patients had evidence of wind up on QST, 6 of these were unchanged from preoperative.
Two month follow up was completed on 22 patients:
2 patients were sLANSS positive at this time (one of whom was positive preop).
5/22 (22.7%) patients had ongoing pain (one of whom had preoperative pain).
Conclusion
In our small sample, there was no clear predictive pattern for the occurrence of severe postoperative pain or pain at two months. Complete follow up of patients is difficult within the confines of a busy acute pain service. Testing developed for clinical use in guiding levels of pain management has to be achievable in this context.
Factors previously identified as associated with chronic pain development following surgery, were not clearly predictive of this in individual patients in this patient cohort.
Severe acute postoperative pain and longer term pain remain a problem. Further research into how to best identify patients is necessary.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Hysterectomy is the most common gynaecological surgery in the UK and the most common surgical procedure after caesarean section for women of reproductive age. It is performed by abdominal hysterectomy most commonly in the UK and is associated with moderate to severe post-operative pain and with an estimated 32% of patients developing chronic post-operative pain. Many studies have investigated different anaesthetic and surgical techniques to reduce this post-operative pain. .
Aims
To evaluate our current perioperative service with respect to patient satisfaction and post-operative pain following abdominal and laparoscopic hysterectomy. To analyse any associations arising between anaesthetic and surgical technique and post-operative pain and satisfaction and to assess whether any areas were highlighted where service improvement was warranted.
Methods
A prospective study was undertaken at Basingstoke and North Hampshire Hospital to analyse and evaluate the current levels of post-operative pain and post operative satisfaction in patients undergoing an abdominal and laparoscopic hysterectomy. A data entry form was designed for the anaesthetist and recovery staff to fill in operative and post operative details. The patients were given a feedback questionnaire asking about the level and frequency of pain over the first 24 hours post operatively and whether they were satisfied with the way the pain was managed. At the end of the study period the data entry forms were assessed and the e-prescribing database for the period was analysed. Any uncertainties in data were resolved by post-hoc notes analysis, and where uncertanties remained the data was excluded.
Results
Over the study period 39 patients were included with an age range 31 - 80 years. Surgical techniques were documented as Total Abdominal Hysterectomy (TAH) Pfannenstiel (23), TAH Vertical subumbilical (12), TAH Vertical supraumbilical (2), Laparoscopic (2). Pre-medications were Nsaids 17.5%, Paracetamol 12.5%, Zomorph 15%, Oxycontin 7.5%, Gabapentin 5%. Spinal anaesthesia was used in 66% of patients with diamorphine doses from 300 to 1000mg. Intra-operative analgesia used: Paracetamol 70%, Fentanyl 57.5%, Morphine 37.5%, Ketamine 17.5%, Clonidine 12.5%. Post-operative medication included: regular Paracetamol 95%, NSAIDS 82.5%, PCA Morphine 45%, PCA Fentanyl 30%, MR Morphine 25%, Oramorph 22.5%. Pain was reported with the following classified frequency in first 24 hours: Almost constantly 7%, Frequently 17%, Occasionally 15%, Rarely 13%, No pain 48%. The pain experienced was classified as: Very severe 14%, Severe 10%, Moderate 52%, Slight 24%. 95% of patients reported that they were satisfied the way their pain was managed.
Conclusion
The study highlighted very high levels of patient satisfaction despite a quarter of patients being in frequent or constant pain, and of those reporting pain almost a quarter describing it as severe or very severe. Although the data population was too small for significant correlation analyis, there were no striking associations between anaesthetic or surgical technique and patient reported post-operative pain. This was suprising given the variety of techniques. Future analysis could also focus on the use of regional blocks, analgesia beyond 24 hours, time to discharge and other satisfaction criteria such as nausea and vomiting.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
In the authors Trust the prescribing and administration of oral (PO) and intravenous (IV) oxycodone has seen an increase in the last two years since the introduction of the Enhanced Recovery Programme (ERP). The protocol for the pain management of patients undergoing elective orthopaedic and colorectal surgery under the ERP is oxycodone as first line (IV or PO), due to its suggestion of rapid and reliable onset and reduced side effects in relation to constipation and nausea.
The rotation of junior doctors across 2 hospital sites is frequent and the Pain Service had noticed a rise in frequency of oxycodone prescribing, not only in the elective surgical hospital site, but also in the acute trauma site. Patients who were not part of the ERP had been prescribed oxycodone as first line management, despite morphine being first line oral opioid of choice when initiating treatment (NICE 2016).
Aims
The objective of this study is 2 fold; firstly to identify the number of patients who were prescribed oral oxycodone as first line strong opioid for the management of acute pain and the second to review all oxycodone prescriptions to ensure legible, safe and rationalised prescribing of strong opioids.
Methods
The audit was conducted over a 6 week period, between May and June 2016, reviewing inpatients requiring medical and surgical pain management within secondary care aged 16 years and over. A total of 66 patients were identified during this time with a prescription of oral oxycodone, either as a preparation of modified release (MR) tablets and/or immediate release (IR) solution. The clinical nurse specialists (CNS) in pain management collected the data retrospectively from inpatients medical records and medication charts to support their original objectives. Once data was collected it was referred to the trust audit department for analysis and reporting.
Results
Twenty-four patients were excluded as part of the ERP. The data presented evaluates the remaining patients (n=42) who were all prescribed oral oxycodone, either MR or IR preparation.
Of these patients a total of 19% were prescribed oral oxycodone prior to admission.
Morphine had not been trialled prior to prescribing oxycodone in 92% of the total study population, indicating oxycodone had been first line strong opioid of choice in the majority of cases. In 85% there was no documented clinical reasoning as to why this choice was made.
Whilst evaluating the legibility and accuracy of prescriptions of oral oxycodone, 30 prescribing errors were identified. Of these the most common prescribing error (53%) was not clearly identifying which form of preparation was required: either MR or IR. Additionally the frequency of administration was often omitted or incorrect as well (17%).
Conclusion
It is acknowledged that oxycodone is an efficacious opioid for the management of moderate to severe pain where morphine is contraindicated. The increasing use has had cost implications for the Trust as oxycodone is significantly more expensive than morphine (BNF, 70). A preliminary literature search identified that there is limited evidence to support that oxycodone is superior to morphine.
Post audit, areas for improvement included the implementation of a Trust wide pain management guideline, giving guidance and restrictions for all opioid prescribing, identifying clearly the 1st, 2nd and 3rd line choices and rationale.
Oxycodone must now only be prescribed
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Pain as a presenting problem accounts for up to 78% of attendances at the Emergency Department (ED) (Todd et al., 2007), a statistic which includes those who repeatedly attend for similar or related problems. Patients who frequently attend the ED symbolise unmet need: whether the complaint is the same or different, patients who often attend more than 10x per annum, bear a significant economic and personal burden due to their symptoms or anxieties being insufficiently alleviated in the ED. So much so, they repeatedly return. Frequent Attenders (FA) typically present with a complex and chaotic background and unexplained symptoms (Olsson & Hansagi, 2001); they are considered to be psychologically and socially vulnerable in addition to experiencing health difficulties (Byrne et al. 2003). However, studies report that frequent attendance is associated with health problems that could be better managed elsewhere (Penson et al, 2012).
Aims
This study was commissioned to identify the defining characteristics and unmet need of frequent attenders in a community hospital ED and the multisystem context within which this behaviour occurs. A secondary aim was to develop clinical recommendations and service-based strategies to then meet the needs of this group.
Methods
A mixed methods approach was used to achieve the objectives of the study:
Brief structured interviews with patients referred to the ‘majors’ section of the ED were conducted in vivo (N=30) to assess relevant factors associated with attendance. Interview questions were developed iteratively between the ED lead consultant and study authors and based on extant evidence.
Hospital business data from the pool of most FAs (N=50) were analysed. A quantitative descriptive analysis of the group would be produced, including hospital related activity, demographic information and referral path.
Case note analysis of most FAs (N=10), producing a qualitative narrative of common themes.
Staff interviews with a sample of ED and pain clinic staff (N=8 ) using a brief semi-structured format to elicit views and attitudes towards the FA.
Results
Findings can be summarised as follows:
Attendance at the ED appeared to be influenced by familial history of serious illness, relatives encouragement to attend and pain which exceeded 7/10 (a threshold where patients believed intervention was required).
The top 50 attenders averaged at 18 attendances per annum: 49% were admitted, 60% were discharged within 48 hours and over 80% were discharged without intervention. Most FAs were 21-40 years of age and were roughly evenly split in gender, 70% attended via emergency services.
All FAs had long term conditions, most also presented with unexplained symptoms. Approximately half were reported to have complex psychosocial needs, the majority were prescribed multiple medications.
Staff interviews identified a split between those who viewed FAs compassionately and those who were less sympathetic. Staff agreed that current systems were ineffective at meeting the need of the FA, which contributed to staff anxieties around ‘missing something’ in the FA.
Conclusion
Findings from this study suggest that the current model of working within the ED is not effectively meeting the needs of the FA. Pain associated with high levels of anxiety on the part of the patient or clinician in the ED environment is fuelling a better ‘safe than sorry’ culture. This implies a decision making process based on fear rather than facts; the problem is of a systemic nature and a new overarching framework should be defined by the understanding that this group are vulnerable, complex and presenting with genuine need. Recommendations and future avenues of service development are suggested.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Complex Regional Pain Syndrome (CRPS) is a relatively rare (incidence 5.46 to 26.2 per 100,000 person years) persistent pain condition of unknown aetiology, usually triggered by limb trauma. Associated with sensory, motor, dystrophic and autonomic symptoms, CRPS can lead to both significant long-term disability and healthcare resource use. Currently, there is little evidence for existing treatments and nor is there a cure.
This is the first survey to be conducted internationally to identify current care, treatment aims and the associated challenges.
Establishing what is available to patients in terms of care or treatments will help inform future patient and health professional service delivery, education initiatives and content of clinical guidelines.
Aims
This survey aimed to gain insights into existing care and treatments. The following questions were asked:
What are clinician’s CRPS treatment aims and how is care being provided?
What are the barriers and facilitators to practice: what helps and prevents clinicians achieving their treatment aims?
Methods
Following University ethical approval, an online survey using the free version of Qualtrics Insight Platform was created and piloted with three groups: the team, University colleagues and national and international experts in CRPS.
Groups contacted for potential participation included IASP Special Interest Group for CRPS, country specific Pain Societies and relevant health professional national/international organisations.
Survey dissemination included: -
Requesting the clinical networks contact to post an advertisement on their webpages with an embedded link directing people to the survey
Tweeting a survey link to professional special interest groups
The professional bodies’ contact posting an advertisement on their webpages alerting members to the survey
Snowballing where the link might be sent to those who had interest in CRPS
-
Organisations disseminating survey information to their members.
The survey was open during September 1st - October 31st 2016; a reminder was issued after two weeks.
Results
271 completed questionnaires were returned from 35 different countries. Clinicians (n=193, clinical/academics n=48) formed the majority of respondents (n=164 hospital based, n=85 community.
Preliminary qualitative data analysis identified two leading areas as the foci of treatment aims: -
The treatment of pain
Supporting function of the affected limb.
Sub themes of: -
increasing range of movement and
attending to swelling of the limb were identified.
The barriers to achieving these aims were identified as
The pain the patients encountered
The patients themselves, described variously as non-compliant, resistant and failing to adhere to treatment.
However, one of the three themes that emerged as facilitators or enablers of achieving the treatment aims was the importance of patients’ positive engagement with the treatment. Remaining themes included: -
The value of collegiate and multi - disciplinary working
Clinical staff education in the complexities of CRPS.
Conclusion
Respondents were generous in their feedback providing a rare opportunity to gain insight in this field. The qualitative data captured a breadth of experience from clinicians internationally who support patients with CRPS. Preliminary analysis provides opportunities to consider the treatment aims of clinicians and if they are consistent with current CRPS treatment guidelines.
Future observational work might usefully explore the relationship between clinician and patient to consider the role of the patient as both facilitator and barrier to achieving treatment aims in this rare condition.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Pain is the primary symptom in knee OA. Associations between knee OA pain and augmented central processing have previously been reported and therefore treatments that reduce central sensitization might have analgesic benefit in some patients. However, validated, clinically applicable tools that could identify people with centrally augmented OA pain are not currently available.
Reduced pressure pain detection thresholds (PPTs) at sites distant to the affected joint have been interpreted as reflecting central pain augmentation. However, application of PPTs to clinical practice has been limited.
Widespread pain is associated with central pain augmentation in people who do not necessarily have knee pain. Increased numbers of painful sites shaded on a body pain manikin are associated with knee OA pain severity, poorer mental and physical health. We therefore hypothesized that self-reported pain distribution using a manikin might provide an index of augmented central pain processing in people with knee OA.
Aims
We aimed to determine whether self-reported pain distribution, using a pain manikin, is associated with PPTs in people with OA knee pain. Further, we sought to define the optimal manikin-derived measure as an index of augmented central pain processing.
Methods
441 individuals from the Knee Pain and related health In the Community (KPIC) baseline survey represented people with no knee pain (n=94), or knee pain for less (n=239) or more (n=103) than 3 years. Participants were invited for PPT assessment at or distal to each knee and at the sternum. Using shaded areas on a manikin, pain other than knee pain was quantified according to 7- or 23- mutually exclusive regions, or five binary classifications.
Principle components analysis was used to define a common component for log-PPT measurements across sites. Pearson’s correlations between PPTs and manikin data were reported for knee pain participants. Z-scores >1.28 indicate log-transformed PPTs lower than the 80% confidence limit of the pain free group. T-tests compared between-group differences in PPTs as a function of a priori or ROC-derived binary manikin classifications.
Results
PPTs at anterior tibia distal to the index knee showed significant but weak correlations (r< −0.2, p<0.01) with number of painful sites other than the knee.
At least 5 of 7 (AUC = 0.58; sensitivity = 0.3; specificity = 0.8) or at least 6 of 23 (AUC = 0.58; sensitivity = 0.3; specificity = 0.8) other painful sites optimally distinguished those with low anterior tibia PPTs. Anterior tibia PPTs were significantly lower in individuals who met the ROC-derived cut-offs of ‘?5/7- or ?6/23- other painful sites, or indicated on the manikin ‘pain other than knee pain below the waist’.
Principal component analysis of PPT values from all anatomical sites identified one component interpreted by us as “sensitization”. Confirmatory analysis of binary measures using PPTs at sites other than the anterior tibia of the index knee or derived component scores supported findings with anterior tibia PPTs.
Conclusion
Individuals reporting ‘pain other than knee pain below the waist’ on the manikin show reduced PPTs at sites distal to the index joint and elsewhere, possibly indicative of centrally augmented pain processing or central sensitization.
Our results suggest that pain distribution, self-reported using the pain manikin, is not robust for classifying PPT, but might reflect additional features of centrally augmented knee pain that are not directly measured by PPT.
The pain manikin might have value if used alongside additional predictors of centrally augmented knee pain (e.g. catastrophizing, neuropathic pain, etc.) within a composite self-report tool.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
We are a busy DGH covering a population of 800000 in Kent. We have a multidisciplinary team of health professionals and interventions form a key part of our service. Measuring and publishing treatment outcomes will help improve quality of care. The Faculty of Pain Medicine of Royal College of Anaesthetists in their publication Core Standards for Pain Management Services in the UK emphasise on the importance of gathering outcome data. Outcome for pain treatments should not only include pain scores but also various other domains as suggested by IMMPACT recommendations.
Aims
Develop a system which will allow data collection and outcome reports for interventional pain procedures. The system should be user friendly not only at point of data entry but should also allow automatic report generation on regular intervals.
Methods
All patients undergoing interventional pain procedures in our trust are given a telephone follow up 6-8 weeks following their intervention. This follow up is usually done by Clinica Nurse Specialist (CNS). We have setup a standardized electronic questionnaire which the nurses will administer during this follow up. The questionnaire records information in various domains mentioned in IMPAACT recommendations such as - pain relief, use of medication, physical and emotional functioning, improvement in quality of life, adverse effects. The data from this is directly captured in a database in the Electronic Patient Record (EPR). The data serves two purposes. Firstly the data is automatically entered into the GP letters using a standardized template. Secondly the data can be automatically exported at regular intervals into a reporting tool we have developed using a spreadsheet (MS Excel). The report can also be emailed to physicians and CNS automatically at regular intervals.
Results
The primary outcome measures are the patient reported pain relief in percentage and duration of pain relief. Secondary measures include reduction in use of analgesics, improvement in physical functioning, sleep, mobility, quality of life and outcome of the treatment(e.g discharge to GP, proceed to RF denervation). Data from July to Oct captured outcomes from 722 procedures done by 5 pain physicians. 68% (411) of patients reported more than 50% pain relief, with 41% reporting more than 3 months of relief. 24%(176) were discharged back to GP with successful outcomes.
Aside from the benefits of the data and analytical tool this project has also other advantages. The questionnaire is automatically entered into the GP letter along with short and precise comments from our CNS. This provides a concise and standard GP letter.
Conclusion
This project is designed to be running continuously and has advantages to all members of our multidisciplinary team. We were pleasantly surprised by the enthusiasm shown by our CNS as this makes it quicker for them record information objectively during the telephone follow up. Moreover as the information is automatically transferred to patient’s GP letter it obviates the needs for lengthy letters. For the clinicians it is an invaluable tool to measure their own performance and also compare it with others and the report can be used in appraisals and revalidation. The outcome data is also being used by our
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The use of patient related outcome measures (PROMs) has been a priority in the National Health Service (NHS) since 2009. Although potentially integral to patient choice decisions, the collection of this data presents an additional burden to individual patients without obvious immediate benefit. Patient views of this data collection and their difficulties in submitting the answers are scarcely studied.
Routine PROMs data have been collected electronically at the Chronic Pain Centre at the Royal National Orthopaedic Hospital for the last two years. This takes place before the clinic consultation and may be facilitated by ‘data advocates’ who help patients answer standardised questionnaires on hand held tablets. Patients can also submit data remotely through a password enabled patient portal using any computer with internet access.
Aims
We set out to evaluate PROMs data collection at the pain clinic at RNOH from the service users’ perspective. In order to minimise adding to the burden of data collection, only one rating question was asked followed by the option of qualitative comment.
Methods
Patients attending pain clinic were asked at the end of PROMs questionnaire completion whether they would be willing to answer two additional questions to evaluate it. Those who agreed were asked to:
Rate the system for electronic data collection as a whole on an 11-point Likert Scale from 0 – 10.
Provide free text comments about outcomes data collection with unlimited word count
Free text comments were treated as qualitative data. Each respondent’s comments were classified according to whether it was only positive, only negative or had both positive and negative elements. As a separate exercise the text was analysed using thematic analysis methodology.
Results
Two hundred and fifty nine patients who attended the clinic between 1st June 2014 and 1st April 2015, provided a rating score on the patient portal & PROMS data collection. The mean score given to the electronic data collection system at RNOH was 8.7.
Comments were left by 150 patients. Of these, 54 (36%) were positive, 61 (40%) negative, 14 (10%) had mixed content and 21 (14%) were irrelevant to outcomes data collection.
Relevant comments fell into three groups:
Comments on the nature of the questions reflected patients’ anxiety about the answers accurately representing them or their pain condition
There were concerns that the questions “used appointment time” and prevented in-depth assessment
Comments on the electronic technology and role of data advocates were mostly positive. Many of the comments indicated that more disabled patients found it difficult, painful and stressful to use electronic technology without help.
Conclusion
Patients are often not aware of clinician’s reasons for collecting outcomes data and are anxious about how their answers, which they perceive as limited reflections of their condition, influence clinical decision making.
Helping patients use electronic data collection systems is essential to creating complete data sets. Without this, more disabled patient subgroups are more likely to opt out of answering questionnaires.
In response to these findings we now provide more information about the purpose of PROMs data collection to our patients. We agree with other authors that outcomes data collection needs to be a more collaborative process.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Alcohol consumption is widespread and socially acceptable, with 85% of the population drinking but 26% drinking more than the recommended lower-risk guidelines. It is estimated that alcohol related illness costs the NHS £3.5 billion per year; alcohol misuse is a major public health concern. Alcohol remains cheap and easily available.
There is evidence in some mental health disorders, of patients using alcohol to ‘self medicate’ and this seems to be associated with worse outcomes. There is a lack of information about alcohol use in patients suffering from chronic pain.
Assessment of alcohol intake is poor; patient self-reporting and health care staff knowledge has been shown to be inaccurate. Early identification & brief advice (IBA) has been shown to be effective. The Academy of Medical Royal Colleges recommends that all health professionals should be competent to identify those at risk.
Aims
What is the alcohol consumption and behaviour of patients attending an outpatient pain clinic? Is this different from the general population?
Have patients used alcohol to reduce their pain.
Is the questionnaire acceptable to patients and easy to use?
Methods
All patients attending a weekly outpatient pain clinic, over a 2 month period, were asked to complete the form anonymously. They were a mix of new referrals and follow up patients.
The AUDIT (Alcohol Use Disorders Identification Test ) was used. This is a widely used and validated tool. It consists of 10 questions, each with a score of 0-4.Usually the first 3 questions are used as a screening tool, AUDIT-C, with a score of 3 or more leading to more detailed assessment. As the form was being completed anonymously, the full AUDIT was used.
An additional question was added; have you ever used alcohol to help reduce your pain? yes/no.
A visual guide was added to the top of the questionnaire to show
how much one unit of alcohol was
how many units in 1 pint of beer, bottle of wine etc.
Results
57 questionnaires were completed out of a possible 80 (71%).This was similar to return rates for previous surveys carried out in the clinic.
AUDIT-C (the first 3 screening questions for frequency & amount of alcohol) showed the widest range of scores. The following 7 questions about drinking behaviour showed very little variation, with 93% having scores of zero.
AUDIT-C was positive (3 or more) in 20 patients (35%). Indicating hazardous drinkers who would require further assessment (completion of the full AUDIT, which had already been completed in this survey).
The majority of patients had never used alcohol to help reduce their pain, 50 patients (88%). Of the 7 patients (12%) who had used alcohol to reduce pain, there was little difference in their AUDIT-C scores; three patients with scores less than 3,four patients with scores 3 or more.
Conclusion
The AUDIT-C questionnaire identified 35% of pain outpatients as potentially hazardous drinkers. This is slightly higher than the national data estimate of 26%. However the sample size is too small to draw any conclusions and the AUDIT-C tool may not have been used to inform the national data.
Few patients (12%) had used alcohol to alleviate their pain, which is perhaps surprising.
No mention had been made of alcohol intake in the referral letters or hospital clinic notes. The AUDIT-C questionnaire provided a quick & accurate way of identifying those at risk who need further assessment.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Conditioned Pain Modulation (CPM) has been found to be impaired in a range of chronic pain conditions and is commonly thought to be a key clinical marker of central pain inhibitory processes. However, to what extent CPM could be explained and influenced by other psychophysiological variables (e.g., distraction, pain catastrophizing and sleep) has not been systematically studied. There is also an urgent need to establish CPM as a dependable biomarker of individual difference in pain perception and pain response.
Aims
This current study aimed to assess the reliability and differences between two conditioning stimuli to elicit CPM responses; a standard experimental pain inducing stimulus compared to a real-life back pain-inducing stimulus. In addition, we evaluated the independent influence of cognitive distraction, pain catastrophizing, and subjective sleep disruptions on CPM response.
Methods
The study consisted of two experiments with healthy young adults (Experiment 1: n = 57, 84.2% females, mean age 19.4 years; Experiment 2: n = 118, 79.7% females, mean age 19.5 years). Participants underwent two identical quantitative sensory testing (QST) sessions a week apart and completed the pain catastrophizing scale and daily sleep diary in-between. QST was carried out to assess CPM response - Pressure Pain Threshold (PPTh) assessed on the right upper shoulder/forearm alongside two conditioning stimuli to induce pain on the contralateral side of the body: Cold Pressor Task and Bag Holding Task (novel means of inducing musculoskeletal pain in the back). CPM was calculated as % change in PPTh during conditioning stimulus relative to baseline PPTh. Experiment 2 also included two additional distractor conditioning stimuli (attention demanding cognitive tasks) similar in design to the cold pressor and bag holding task to examine distraction effects.
Results
Pressure pain threshold with cold pressor stimulus showed the strongest and most reliable CPM response. Bag holding stimulus showed the weakest CPM response as the pain elicited by the task may not be enough to engage CPM response in this sample of healthy participants. Cognitive distraction also had some effect on pain inhibition; the distraction tasks elicited CPM response but less magnitude (11%) compared to the cold pressor stimulus (29%). There was also some evidence for the influence of pain catastrophizing and sleep – few participants showing impaired pain inhibitory responses (CPM non-responders) reported greater pain catastrophizing and more subjective sleep disruptions compared to CPM responders.
Conclusion
The current study provides further support for CPM as a robust physiological mechanism independent of cognitive processes. The findings also provide preliminary evidence that less efficient CPM response may be associated with pain catastrophizing and subjective day-to-day sleep disruptions. This could have implications for our understanding of pain assessment and pain processing in healthy individuals and clinical populations with chronic pain.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Assessment of outcomes from health interventions is of increasing importance, primarily to identify effective and safe treatment, but also to justify funding decisions. The Bath Adolescent Pain Questionnaire (BAPQ) is a self-report questionnaire validated in 11-18 year olds, assessing the impact of pain in multiple domains of adolescent life: namely, daily functioning (physical and social), emotional functioning (depression, general and pain related anxiety), family functioning and development. The same group proposed and validated a similar questionnaire aiming to assess the impact of chronic pain on adolescents from their parents’ perspective (BAPQ-P).
The service specification for specialised pain management services for children identifies several outcome measures that should be measured in Domains 2 (Enhancing quality of life for people with long-term conditions) and 3 (Helping people to recover from episodes of ill-health or following injury). One of these is the BAPQ, but its routine use in clinical settings is not reported.
Aims
Sheffield Children’s Hospital provides a comprehensive out-patient paediatric pain management service. A service evaluation to assess change in functioning, using BAPQ data, was planned and registered with our Audit department. We conducted a prospective study, routinely planning to collect BAPQ data at initial assessment and 6 months later.
Methods
All patients aged between 5 and 19 attending Sheffield Children’s Hospital pain clinic for the first time between December 2009 and December 2014 were included. Data were collected by mailed BAPQ questionnaires sent before first appointment and 6 months later. Questionnaires were reviewed and the score for each of the 7 sections calculated. Domain functioning scores were calculated by adding the specified sections as originally described. To assess change over the 6 months we computed the domain data as a difference between first and second questionnaires and did a one-sample t-test, using 0 as the target value (no difference at 6 months): a reduction in the score representing a positive improvement in function. This was done for both total BAPQ scores and the 4 domains (daily functioning, emotional functioning, family functioning and development).
We also looked for a difference between patient and parent perception in each domain.
Results
We received 376 questionnaires at time 0 and 96 at 6 months (26%). Age demonstrated a mean of 13 years (5 - 18).
Considering all patients, we found significant differences on patients’ BAPQ questionnaires at 0 and 6 months, showing improvement in total BAPQ score and all domains for a significance level of p < 0,05. The biggest numerical improvement was in emotional functioning. A different result was found on parents questionnaires where we only found a significant difference on total BAPQ score, daily and emotional functioning. There was no difference on parents’ perceived improvement on family functioning and development.
The BAPQ is only validated in adolescents aged 11-18. Comparing child (5-10) and adolescent (11-18) groups showed no significant difference in any of the domain scores. We found significant differences on total BAPQ score and daily functioning at 6 months, with children showing greater improvement than adolescents.
Conclusion
We acknowledge that the response rate for 6 month BAPQs was low at 26%. Improving the response rate would require additional administrative time to allow telephone follow-up, a resource that was not available to us.
6 months into treatment we found significant patient improvement in all four domains of the BAPQ. The domain that showed greatest improvement, for both patients and parents, was the emotional domain, which may reflect acknowledgement that their symptoms are believed and that someone is actually helping.
Our experience and results suggest that the BAPQ can be used in routine clinical practice to assess patient outcome.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Complex Regional Pain Syndrome (CRPS) is a chronic pain condition. Due to its low incidence, for meaningful clinical studies, there is a requirement for multi-centre collaborative projects. CRPS clinical trials have historically used a range of different outcome measures to capture the multidimensional nature of CRPS. This has impeded our understanding of the mechanisms and management of CRPS. In 2013, an international consortium of patients, clinicians, researchers and representatives from industry was established, under the auspices of the IASP CRPS Special Interest Group, to develop and agree a minimum core set of standardised outcome measures for use in all future CRPS clinical trials (COMPACT). COMPACT will facilitate the comparison and pooling of data to answer research questions agreed as internationally important and relevant for the advancement of the treatment of CRPS. To assess the future impact of COMPACT, an online survey was conducted in 2016 and will be repeated 2019.
Aims
To identify which questionnaire outcome measures are currently used by the international CRPS research community.
Methods
Informed by published literature and expert practice, an online survey was created using survey software Qualtrics. The survey included questions identifying current practice in addition to questionnaire outcome measures. Results which identified CRPS current practice are reported elsewhere. Following University ethical approval, potential participants from the IASP Special Interest Group for CRPS, country specific Pain Societies and relevant health professional national/international organisations were recruited via the following routes:
An advertisement with embedded link directing people to the survey posted on clinical network webpages
A ‘tweet’ with a link to the survey sent to professional special interest groups
A link on professional bodies’ webpages alerting members to the survey
Contacts within organisations disseminating survey information to their members.
The survey was available between September 1st - October 31st 2016. A reminder was issued after two weeks.
Results
271 completed questionnaires were returned from 35 different countries. Clinicians (n=193, clinical/academics n=48) formed the majority of respondents (n=164 hospital based, n=85 community). They were relatively experienced (n=121 ? 6yrs in practice), working predominantly in Orthopaedics (41%), Pain (40%) and Rehabilitation (47%) specialities. Of the 271 respondents, 19% (n=52) reported they, or their organisation, recommended the use of questionnaire outcome measures for CRPS clinical trials. The questionnaires reported as most frequently used in each domain were: 1) Pain - Visual Analogue Scale (n= 13), 2) Physical function - Disabilities of the Arm, Shoulder and Hand (DASH) (n= 16) 3) Emotional and psychological function - Pain Catastrophising Scale (n=9) 4) Quality of life - 36-Item Short Form Health Survey (SF-36) (n=8). For each domain, a large number of different questionnaires outcome measures were reported (range 20-36).
Conclusion
Currently, researchers conducting CRPS clinical trials continue to select from a broad range of questionnaire outcome measures. Recommending the use of a core measurement set (COMPACT) within all CRPS clinical trials will facilitate the pooling and comparison of data to advance our knowledge and treatment of the condition. The impact of COMPACT will be reported after the survey is repeated in 2019. Quality Research funding was received from the University of the West of England.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The Glasgow Pain Management Programme (GPMP) is a psychology-led, outpatient, group rehabilitation programme for adults with chronic pain. Patients referred to the service are assessed by a multidisciplinary team. One small part of the assessment process requires the clinicians to make a judgement about the patient’s acceptance of pain and readiness to engage in self-management. The primary reason for doing this is to guard against any one group being populated mainly by patients who struggle with self-management, in case the group dynamic is characterised by a lack of progress. In order to aid these judgements the GPMP developed, what it calls, a “Traffic Light” system. This system asks clinicians to make an assessment of the patient’s readiness to change and either scores the patient as green (ready to change), red (not ready to change), or amber (between red and green).
Aims
The aim of this study was to test the validity of the traffic light judgements by examining how well they predict patient progress in terms of the likelihood of the patient dropping-out from treatment and whether or not the routine outcomes that the GPMP collects, vary across the three groups.
Methods
Data was pulled up from the Greater Glasgow and Clyde Pain Management Programme’s database between 11/01/11 and 17/08/16. Patients were classified as having completed the GPMP if they attended 7 or more sessions. However, complete attendance data was only available up until March 2013 and therefore the data was available on only 152 patients. Completion and drop-out rates were compared across the three traffic light groups using a chi square test.
Routine outcome data covered pain severity, disability, fear of movement, acceptance of pain and anxiety and depression. In this second set of analyses, complete data was available for a larger group of patients (n=372) and this allowed for these outcomes to be compared across those patients who were classified as ‘red’ (n= 103) ‘amber’ (n=165) and ‘green’ (n=104). The analyses were conducted using a series of two way analyses of variance in the statistical package ‘R’.
Results
The chi square analysis did not show any significant differences in drop-out rate across the three traffic light groups (?2 = 4.2, df=2, p=0.121). The two way analyses of variance showed a statistically significant main effect of time (all outcomes improved between the start and the end of the programme) as well as a statistically significant main effect of traffic light classification (the red group had poorer scores than the amber and green group, and the amber group had poorer scores than the green group). However, there were no statistically significant interactions between time and traffic light classification.
Conclusion
The simple, global impression, traffic light system does not predict drop-out from the GPMP, nor does it predict how well patients who complete the GPMP do, in terms of changes on their outcome measures. This suggests that these classifications are probably not tapping into the concepts of pain acceptance and readiness to change and instead they are proxy measures for the overall severity of patients’ problems. The utility of the traffic light systems, in helping to balance group composition, is unproven.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic low back pain (CLBP) is common, often lacks discernible aetiology and contributes to morbidity and low quality of life. Treatments often focus on pain relief and improving motor function but outcomes remain moderate and many experience ongoing pain.
In Complex Regional Pain Syndrome and Phantom Limb Pain, the cortical neurophysiology and specific sensory outputs are altered. Interventions to reverse these impairments coincide with a reduction in pain intensity. Sharing similar neurophysiological characteristics, it’s plausible that similar approaches may improve CLBP outcomes so identification of similar features in this group is needed.
We conducted a systematic review regarding the questions: Are two-point discrimination threshold (TPDT) and body schema (BS) altered in adults with CLBP and do they relate to impaired lumbopelvic motor control (LMC)?
This review initiated stage two; data collection to investigate TPDT, BS, LMC, back-perception, disability, kinesiophobia and clinical outcome measures in adults with CLBP and matched controls.
Aims
Following a systematic review to guide our study, we aimed to identify differences in tactile acuity, body schema, lumbopelvic motor function and association with clinical outcome measures when measured in adults with chronic low back pain and matched controls.
Methods
Using a systematic search strategy, a literature search of 12 bibliographic databases, grey literature, Google Scholar and the reference lists of included articles was undertaken over 5 months to Feb 2016. Studies involving adults aged 18 or older with CLBP longer than 3 months duration were included. Pregnancy, 6 months post-partum, central neurological conditions and nerve root pathologies were exclusion criteria. Two independent reviewers’ assessed for quality using an adapted Downs and Black Quality Index Score. Studies of high (?70%) or medium (60-69%) quality involving adults with CLBP ?3 month’s duration were included. Varied research designs led to a narrative data synthesis.
In stage two, data collection was undertaken in two matched groups (CLBP and control) using established measures of TPDT and tactile threshold on the low back and finger-tip of dominant hand, low back laterality discrimination, lumbopelvic motor control and outcome measures such as disability, kinesiophobia, back-perception and pain.
Results
The review identified 335 studies. Following inclusion and exclusion screening, nine met the selection criteria and were included in the data extraction process. Assessment revealed similar quality strengths with eight of high and one of medium quality. Only one reported power. Sample sizes ranged from six to 51 with a total of 398 participants. All included male and female participants with a mean age of 44.2 years. The studies utilised different techniques and populations to explore tactile discrimination, body schema and motor function but critically; none explored all three.
Stage two data collection has been completed in 62 adults (31 per group) and data analysis is underway. Preliminary results reveal significant between group differences for TPDT, disability, kinesiophobia, back-perception and motor-function. Lateral discrimination and associations have yet to be analysed and results will be presented in the final poster as; a) differences between groups and b) relationships to outcome measures.
Conclusion
Our systematic review revealed TPDT to be altered in those with CLBP and it related to altered LMC. Body schema tasks may also be altered but the evidence is limited.
The relationship between BS and LMC remains unknown and the relationships to other clinical measures are unclear.
Data analysis is underway and some of our results correspond with the systematic review (TPDT, LMC) but others do not (BS). Association analysis continue and further results and conclusions will be presented on the poster once complete.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
There are a few scales available to assess level of consciousness of sedation. However, from peer experience, they don’t accurately reflect the different levels of sedation.
SedateUK has developed a unique tool entitled Alertness in Sedated Patients (ASP) score in order to better assess levels of consciousness during sedation. This will hopefully assist the sedationist in clinical decisions regarding doses and drugs so the patient is kept in the expected level of sedation and does not go deeper than what is required for the procedure.
Aims
The aim of this research consists on Alertness in Sedated Patients (ASP) score validation, specifically feasibility, clinical relevance and satisfaction.
Methods
A questionnaire was developed to assess feasibility, clinical relevance and satisfaction with the Alertness in Sedated Patients (ASP) score. The questionnaire has 8 questions in a 5 point Likert type scale ranging from strongly disagree, disagree, neutral, agree or strongly agree.
Sedationists in an NHS Trust in London and in a Private hospital in London responded to the questionnaire after using the Alertness in Sedated Patients (ASP) score during interventional pain procedures performed under sedation. Data was collected and descriptive statistics obtained.
Results
Descriptive statistics were obtained regarding each question, assessing simplicity to understand the score; easiness to use; accuracy; relevance; influence in clinical decision; ability to improve practice; ability to communicate effectively outcomes of sedation; and satisfaction. Results show a positive response from all participants regarding each item, proving validity of the Alertness in Sedated Patients (ASP) score in terms of feasibility, clinical relevance and satisfaction.
Conclusion
The Alertness in Sedated Patients (ASP) score has been validated in terms of feasibility, clinical relevance and satisfaction, proving to be a good alternative to other tools used to assess level of consciousness during sedation.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Fibromyalgia (FM) is a syndrome characterised by chronic musculoskeletal and soft tissue pain and tenderness and associated symptoms. Pain is continuous by affecting most of the body (positivity to at least 11 over 18 tender points accordingly to the ACR 1990 criteria, lasting at least three months. Clinical research in FM is limited due to a high number of failures with treatments often responding marginally or no better than placebo. Stronger placebo responses have been observed in psychiatric studies, and recent data have shown similar trends for FM studies. Three drugs only are approved USA for the management of FM. To date, no medications are approved for the treatment of FM in Europe.
Aims
This review aims to characterise the placebo phenomena for FM studies.
Methods
A systematic review of FM studies evaluating the placebo response was performed. MEDLINE/PUBMED search was utilised to identify all relevant FM trials between 2005 to 2016.
Results
A relevant placebo response in FM studies has been observed. Within the class of the alpha delta 2 ligands, data published with pregabalin proved a variable placebo response of −1.15; −1.40; −1.04; −0.72 of ADPS at 8 (105 study, L.J. Crofford et al, 2005), 13 (1056 study) and 14 weeks (1077 and 1100 studies) endpoint vs baseline, respectively. −0.70 was the placebo response in the EU subpopulation of 1100 14-week study. The apparent rise in placebo response seems to reach a plateau as shown from results of the Freedom study with pregabalin. SNRI data published with duloxetine in FM showed a placebo response of −0.64 (L. Arnold et al., 2009). With milnacipran the placebo response at endpoint versus baseline was −10.93 (24 h –Recall Pain VAS: 0-100 mm scale). The associated responder rates (>30% reduction in pain from baseline) for placebo groups has been shown to be between 27-34%.
Conclusion
The magnitude of the placebo response in FM is substantial and may be due to the complexity of FM. Key contributors to the enhanced placebo response include concomitant depression, changing participant characteristics, increased patient expectation of improvement and frequent face to face visits. Placebo response may be attenuated by innovative study designs (randomized withdrawal). Additional approaches include: enrolling patients with greater baseline pain severity; minimizing treatment groups; strategies to decrease investigators/patient expectations; improving patient selection to pre-identify placebo and active responders. The impact of this trend will need to be further assessed, including future trial sizes and duration.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Persistent pain is reported in 15-50% of post-surgical patients. The transition from acute to persistent post-surgical pain (PPSP) is an area of considerable interest and research.
Developing interventions to reduce PPSP must be informed by a clear understanding of the population in which they are to be tested. The Royal Marsden Pain Management Service has developed a platform that routinely collects data from patients attending pain clinics. This technology offers the potential to define the pattern and characteristics of pain in this population.
Presented here are preliminary data, describing PPSP in a cancer population. In particular, considering the hypothesis that early pain specialist review may reduce the risk of PPSP, the time between surgery and pain clinic review is explored.
Aims
Using data from patients attending the Royal Marsden Pain Management Clinics between January-November 2016:
Determine the prevalence of PPSP
Determine the time between Surgery and first Pain Clinic review
Compare pain characteristics in PPSP patients with non-PPSP patients
Methods
Patients seen in Royal Marsden Pain Clinics between January – November 2016 who provided data and where pain diagnosis is documented were included.
Patients consent to data collection and use for research. The database complies with Information Governance requirements and has Research Ethics Committee approval (16/LO/1989).
Prevalence was calculated using the proportion of individuals diagnosed with PPSP in the database population. This was stratified according to surgical speciality and, where relevant, according to procedure.
For PPSP patients, the date of first Pain Clinic review and of Surgery was extracted and time between the two was calculated.
Comparisons between PPSP and non-PPSP patients, and between PPSP patients seen less or more than 6 months post-surgery were made for:
pain severity and interference (Brief Pain Inventory, BPI ?7)
neuropathic pain (Douleur-Neuropathique-4, DN4 ?4)
anxiety and depression (Hospital and Anxiety Scale, HADS ?11)
Comparisons were assessed using the Chi-Squared test.
Results
A total of 278 patients were included, of which 91 (33%) were diagnosed as PPSP. 44 (48%) of PPSP patients had had breast cancer surgery (12 reconstructive, 11 including axillary node clearance).
Severe pain (BPI >7) was reported by 11 patients (12%). Whilst neuropathic features, anxiety and depression were more common in patients with PPSP than those with other pain diagnoses, these differences were not statistically significant.
26 (29%, median 94 IQR 48-136 days) PPSP patients were seen in the pain clinic within 6 months of their surgery. The majority were seen within a year but a small number presented more than 5 years post-surgery. Median time to clinic review in patients seen later than 6 months was 491 (IQR 309-1026) days.
There were no significant differences in pain severity, interference, anxiety, depression or neuropathic features between those attending within 6 months and those attending later.
Conclusion
PPSP was diagnosed as the cause of pain in one third of outpatients attending pain clinics at a specialist cancer centre, almost half of whom had breast cancer surgery. Pain was severe in ~10%. This is similar to other published reports.
Whilst most patients attended Pain Clinic within a year of their surgery, a substantial tail presented years later. This has also been reported elsewhere.
Whilst this study lacks adequate power to discern differences between pain severity, psychological comorbidity and response to treatment, ongoing routine data collection aims to remedy this.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The West of Scotland Interventional Cancer Pain Service (ICPS) takes referrals from Palliative Medicine Consultants throughout the West of Scotland in order to assess patients with refractory cancer pain. We offer assessment and, where appropriate, interventional options for treatment of pain where traditional approaches have been unsuccessful. The service has been in place since 2007 and operates with a multidisciplinary (MDT) team approach to assessment and management. The team consists of input from Consultants in Palliative Medicine, Consultants in Chronic Pain, Palliative Care Nurse Specialists, Specialist Physiotherapists, and a Clinical Psychologist. The aim of this retrospective analysis was to look at the outcome of MDT referral and assessment for patients with difficult cancer related pain who were referred for a possible chronic pain intervention.
Aims
The aim of the retrospective analysis was to look at outcomes of both referral and assessment of patients who had been referred to the ICPS over a 10 year period.
Methods
Data was collected for every patient who was referred to the Interventional Cancer Pain Service (ICPS) between 2007 and 2017. Patients were referred into the service, discussed at a referral meeting and then if appropriate were given an appointment for assessment by the ICPS multidisciplinary team. If assessment was not appropriate the reasons for this were recorded. The outcome of the assessment was categorised into patients who were offered an intervention and those that were not offered an intervention with the reason recorded. The interventions offered included intrathecal drug delivery, coeliac plexus block, cordotomy and central neuraxial single injections. Data was also collected on patient demographics and cancer diagnosis.
Results
A total of 370 patients were referred to the service over a 9 year period. 300/370 (81%) of patients referred for initial discussion were offered an appointment for assessment, with 25/300 patients either declining the appointment or deteriorating before the assessment. After assessment 130/275 (47%) patients were offered an intervention, 27/275(10%) were not medically fit for an intervention, 24/270 (9%) other specialty review was felt more appropriate, 24/270 the pain distribution was not amenable to an intervention, 22/270 (8%) the pain was not significant enough to warrant an intervention and 19/270 (7%) had psychosocial red flags precluding an intervention.
Of the 130 patients that were offered an intervention 103/130 (79%) proceeded with the intervention.
The 103 procedures that went ahead included 47/103 trial of ITDD, 22/103 coeliac plexus blocks, 14/103 neuraxial steroid injections 5/103 cordotomy and 15/103 miscellaneous blocks.
Conclusion
From 2007 to 2017 the ICPS received 370 referrals with 103/275(38%) patients assessed proceeding to intervention. A total of 40/370 (11%) of patients referred were no longer fit either for assessment or intervention, indicating that interventions may still be considered a ‘last resort’. Our data shows that the MDT process is a valuable means selecting the appropriate care for individual patients including interventional pain control where appropriate. These audit results have been used to better inform expectations of both referrer and patient; with written information stressing that after assessment only 4 in 10 patients go on to receive an intervention.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
There is good evidence that very little pain education is provided in medical schools. Pain education amongst other healthcare professionals can also be improved. Although good online resources do exist, the information is not tailored to be reflective of local practice and may not be of relevance to healthcare professionals treating pain patients. There is increased emphasis on self-management and patients also need a reliable local source of information that is available in a format that is easily and quickly accessible.
Aims
To set up a pain education and information point in an electronic format that can provide accurate up to date evidence based information for patients and healthcare professionals.
Methods
An initial survey was carried out in 2013 on junior doctors in the trust evaluating existing pain knowledge and prior exposure to pain training. The survey also explored possible choices of information provision and not surprisingly, given the demographics, they wanted something that was smartphone and tablet enabled. A similar survey was carried out on patients attending the pain clinic and the patients also expressed a desire to be given information that was simple to understand, preferably about various pain killers and doses. Informal discussions with local commissioners and General Practitioners and pharmacists also highlighted the need for such an educational resource to be provided so that a consistent locally relevant message can be disseminated.
Results
We enhanced our internal trust website so that it would provide the relevant pain education and information to junior doctors and trust healthcare staff. A patient information book was made available as an electronic download about various analgesics prescribed locally. Finally a mobile and tablet application was also produced that integrated the information both for junior doctors/local healthcare professionals and patients in a single app available across all mobile platforms. The app is free to download for patients and other healthcare professionals. The information is customizable and frequent updates can ensure its continued relevance. The pain unit has been at the forefront of providing evidence based pain education to all HCPs.
Conclusion
The Royal Berkshire Pain education mobile app is a maiden and unique attempt at creating a single point of pain medicine education and information that is quickly accessible to patients, junior doctors looking after hospital inpatients, busy GPs and other healthcare professionals. More importantly, it can prove to be an effective tool to disseminate high quality Pain Management national society guidance from the faculty and BPS in byte sized chunks to all those who need it.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
One of the main objectives of The Faculty of Pain Medicine of Royal College of Anaesthetists is “ to educate medical practitioners to maintain the highest possible standards of professional competence in the practice of pain medicine for the protection and benefit of the public”.
The Faculty works through a network of the Local Pain Medicine Education Supervisors (LPMES) and Regional Advisors in Pain medicine (RAPM). Their duties are many and varied.
Though the Faculty “recognizes and records its appreciation that many employers allow time for these extra efforts”, there are no minimum mandatory allocation for the same.
Although we understand that the NHS is facing severe financial constraints, we speculate that failure to recognize these important roles within Consultants’ job plans can affects the role and morale of the faculty representatives at the ground level and this could potentially have a negative impact on recruitment within these roles.
Aims
The aim of this survey was to gather information on Trusts’ recognition and support within Consultant job plans for the role and responsibilities of LPMES and RAPM. As a corollary we also wanted to assess if this support or lack thereof affected the willingness to undertake these roles.
Methods
We conducted a survey by sending electronic questionnaires to all RAPM’s and LPMES’ in England.
Issues addressed were specifically:
SPA time allocation for LPMES and RAPM duties.
Allowance of professional leave from work to fulfill these duties.
Effect of individual hospital policies on professional support on the willingness amongst Consultants to take up these duties and roles.
Results
Response rate to the survey was >80%. 34% LPMES’ and 50% RAPM’s had specific allocation of professional time to fulfill their duties and responsibilities as set out by the faculty. The SPA allocation varied from 0.125 to 1.5; Professional leave to undertake obligations attached to these roles varied widely amongst the responders. 28% of RAPMs and 36% of LPMES’ felt that their Trust policy on support provided to them, affected their and their colleagues’ willingness to undertake these roles.
Conclusion
In a financially strapped NHS, the Faculty as well as Trusts across the length and breadth of the country depends on the goodwill of Consultants to continue providing and supporting education in pain medicine for trainees. RAPM also have an important role to play as advisors in Consultant appointments. A number of them also have other roles within the Faculty.
In these challenging times, it is more important than ever to strengthen the support and appreciation provided to Consultants who undertake these essential roles.
We present our findings to create awareness of a need to address this issue.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Torbay and South Devon NHS Foundation Trust covers a large geographical area. With the exception of Torquay, Paignton and Teignmouth, the population served by the Trust is largely rural. The Pain Team includes medical consultants, nurses, physiotherapists, clinical psychologists and an exercise co-ordinator.
We work with patients to help them manage the effects of on-going pain, with pain relief and management being offered simultaneously. One route to facilitate engagement is through internet based resources that potentially enable us to reach more people in a timely way. A Cochrane review in 2014 (Ecclestone et al) found support for the delivery of internet based psychological treatments in reducing pain sensation, disability and distress. Web-based interventions can effect behavioural change.
Our website was developed in response to patient feedback following completion of one of our pain management programmes. Data from 55 post-programme interviews revealed several themes. One of these was reconnecting to values-based activities. ie “reconnecting to life”.
Aims
To develop a web-based resource accessible to all those attending the Pain Service or considering doing so
To provide information about pain management for use in general practice, and community healthcare agencies
To signpost to self-management options
To audit its uptake.
Methods
Semi-structured interviews (N=55) explored treatment outcomes from attending a group pain management programme. Data collected consisted of self-reported quantitative Likert scales and qualitative reports of patient experiences. Five qualitative themes emerged from the semi-structured interviews: Understanding pain (and pharmacological management); Improving health and fitness; Learning new skills (relaxation, mindfulness meditation); Reconnecting with values-based activities; and Changing the way you think and feel (emotional well-being).
These themes formed the foundation for the ‘website nodes’ on the Reconnect2life wheel.
Focus groups with patients were used to further validate these themes.
A working group including a representative from each clinical speciality in the multidisciplinary team met with the Trust web-designer to develop the “Reconnect2life” website. Physiotherapy took the lead role in this project. The whole team produces and updates content.
Ongoing audit follows a recognised cycle, and informs site development. Monthly web monitoring reports are produced by google analytics.
Results
The website is a resource available to all, without the need to travel.
All patients are now signposted to the website prior to being seen in the Pain Service.
Since its inception in September 2014, the website “hits” have risen from 500 per month to 2,100 per month in November, 2016.
Pain Physiotherapy is the arm of the pain service that deals most with pain management. The average ratio of new to follow-up appointments in pain physiotherapy has fallen from 1:5 to 1:2.5.
The website is used by the Outpatient Musculoskeletal Physiotherapy service. Since it’s introduction in 2014, referrals from Musculoskeletal Physiotherapy to Pain Physiotherapy have fallen by approximately 40%.
Conclusion
ReConnect2Life unites the Pain Team with a shared philosophy of care. Self-management concepts are introduced from first contact. Local GPs signpost patients prior to or at the point of referral. Patients endorse its use to their friends and family. It is a resource that can be accessed by patients without the need to travel. Multiple hospital appointments are reduced, waiting times have improved. The intention for the future is to make the website more interactive.
Alongside “Involve”, our patient involvement group, we seek to ensure that the website continues to be wholly supportive for all our patients’ healthcare and lifestyle needs.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
For patients suffering with chronic non-cancer pain (CNCP) the success of pain management strategies to improve functional and psychological status, whether in tandem with pharmacological or interventional treatments or not, is best applied in the context of a bio-psycho-social model.
As a cornerstone of this strategy, patient education and the acquisition of self-management skills are paramount and are advocated widely.
Traditional Pain Management Programs (PMPs) promote changes in behaviour to enable those with chronic pain to lead as normal a life as possible by improving the individual’s ability to self-manage pain-associated disability and reduce reliance on healthcare resources.
Typically, multidisciplinary teams work with patients for half a day per week over 12 weeks and course facets include: education on pain physiology, pain psychology, guided exercise and activity management, goal-setting, identifying and changing unhelpful beliefs and ways of thinking, relaxation and changing habits which contribute to disability, amongst other techniques.
Aims
PMPs are often utilised as a treatment of last resort. The hypothesis that early application of PMP principles may help to reduce disability led us to design a half-day education session which we could offer to a wide cohort of our CNCP patients to improve their lives.
Methods
A half-day (2½ -hour) pain education session was designed using the principles of the PMP by a multidisciplinary pain management faculty with experience in delivering traditional PMPs.
Patients were identified for invitation from the parent hospital’s general pain management clinics at the discretion of the physician or specialist nurse. The session consists of a series of low-fidelity lectures and interactive sessions.
Topics covered include: pain biology, medications and interventions (physician led), impact of pain (specialist nurse and clinical psychologist led) and self-management and exercise advise (specialist physiotherapist led).
Pre-session data collected serves to help us understand our attendee population better and includes information on: general demographics, health-professional interactions, Pain Catastrophizing Scale score, Pain Self-Efficacy Questionnaire score and EuroQol five dimensions questionnaire.
Post-session qualitative data collected includes feedback on the delivery of the session and if it helped patients understand or manage their pain better.
Results
Complete data sets from 23 patients over four sessions were available.
Patients suffered from a wide variety of pain diagnoses but mainly including widespread pain/fibromyalgia and musculoskeletal or neuroaxial pain.
Some patients had received invasive pain management procedures and others were awaiting their first.
83% of participants (n=19) found their session ‘extremely’ or ‘very’ useful.
74% of participants (n=17) found their session ‘extremely’ or ‘very’ informative.
61% of participants (n=14) found their session ‘extremely’ or ‘very’ enjoyable.
83% of participants (n=19) found the information given ‘extremely’ or ‘very’ clear.
83% of participants (n=19) found their session ‘extremely’ or ‘very’ understandable.
65% of participants (n=15) thought the information given was ‘extremely’ or ‘very’ sufficient.
70% of participants (n=16) felt that they were ‘extremely’ or ‘very’ helped to understand their pain better with 52% (n=12) feeling that the were ‘extremely’ or ‘very’ much more able to manage their pain better.
Conclusion
Although in its infancy, anecdotal comments and qualitative data suggest that future quantitative data from validated questionnaires is likely to show significant impacts on satisfaction, well-being and functional outcomes.
With positive impact data, formal commissioning of this type of intervention will enable us to expand the participants invited to other patient populations including orthopaedics, rheumatology and spinal surgery. This will help us to develop a wider pool of expertise and available resources.
Ongoing data collection using a PDSA cycle will help us to self-evaluate and enable our program to evolve.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
EPM Lite is a structured method of teaching an algorithmic (RAT - Recognize, Assess, Treat) approach to pain management.
Medical schools and postgraduate deaneries evaluate teaching, but no simple method of evaluation has been agreed across the UK, or even within a single institution. EPM Lite faces several difficult challenges: we have minimal central organisation and actively encourage medical schools to adapt the available materials to their needs. EPM lite has been taught in different years of the medical school curriculum and also to postgraduate trainees. Group size is commonly around 30 but has varied from 5 to 240 participants. The course is brief (between 2.0 and 3.5 hours) so that any feedback from participants has to occupy minimal time.
Aims
We wished to integrate a number of methods of evaluation into a simple spreadsheet designed to take little time to complete and little effort to co-ordinate centrally, in order to be of value to both local organizers and the Faculty of Pain Medicine centrally.
Methods
The main elements are:
A show of hands on ‘3 simple questions’:
Have you had undergraduate training in the multidisciplinary management of pain?
Do you feel confident in being able to manage pain after you have qualified?
Do you feel that UK undergraduates currently receive adequate training in the multidisciplinary management of pain?
‘Delphi Walls’. We put 3 flip-chart papers on the walls headed ‘What we learned’, ‘What we enjoyed’ and ‘What to improve’. Participants write on the papers and agree with any previous comment by placing a tick beside it. This leads to rapid convergence around key themes organized by the learners themselves. We have not been able to find any reference to this self-organizing method of feedback (although we can’t believe it’s entirely new) and have tentatively named it ‘Delphi Walls’, as one of the sources of inspiration came from the Delphi process.
An MCQ.
Results
We piloted this in Kingston Hospital with 24 core trainees in Anaesthesia.
86% had received no formal training in Pain Management as undergraduates, 76% had not felt confident in managing pain at the time they qualified and all felt that current undergraduate training in pain management is inadequate.
The Delphi walls were easy to assimilate and summarize for the teachers, for example participants particularly learned to use the RAT approach and appreciate the benefits of remembering non-drug treatments.
The MCQs revealed some misconceptions about addiction and opioids; for example 33% felt that patients with advanced cancer taking morphine, should be warned of the risk of addiction.
Conclusion
Our ‘3 Simple Questions’ and ‘Delphi Walls’ approach has allowed a time-friendly but content-rich method of evaluating the EPM Lite course.
The ‘’What to improve’ sheet provides key feedback on learner needs for further development of EPM Lite for groups beyond medical students.
The importance of taking EPM Lite to qualified staff is highlighted by serious misunderstandings about opioids and their side-effects, even among doctors who have been qualified for more than two years.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
There is a gap in the provision of information services for patients with chronic pain in Primary Care in NHS Greater Glasgow and Clyde. The Primary Care Pain Education sessions were developed as part of the Glasgow Chronic Pain Managed Clinical Network’s pilot that aimed to improve the management of chronic pain in the community.
Aims
To improve early access to evidence-based, pain self-management information in a community setting to individuals who have suffered from chronic pain for more than one year.
Methods
Education sessions which deliver early evidence based self-management information were developed, tested and refined by the NHS Greater Glasgow and Clyde Pain Management Programme and the NHS Greater Glasgow and Clyde Chronic Pain Managed Clinical Network. These sessions lasted for two hours, and were designed to be a ‘one-off’ introduction to various topics relevant to the self-management of chronic pain. Patients were sign-posted to the Pain Education Classes by GPs, Pharmacists, Physiotherapists, and via poster advertisements that were displayed locally. Patients were then required to self-refer. The charity Pain Concern worked in partnership with NHS Greater Glasgow & Clyde and took over the day-to-day administration of the classes.
Results
Fifty seven individuals who attended the Pain Education Classes between 30/10/2014 and 30/06/2015 completed the evaluation. The majority (66%) of those who provided information on referral source reported being signposted to the classes by their GP, whilst the remainder found out about the classes through a variety of sources. In terms of an overall evaluation, the classes were very well-received, with 98% of those completing the evaluation being happy to recommend it to other patients. In terms of the individual education topics, all appeared to be well received by patients.
Conclusion
The education sessions appeared to be well-received and have met a previously unmet need in the community. Data continues to be collected on changes in patient understanding and self-efficacy. More recent developments have included training patients who have graduated from the Glasgow Pain Management Programme to deliver the classes.
Most patients with chronic pain never attend a pain clinic and are therefore unlikely to have access to specialist information on the self-management of their condition. These classes can be portrayed as the first ‘rung’ of a stepped care model for chronic pain.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Postoperative pain control is managed using continuous epidural infusion and patient controlled analgesia (PCA) devices. Closer monitoring of observations is required for these patients as per national and institute guidance due to risk of adverse effect such as respiratory depression and formation of epidural haematoma. There was a lack of knowledge surround frequency of observations and this resulted in an increase risk of adverse events not being detected. Variety of teaching and staff engagement methods where undertaken to improve patient safety. These included ward based teaching, redesign of pain study day and engagement with sisters and matrons.
Aims
100% of patients should have hourly respiratory and sedation observations while on continuous background infusions via PCA
100% should have 4 hourly observations with epidural analgesia
100% should have epidural observations performed for 48 hours after removal of epidural catheter
Methods
Baseline Retrospective audit over one month and prospective spot check of 5 observations charts on the ward environment consisting of 21 patients, this was then repeated again with a further 2 post intervention audits after 6 months consisting of 41 patients.
Results
PCA:
Baseline results showed 27% compliance with hourly respiratory rate observations, this decreased to 0% in spot check audit. This increased in post intervention audit to 76% compliance.
Epidural:
Baseline 50% compliance with 4 hourly observations which increased to 100% in post intervention audit.
Baseline 0% compliance with 48 hour observations following removal in retrospective and spot check.
Increased to 78% compliance for 48 hours and 22% for 24 hours in post intervention audit.
Conclusion
Implementation of educational interventions has had a marked improvement in compliance of observations being performed. Audit standard of 100% has yet to be achieved and further educational interventions including additional ward teaching, pain road show and redesign of documentation to act as a prompt.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Effective doctor-patient communication is a key to building a therapeutic doctor-patient relationship. Communication skills are essential with patients, their families, colleagues and in training. However, anaesthetists have traditionally focused on technological and pharmacological advances with relatively little focus on communication skills training. In comparison to other specialties, such as general practice, there is no training on consultation models or skills during training.
Aims
Ascertain the amount of awareness of different consultant formats, and how much training in communication skills had occurred.
Methods
As a first step, I conducted a survey to ascertain if trainees were aware of any consultation techniques, what training they had in this and whether these skills had been assessed and by whom.
I developed a survey using the Survey Monkey tool. This had 10 questions and was sent out to the higher and advanced pain trainees and consultant colleagues nationally.
Results
The survey had 38 responders. It showed only 60% had had communication skills training since medical school, highlighting that 40% had never undergone any form of communication skills training.
80% of respondents had not heard of any consultation models.
Consultants provided feedback on trainees’ communication skills, despite having little training in this area themselves.
20% of respondents felt that communication had added to a complaint they had received.
95% of responders would like specific training in communication skills. We are starting a communication skills course to action the results of this survey.
Conclusion
Communication skills are at the heart of pain medicine. Surprisingly, this is poor taught nationally. It is imperative that doctors receive training in communication skills to enhance the management of some of the complex patients in medicine, who often present with psychological and social problems. I have designed a course to teach communication skills and consultation models to doctors.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic pain affects a third of the population in England. Opioid analgesics are typically used to manage long-term pain but there are very few studies to support the long-term effectiveness of using strong opioids for chronic non-malignant pain. Despite this opioid prescribing continues to rise at an alarming rate, with a 3% increase between 2004 and 2014. The largest proportion being issued in the North of England (33%)
No study to date has examined the spatial distribution of chronic pain across the regions of England and its relation to deprivation. Nor has previous research examined the association between prevalence of chronic pain and opioid prescribing or usage. This is the first study to examine the spatial distribution of chronic pain, pain intensity, opioid prescribing and usage in England.
Aims
Are there regional inequalities in the prevalence of chronic pain and pain intensity in England?
Can they are explained by area-level deprivation?
Does opioid prescribing and usage differ regionally across England?
Is there a regional association between chronic pain and/or pain intensity and opioid prescribing after controlling for deprivation and other potential confounders?
Methods
Cross-sectional, local authority level prevalence data for 2011 was obtained for chronic pain, pain intensity (Health Survey for England), opioid prescribing (Health Survey for England), and opioid usage (National Treatment Agency) as well as area-level deprivation (Department for Communities & Local Government). Chronic pain and opioid data were mapped at local authority and regional level for England and prevalence examined by area-level deprivation. Mixed effects multi-level modelling was then conducted for the following outcomes: chronic pain, pain intensity, opioid prescribing and opioid usage (adjusting for area-level deprivation and individual level age, sex, ethnicity, household income).
Results
There were significant regional inequalities in the prevalence of chronic Pain: prevalence was 31% lower in London (0.69; 0.52-0.91) than the North East. Data for pain intensity showed that there was significant variability in pain intensity within the North: the North West had significantly higher pain intensity (0.07; 0.00-0.14) compared to the North East but significantly lower than Yorkshire and the
Humber but there were no significant differences in pain intensity between the North and South. The North-South divide was clearer for opioid prescribing and usage: prescribing was significantly higher in the North compared to the South (Londoners were 71% less likely (0.29; 0.13-0.65) to be prescribed opioids than those living in the North East). Opioid usage was significantly associated with living in the North compared to the Southern parts of the country. Opioid prescribing was not associated with area-level deprivation but estimated area-level opioid usage showed that usage was greater in the North.
Conclusion
There were significant spatial variations in chronic pain, pain intensity, opioid prescribing and opioid usage in England and there was a significant North-South Divide, with the North East doing particularly badly compared to other parts of England. The regional divide was not as clear for prevalence and intensity of chronic pain. Area-level deprivation was independently and significantly associated with chronic pain, pain intensity and estimated opioid usage but not opioid prescribing, perhaps suggesting that there are different prescribing habits operating in the North compared to the South.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Fibromyalgia is characterised by chronic widespread pain and tenderness; commonly associated with fatigue, cognitive disturbance, somatisation and psychiatric symptoms. It has often been reported to occur concomitantly with chronic rheumatological conditions. Behçet’s disease is a chronic relapsing, multisystem, autoinflammatory disease. It has the potential to significantly impair quality of life, with the degree of impairment directly relating to disease activity.
Some patients with Behçet’s disease suffer from vague musculoskeletal pain but there is only rarely joint involvement, and the pathophysiology of this pain is yet to be fully understood. Currently there is limited understanding of a potential relationship between fibromyalgia and Behçet’s disease. This review considers what evidence is available on the prevalence of fibromyalgia in Behçet’s disease.
Aims
Given the potential detrimental influence of pain on the outcome of chronic disease, the aim of this review is to gain an understanding of the incidence and presentation of fibromyalgia in Behçet’s disease.
Methods
Electronic databases Scopus, Medline, Pubmed, and UpToDate were searched in April 2016. Behçet’s disease and alternative search terms were entered in combination with AND: fibromyalgia, chronic widespread pain or chronic pain. All titles and abstracts were screened according to inclusion criteria and full text papers ordered where appropriate. Exclusion criteria included: unclear if BD had been diagnosed using established criteria, only study abstract available, pain in BD that was unspecified or was related to inflammatory processes of BD. No date limitations were applied to the search, all study types were included and only papers written in English were included. Study participants had to be diagnosed using established criteria for the diagnosis of both Behçet’s disease and fibromyalgia.
Results
Of 269 studies identified, 4 studies met the inclusion criteria. All cases were assessed for the presence of fibromyalgia according to the 1990 or 2010 diagnostic criteria of the American College of Rheumatology, with Behçet’s disease diagnosed according to ISG criteria. A higher prevalence of fibromyalgia was reported in Behçet’s disease, ranging from 5.7 – 37.1% compared to a general population prevalence of approximately 2-3%. All studies reported a higher proportion of females in those with fibromyalgia and Behçet’s disease than those without fibromyalgia and with Behçet’s disease. 3 of 4 studies considered Behçet’s disease activity in those with and without fibromyalgia. 2 studies noted differences in disease activity in those with fibromyalgia compared to those without: 1 reported an overall increase in disease activity, the other in clinical features headache, arthralgia and fatigue. 1 study reported no differences in disease manifestations in those with and without fibromyalgia.
Conclusion
This review provides some evidence that fibromyalgia appears to be more prevalent in those with Behçet’s disease than would be expected in the overall population. However, this needs to be considered within the context of limited available evidence. The potential impact of these conditions on the disease activity of each other is not clear and may require a prospective study.
With consideration of the influence of fibromyalgia on pain perception and its unfavourable implications on quality of life, it is important that both conditions are diagnosed where they co-exist to ensure appropriate patient treatment choices.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The Faculty of Pain Medicine published guidelines on Core Standards for Pain Management Services in the UK in 2015. We aimed to compare the Pain Services in Wales to the ideal multidisciplinary composition, as well as looking at the availability of consultant-led Acute Pain Rounds. There is a variation in the availability of pain clinicians and allied health professionals. The presence of a multidisciplinary team is crucial to improve the quality of care that can be provided to patients with Pain.
Aims
To establish demographics of number of patients seen by different Pain Services within Wales, assess medical staffing levels, assess multidisciplinary staffing levels and ascertain the proportion of trusts that offer consultant-led acute ward rounds.
Methods
The survey questions were based on aspects of the Core Standards for Pain Management Services in the UK. Demographic questions looked at the population number served by each Health Board in Wales, and the estimated number of patients seen on an annual basis. Questions on medical staffing levels included the number of pain consultants, and general practitioners and staff grades with an interest in chronic pain. Multidisciplinary staffing levels were also looked at, specifically the number of full time equivalent psychologists, physiotherapists, pharmacists, occupational therapists, and nursing staff dedicated to pain medicine. A question was also included to gauge the general sentiment of importance of having a multidisciplinary team to look after pain patients. Finally, a question focused on the availability of consultant-led acute pain rounds. A survey was generated using an online survey software, and sent electronically to the Clinical Leads of each Health Board in Wales.
Results
At the interim stage, 4/8 (50%) of responses were complete, and one response was for a section of a Health Board. The estimated population served ranged from 20000 to 450000 (average 316250). The number of patients seen by Pain Services ranged from 1000 to 3200 (average of 16 patients per 1000 population). The number of full-time equivalent pain consultants/ general practitioners ranged from 0.42 to 10 per 100000 population served, and one trust had 0.28 staff grades 100000 population served. There was a large range in the number of multidisciplinary staff available in each region, with an average of 1.5 (0-4) psychologists, 1.38 (0-3) physiotherapists, 2.63 (1.5-5) clinical nurse specialists, no pharmacists, and only one trust with an occupational therapist. The importance of a multidisciplinary team was rated as ‘Very important’ by all respondents. There were consultant-led acute pain rounds reported by 2/4 respondents, occurring four times per fortnight.
Conclusion
There is a large variability in the availability of Pain Services throughout Wales. The numbers of pain clinicians and multidisciplinary colleagues do not appear to correlate with the number of patients. 1/4 (25%) of the respondents stated they did not have a clinical psychologist dedicated to pain medicine, and none had a pharmacist for Pain patients. 2/4 (50%) did not have consultant-led acute pain ward rounds. This survey highlighted that Pain Services require more investment, and more allied health professionals are required to facilitate the provision of a truly multidisciplinary approach to pain management.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Many biological, psychological and social factors affect pain sensitivity response of healthy pain-free individuals. In 2015, we conducted an experiment on 74 healthy participants to determine whether there were differences in response to noxious stimuli between obese and non-obese individuals categorised by body mass index (Astita et al., Annual Scientific Conference of the British Pain Society. Glasgow April 2015). We found that obese participants had lower pain thresholds to blunt pressure stimuli but not noxious thermal stimuli when compared with normal and overweight individuals.
Aims
The aim of this secondary analysis of data from our previous experiment was to determine the effect of age, sex, body location and fat percentage on the perceptual response to contact heat stimuli.
Methods
The original study included 74 pain-free participants (age = 18 to 47 years, BMI = 18 to 44.9 kg/m2, 50 women) recruited from West Yorkshire. Measurements of warm detection threshold, and heat pain threshold and tolerance were taken using the method of ascending limits and a 30cm2 thermode (TSA II, Medoc,) applied at the thenar eminence of the non-dominant hand and the suprailiac region (waist). Body fat percentage was calculated from measurements of skin folds at four sites. Data was analysed using forward regression with perceptual responses as dependent factors and age, sex, ethnicity and body location and fat percentage as independent factors.
Results
At the waist region, sex and gender was a predictor of heat pain threshold (r=0.3, p=0.01) but not heat pain tolerance. Women were less sensitive to warm detection threshold (mean+SD=35.8±2.4°C) than men (34.7±1.7°C, p=0.009). Heat pain threshold was higher in women (43.1±3.0°C) than men (41.0±3.6°C, p=0.015, Mann Whitney test). At the thenar eminence, there was no linear regression between perceptual responses and any of the independent factors. Heat pain tolerance of men (48.7±2.7°C) was higher than women (48.0±1.9°C, p=0.037). No other differences between the two sexes were significant. Age had no effect on the sensory and heat pain responses.
Conclusion
Sex and gender, and body location were the most important factors in determining warm detection and heat pain thresholds. The direction and magnitude of sex and gender differences in pain sensitivity response differed between the two body locations. This may be explained in part by differences in fat content at different body locations.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
There is epidemiological evidence that women are more susceptible to certain clinical pain conditions than men. There are sex and gender differences in experimental pain responses with women having lower pain thresholds and usually rating their pain higher. Most of the studies on sex and gender differences have been conducted in North America and Europe. There is some evidence to suggest that some ethnic groups in the West may behave in a different manner to the host populations in response to noxious stimuli and at present there is limited research on sex and gender differences in experimental pain in sub-Saharan African population.
Aims
The aim of this study was to investigate sex and gender differences in pressure pain and cold pressor pain responses in Nigerian healthy participants living in the UK.
Methods
Thirty healthy, pain-free Nigerian participants (15 women, age ranged from 18 to 33 years) were recruited and subjected to two cycles of cold pressor task and pressure algometry. During the cold pressor task participants put their hands into a warm water bath and then transferred it into a bucket of icy water (kept at 0-2 C). The Nigerian investigator recorded when they felt the first sensation of pain (pain threshold in sec) and when they couldn’t tolerate pain any more (Pain tolerance in sec). At the end of each cycle participants were also asked to rate their pain intensity and pain unpleasantness (on a 100 mm visual analogue scale). Pressure pain thresholds were recorded in Kpa by applying a Somedic algometer on their thenar eminence. The order of delivering cold pressor task or pressure algometry was randomised.
Results
The cold pressor pain thresholds of Nigerian women in this sample were significantly lower than that of Nigerian men (25.1±12.5 sec for men versus 19.8±18.0 sec for women, p=0.33, Mann Whitney test). The cold pressor pain tolerance for women at 54.4±102.2 sec was significantly lower (p=0.029) than that of men at 61.8 ±72.6 sec. However, the effect size of these differences in cold pressor pain threshold and tolerance were small (Cohen’s d=0.3 and 0.09, respectively). The sex differences in PPT were significant (p=0.04) with women showing less PPT (793.3±162.4 Kpa) than men (909.9±155.4 Kpa). The effect size of the sex differences in PPT was high (Cohen’s d=0.7). No significant differences were found in the rating of cold pressor pain intensity (p=0.45) and unpleasantness (p=0.79).
Conclusion
Sex and gender differences in this Nigerian healthy participants sample showed the same trend in sex and gender differences in experimental pain responses reported elsewhere in the world. These finding while suggesting that there are may be strong biological factors explaining these differences don’t rule out the existence of universal psychosocial behaviour resulting in these differences. These results again showed that most sex differences existed in response to the mechanical noxious stimuli in this study population.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Evidence exists from both animal and human studies that some opioids have immunosuppressant effects, which may be of clinical relevance. Natural Killer (NK) cells are a subset of lymphocytes that play a central role in the innate immune response to tumours and infections. LAMP-1 or CD107a can be used as a marker of NK cell functional activity as they line the membranes of the cytolytic granules contained within the NK cells, these are rapidly released thereby inducing the death of a target cell.
Aims
We want to investigate the effects of opioids on the immune system specifically NK cells in patients undergoing surgery.
Methods
23 female patients were randomised to either receive morphine, oxycodone or bupivacaine epidural. All were undergoing an elective gynaecological surgical procedure with a Pfannenstiel incision. Blood sampling for NK analysis was taken at baseline and 6 hrs. NK cells were separated using negative selection and were examined using a degranulation method looking at the expression of CD107a and analysed using flow cytometry
Results
Surface expression of CD107a remained unchanged at 6 h after surgery in all patients in the morphine group even after stimulation. In contrast, expression in the oxycodone group was increased in stimulated NK cells at 6 h compared with stimulated morphine at 6 h (3721 vs. 2008 p<0.02). Surface expression of CD107A was increased after surgery in the epidural bupivacaine group in both the stimulated (2008 vs. 3631·5 p<0.05) and un-stimulated NK cells (1483·0 vs. 3591·0 p<0.05) as compared to morphine at 6 h.
Conclusion
The findings from this study suggest that NK cell activity is suppressed in patients given morphine as compared to the oxycodone and epidural bupivicane group where NK cell activity was maintained.
Several studies point to an immunosuppressive effect of opioids specifically morphine. This may therefore have clinical implications in the appropriate selection of opioids; patients who are immunosuppressed for example may benefit from a more considered approach to their multimodal analgesic regime.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Facet joints are a common source of chronic spinal pain, and lumbar facet joint pain is responsible for 15-45% of patients with low back pain. Percutaneous radiofrequency (RF) medial branch rhizotomy is currently considered the treatment of choice for chronic back pain originating from the lumbar facet joints. The long-term efficacy of the treatment is believed to be strictly related to an accurate patients’ selection and a meticulous technique. However, the percutaneous RF approach does not allow to precisely locate the medial branch or to confirm the complete nerve ablation. A new endoscopic rhizotomy technique has been recently developed to overcome those limitations, allowing for direct visualization of the medial branch, including its anatomical variations and sub-branches. Several surgical tools can be inserted through the endoscope for a complete surgical resection of the nerve under direct vision.
Aims
This study was requested by our institution’s Trust Risk and Quality Committee (TRaQ) to monitor safety and effectiveness of the new endoscopic approach against the current proven standards. It was designed as a prospective clinical audit of outcomes to determine whether the endoscopic medial branch rhizothomy achieved benchmark outcomes.
Methods
This is an observational study based on a prospective, open label cohort of subjects initiated in March 2015. As a clinical audit, no formal ethics committee approval was required; patients confidentiality was maintained at all times.
Under the supervision of our institution’s TRaQ and with arrangements for clinical governance, consent and audit we offered endoscopic medial branch rhizotomy to a selected cohort of patients suffering from chronic, refractory, mechanical axial low back pain who had failed to respond to a percutaneous RF rhizotomy procedure or had refused the percutaneous intervention. We included only patients who reported significant (>50%) albeit temporary back pain relief following a fluoroscopically guided diagnostic medial branch block with local anaesthetic.
Data collected included demographics, diagnosis, and an array of outcome measures routinely used in our interventional pain practice for chronic back pain patients (VAS, Oswestry Disability Index, EQ-5D).Responders were defined as a 50% VAS reduction from the baseline
Results
This clinical audit is currently on going. Six-month data is available for the first 18 subjects included, while nine additional subjects will complete their 6 month follow/up visit before May 2017. Unilateral lumbar endoscopic rhizotomy was performed in 11 subjects, bilateral rhizotomy in 3 while in the remaining 4 lumbar and sacral rhizotomy was performed.
At 6 months, VAS scores in the whole study cohort dropped significantly from 67±20 to 33±30, with a concomitant ODI reduction from 53±20 to 35±22. Ten subjects (56%) were still classified as treatment responders at 6 months: of those, 6 had a previous percutaneous RF rhizotomy (unsuccessfully). The responder group experienced profound pain relief (6M VAS 14±12) and significant improved in disability (6M ODI 24±16).
Adverse events were minimal: 1 subject was admitted overnight for pain control, 1 developed a daily headache (which resolved before the 3M follow/up) and 1 developed post-procedural neuritis (resolving after 3 weeks).
Conclusion
Endoscopic lumbar medial branch rhizotomy might be a potential effective treatment for facet joint mediated pain, especially in those subjects who previously failed the percutaneous RF technique.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Temporary sympathectomy (TS) in refractory angina management is offered at several UK centres. Efficacy had not been established by double-blind randomised controlled trial (RCT) until publication of a study in 2015 by Liverpool Refractory Angina Centre (LRAC, formerly Liverpool Angina Management Programme). Contrary to anecdotal evidence, and possibly resulting from shortcomings in the trial design, neither active nor placebo TS was found to reduce intensity of angina, and while a reduction in frequency of angina episodes was detected, there was no difference between active and placebo groups. Despite methodological shortcomings, the absence of a difference between active and placebo TS in reduction of frequency of episodes may indicate either that the mechanism of TS is placebo, or that it is a mechanical bolus effect rather than a pharmacological effect. Need for a further RCT is suggested using a more refined measure of pain intensity than employed in the previous study.
Aims
Anecdotal evidence suggests that TS reduces intensity and frequency of angina between appointments. In preparation for a follow-up RCT, a service evaluation was designed using angina diaries with more refined numerical rating scales than the earlier study in order to detect any trend reflecting anecdotal patient evidence of efficacy.
Methods
Patients completed an angina diary between two successive appointments for TS (stellate ganglion block by ultra-sound guided, left lateral injection of bupivacaine inferior to the carotid artery in the body of the longus coli muscle). To avoid over-burdening any patients with excessive diarising of symptoms, only TS patients undergoing the procedure at less than 8-week intervals were included, giving a population of 31/35, of whom 2 declined to participate.
Diaries recorded occurrence, intensity and duration of angina as a function of days since the previous TS. Two patients’ diaries were completed incorrectly, giving a total of 27 diaries for analysis. In clinical practice, patients’ reports of efficacy dictate preferred intervals between TS appointments over which symptoms return. Therefore, the time-scale used to produce aggregate histograms over time required the occasion of each episode to be expressed in terms of percentage time elapsed of each patient’s preferred interval between TS procedures.
Results
The number of angina episodes, their durations and intensities were each aggregated over all patients from 5% to 95% of each patient’s usual interval between TS appointments. Aggregates between 0-5% and 95-100% of patients’ preferred intervals were not included as patients frequently did not complete their diary during the day of their TS. The ‘normalised’ time-scale was divided into 5% intervals for aggregation, providing an aggregate normalised 18-point estimation of trend for the three parameters between patients’ two TS appointments.
Episode frequency, duration and intensity all demonstrated a statistically significant (p = 0.0127, log time-scale) increase as a function of time between TS procedures. Episode frequency increased by 86%, intensity increased by 125% and duration increased by 127%.
Conclusion
This evaluation of an ongoing service involved existing patients and was therefore limited by the need to issue diaries to patients between regular TS appointments, so it was not possible to incorporate any control element such as a pre-study ‘washout period’.
Nevertheless, it was emphasised that diaries should be completed accurately regardless of whether patients experienced typical or atypical relief. These results (using more refined diaries than in the previous RCT) correspond with anecdotal patient evidence that TS reduces frequency and intensity of angina episodes, with symptoms increasing as patients’ preferred interval between appointments elapses. A further RCT is indicated.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The UCLH headache service has recently expanded their clinical team to include pain management psychology for headache patients appropriate for occipital nerve stimulation (ONS). These patients undergo a multidisciplinary team assessment including neurology and psychology to assess their suitability for the intervention. Consideration is being given to the best way to prepare patients prior to ONS implant and the need for this is being explored.
Aims
The aim of this study is to explore the experiences of headache patients and the MDT decision making for suitability. By interviewing patients to understand their pain and self-management experiences at different stages, the study aims to identify themes which may shape service development.
Methods
Patients were identified at the following points along the ONS treatment pathway: pre- implant MDT assessment and post-implant stages. Qualitative methods are most suitable for this explorative research. Pre-implant MDT assessments were discussed within team meetings to identify themes formulating clinical opinion towards patient suitability and patient experiences of headache and their expectations, and these themes were categorised. Post-implant patients were surveyed using semi-structured interviews to identify themes around the impact of the ONS in their life and categories were developed. The overall aim is to qualitatively map out important themes towards suitability for clinicians and themes capturing the impact of ONS treatment for patients.
Results
As data collection is ongoing due to the "start-up" nature of this new MDT service, the aim is to collect a total of 12 pre-implant assessments and 6 post implant interview. The themes discussed within MDT assessment meetings including patient expectations and after post-implant patient interviews are to be analysed using content anaysis (Neurendorf, 2002) via inter-rater categorisation of coded themes into categories, resulting in a codebook. Responses are to be coded using this codebook and frequencies recorded which will be tabulated.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic headache, defined as headaches on 15 or more headache days per month over a 3 month period affects 2-4% of the population. Their main impact is in young adults many of whom have both work and family commitments. Supportive self-management programmes have an established place in the management of a range of chronic diseases. NICE guidance on headaches in 2012 did not find any relevant evidence on the use of education and self-management programmes for the treatment of chronic headaches and recommended further research in this area.
Aims
To develop and evaluate an education and self-management support intervention for the management of chronic headaches, specifically, migraine, tension type headache and medication overuse headaches.
Methods
The development of the intervention has been informed by a systematic review of educational and/or self-management interventions for chronic headache, qualitative literature and interview material on the lived experiences of chronic headache, a review of the predictors of poor outcomes from headache disorders, and our knowledge from an existing intervention package for people living with chronic musculoskeletal pain. These data were bought together at an intervention development meeting comprising of the academic team, clinical team and lay people living with chronic headaches.
Results
The CHESS intervention comprises self-management and education topics including acceptance, mood and headache, recognising unhelpful thought patterns and behaviours, stress management, sleep management, medication management, communication and mindfulness. This is a group intervention where participants attend a two day programme delivered by a nurse and allied health professional. Each participant subsequently attends a one to one consultation with the nurse to classify their headache type and discuss medication, lifestyle management and goal setting. Following this, each participant is provided with ongoing telephone or email support for up to eight weeks.
We have delivered four groups during our pilot phase, totalling 20 participants. The overall feedback from the participants and facilitators has been promising. The process evaluation team have interviewed the intervention facilitators and participants to identify what worked well and what requires change before formal testing.
Conclusion
We have developed a complex intervention package after drawing on the evidence base and learning from the pilot phase. This package has been refined and will be rolled out into a multicentre randomised controlled trial during 2017.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Pain interventional medicine relies on the use of fluoroscopy in a variety of different imaging configurations. The proximity of the pain physician (PP) to the ionisation radiation (IR) increases the risk of radiation exposure to the ocular region. A European directive has reduced the limits of occupational ocular dose 7.5-fold. The typical IR exposure to the ocular region in PP is not reported.
Aims
This study seeks to (a) establish the probable IR exposure to the ocular region by a PP; (b) test the study protocol before increasing the sample size and (c) make recommendations on ocular radiation dose protection.
Methods
A Thermoluminescence dosimeter (TLD) calibrated to measure eye lens doses [Hp (0.07)] was fitted close to each eye of a single PP. Furthermore, whole body dosimeters (WLD’s) were calibrated to Hp (10) and fitted to the chest area of 3 PP’s.
After a pilot study (n=35) of C-arm guided pain procedures was undertaken and extended to 682 cases for the main study, carried out over 3 months. The duration of radiation exposure, screening time and procedure type was recorded. Radiation dose was calculated to estimate the effective radiation dose that could be expected to the ocular region annually.
Results
Recorded doses for 682 typical pain procedures were captured. While 54% of the dose limit of 20mSv was recorded during the pilot study, the mean dose value in the main study (n=4) was 16.8% (+ 8.2 s.d) of the dose limit was estimated. Data recording and the method of dosimeter analysis proved successful.
Conclusion
PP’s estimated annual ocular doses are under the new annual dose limit of 20mSv. Current radiation protection measures are appropriate.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The UCLH pain management centre’s neuromodulation treatment pathway has undergone changes in the past 2 years. The treatment pathway now delivers an interdisciplinary team (IDT) assessment and treatment for all patients undergoing neuromodulation for chronic pain; in accordance with NICE guidelines, research and clinical experience. The treatment pathway now includes an IDT approach at assessment, within the pre-implant pain management group programme or APL PMP (Action Potential Living) and at follow ups. Patients referred for neuromodulation complete outcome measures for pain and mood at various stages along the treatment pathway. The team hope this enhanced IDT approach and PMP preparation improves pain and mood outcomes for patients receiving neuromodulation. The research involves 2 stages to evaluate outcome data. Stage 1 explored patients’ experiences of the APL PMP (ASM 2016) and Stage 2 will evaluate patient outcomes from measures collected.
Aims
Stage 1 has been completed. Stage 2 aims to evaluate the outcomes of patients receiving neuromodulation treatment having engaged in the APL PMP; measures used include the Brief Pain Inventory, Pain Catastrophising Scale, Depression and Positive Outlook Scale and the Coping Strategies Questionnaire.
Methods
Patients referred to the new treatment pathway and engaging in the APL PMP were given measures to complete at baseline, on completion of the APL PMP, at 6-8 weeks follow up post implant, and 6-9 month follow up post implant. The evaluations aimed to analyse patients’ outcomes overall along the treatment pathway, but also within the pathway i.e. analysisng for any changes before and after completion of APL PMP prior to stimulator implant. Data from patients was collected between 2014-2016 and had to include completed measures at the 4 stages of data collection along the treatment pathway. Analysis of data from the following measures was completed using SPSS: Brief Pain Inventory, Pain Catastrophising Scale, Depression and Positive Outlook Scale and the Coping Strategies Questionnaire.
Results
The total number of collected questionnaires from patients as they progressed along the treatment pathway was 33, out of a total of 47 referred for neuromodulation in the 2014-2016 time period however not all patients have been implanted in this timeline. As patients were measured at multiple times to capture any changes either after the APL PMP intervention, or stimulator implant, or both, repeated measures ANOVA tests were carried out in SPSS.
Conclusion
The data collected is still undergoing analysis. Although the sample size of patients is small compared to large RCTs of this pain intervention, the outcomes will inform the clinical practice of the IDT. This much needed evaluation of outcomes is important as the pain management centre’s neuromodulation treatment service is predicted to expand in the coming future. The aim is to collect larger data sets to learn more about the effectiveness of an IDT approach to neuromodulation treatment for chronic pain.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Following the recent release of the British Pain Society (BPS) publication ‘Standards of good practice for spinal interventional procedures in pain medicine’ in 2015 we decided to undertake an audit of documentation of pain procedures, combined with an audit of adherence to local guidelines for fasting, pregnancy status and WHO checklist.
We have three intervention lists throughout the week on one hospital site.
Aims
To assess adherence to local guidelines regarding fasting, pregnancy status, WHO safety checklist documentation and to further assess adherence to the BPS guidelines.
Methods
Retrospective data collection from 9 different lists with equal representation of all clinicians regularly undertaking pain procedures at our institution. This identified 46 patient encounters (Male 17, Female 29).
Results
13% of consent forms were completed with the patient in advance of the day of intervention.
50% of patients were fasted for the ‘ideal’ length of time, however 15% of patients fasted for fluid for >12h and 26% of patients fasted for food for >12h. 7 patients had nothing documented with regards to fasting (2 of whom received sedation).
12/16 (75%) of eligible females had inadequate documentation of pregnancy status. 9 of these got as far as the theatre before being asked their pregnancy status.
43% of WHO documentation was fully completed.
Of 46 procedures, 43% had patient position documented, 72% had asepsis mentioned (48% type of skin preparation used). 48% had imaging modality (or landmark) documented. All had the procedure name, drugs and drug dose documented.
Conclusion
This audit has highlighted areas of potential improvement in patient safety which may be gained through improvement in documentation. Failure to adhere to local guidelines and poor record keeping is a result of both staff education and system failures. This is being addressed with a quality improvement project. Following local teaching re-audit showed significant improvement in both pregnancy and fasting status documentation. Following staff consultation, we have introduced an adapted WHO checklist and are also in the process of implementing a procedure documentation form for use in patient notes.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Currently there is growing interest in developing a sensory profile for patients with different chronic pain conditions as there is a great deal of heterogeneity in their presentation. Sensory characteristic profiles may be developed using both validated neuropathic pain questionnaires such as painDetect as well as more objectively using Quantitative Sensory Testing (QST). Spinal cord stimulation (SCS) is one of the most evidence-based treatment for patients with intractable neuropathic back and leg pain (radicular type pain) and is supported by the NICE guidelines TA-159. However the effect of SCS on peripheral and central sensitisation still remains to be quantified. Further there is a need for a more objective tool and possibly a phenotypic marker to evaluate the response of SCS on supra spinal pathways.
Aims
To characterise the sensory profile of patients with FBSS undergoing spinal cord stimulation (SCS).
Methods
This is a prospective open label pilot study to characterise the sensory profile of patients using QST and validated questionnaires in patients with lumbar radiculopathy with FBSS undergoing SCS. A battery of QST and psychometric measurements using validated questionnaires including PainDetect were collected before SCS and also at 18 days and 3 months following SCS.
Results
Twenty three patients underwent the SCS trial of which 20 patients had a successful permanent implant. At baseline, there was high incidence (>50% incidence of moderate to severe sensation) of burning, tingling, electric shock, numbness and pressure pain sensitivity. Following SCS there were significant improvements in burning, tingling, electric shock and pressure pain both at 18 days and 3 months and significant improvement in numbness at 3 months. Touch and temperature sensitivity was less of a problem in these patients (<50% incidence of moderate to severe sensation) although improvement in temperature sensitivity reached statistical significance at 3 months post-SCS. There was a significant improvement in CPM as measured at the back as well as the painful leg both at 18 d and 3 months post-SCS. Following SCS there was a normalisation of the CPM. There was also a significant improvement in PPT’s measured at the painful leg.
Conclusion
There is definite shift in the phenotypic profile of patients following SCS. Following SCS, for the first time we have reported a significant improvement in a number of sensory characteristics including burning, tingling, electric shock, numbness and pressure pain sensitivity. Following SCS the pronociceptive profile becomes antinociceptive profile based on CPM measurements.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Sacroiliac joint (SIJ) dysfunction is a common contributing factor in low back pain with a reported prevalence of 15-25% (Cohen,2005). The diagnosis and treatment is a challenge with a poor evidence base. These patients often experience a low quality of life comparable to other health conditions. SIJ neurotomy is an effective treatment but results are inconsistent due to variability of the joint’s nerve supply. A number of radiofrequency neurotomy techniques such as cooled (SInergy), bipolar(Palisade) and Simplicity have been published with variable results.
Aims
To evaluate the efficacy of three different sacroiliac joint neurotomy techniques performed in Aberdeen Royal Infirmary in terms of short-term pain relief as well as change in the interference of pain on physical and psychological function.
Methods
A retrospective review of patient records who underwent SIJ neurotomy was carried out. All patients had been evaluated in an outpatient pain clinic and had a positive response (> 50% pain relief) to diagnostic blocks prior to proceeding to neurotomy. Patients routinely complete a brief pain inventory at clinic visits and attend clinic 4-6 months post neurotomy. The primary outcome measure was pain relief percentage at follow up and secondary outcome measures were changes to pain severity scores (PSS) and pain interference scores (PIS) at 6 months. All patients who underwent sacroiliac joint neurotomy procedures within a 12-month period at Aberdeen Royal Infirmary (April 2015-April 2016) were included. Three consultant pain physicians performed all procedures. Patients with incomplete procedural details or missing pain relief data were excluded. Only patients with documented pre- and post-denervation pain severity and interference were included in the analysis of the secondary outcome measures.
Results
48 patients underwent SIJ denervation with a total of 41 included. 7 were excluded from the study due to incomplete recording of technique(n=3), no quantification of pain relief(n=3) or were lost to follow up (n=1). 17 episodes made use of cooled RFA; Palisade was employed 21 times and Simplicity only 3. 7/17(41%) patients who underwent cooled RFA had pain relief of >50% while 11/21(52%) who had Palisade neurotomies had relief >50%. There was a trend towards greater percentage pain relief in those that had the cooled technique. Only 1/3(33%) of the Simplicity group had relief >50%. There was a mean reduction in PSS of 6.7 points and 5.2 points for cooled and Palisade respectively with an increase in PSS of 2.5 points for those undergoing Simplicity neurotomy. There was a reduction of 12, 9 and 3.5 points in PIS for cooled radiofrequency, Palisade and Simplicity respectively. No peri-procedural complications reported.
Conclusion
Short-term efficacy of the three neurotomy techniques in our department corresponds well with available evidence from recent clinical trials. Palisade neurotomy compares favourably with cooled radiofrequency in terms of pain relief. There were insufficient case numbers to make an assessment on the efficacy of Simplicity neurotomy. All techniques show promising reductions in pain interference scores. Efficacy at 12 months should now be audited as well as potential benefits on costs and procedural time.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The positive outcome of interventional pain procedures is difficult to predict, it depends on multifactorial components beyond biological symptoms and procedural techniques. So far, there has not been a single diagnostic tool that will help to predict success following injections. Commonly used psychological assessments guided by the Faculty of Pain Medicine for screening, helps clinician to choose the most appropriate treatment. However, the analysis of the score does not precisely define which patient will benefit the most from the intervention. The aim of this analysis was to identify common psychological values assessed before the procedure that will help to anticipate positive outcome following injections.
Aims
The aim of this retrospective analysis was to identify pre-procedural common psychological values that would help to predict outcome following interventions.
Methods
The retrospective data analysis was based on 198 consecutive patients’ cases out of 275 who underwent interventional procedures performed by the same pain medicine consultant. Seventy seven case notes were excluded from the analysis due to incomplete or missing data. Pre-procedural evaluation included severity, interference of pain with daily activities using - Brief Pain Inventory (BPI), measurement of depression and anxiety - using Hospital Anxiety and Depression Score (HAD), patient’s confidence in performing daily activity - assessed with Pain Self-Efficacy Questionnaire (PSEQ) and quality of life recorded on EuroQol EQ5 VAS scale.
Comparison of means were performed with T-test and medians with Mann-Whitney. Receiver operating characteristic (ROC) curves were plotted for numerical variables significant in univariate analysis to identify cut off values. The population was subdivided into subgroups below and above the ROC-derived threshold. Impact of PSEQ, HAD depression and EQ VAS was evaluated using multiple logistic regression model.
Results
A fall in pain score greater than 50% assessed with Numeric Rating Score at 3-month follow-up was the criterion applied to divide patients into groups. Group A consisted of 66 patients whose pain score was reduced by more than 50%.
Group B was inclusive of 132 patients with pain score reduction less than 50%.
The calculations which achieved statistical significance in univariate analysis (PSEQ p=0.013; HAD depression p=0.0016; EuroQol EQ VAS p=0.0003, BPI - pain severity p=0.037 and interference p=0.0029) were included to ROC curve analysis and multiple logistic regression. None of the parameters showed any predicting value.
When more rigid inclusive criteria were applied narrowing the cohort to patient who had spinal intervention procedures only, EuroQol EQ VAS > 50 out of 100 is independent risk factor for success of interventional procedure (p=0.0268, OR 2.61, 95% CL (1.1 to 6.1)).
Conclusion
Pre-procedural quality of life and psychological factors assessed with BPI, HAD, PSEQ, EuroQol EQ5 at the general cohort of chronic pain patients undergoing interventions procedures do not predict the outcome of invasive pain treatment.
However, in carefully selected subgroup of patients undergoing spinal intervention only EuroQol EQ5 VAS>50 score may be independent predictor for successful intervention.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Following the publication of the “gate theory” by Wall and Melzack in 1965 there has been the development of peripheral nerve neuromodulation in conjunction with spinal cord stimulators, albeit more slowly. Following Longs paper in 1981 work began in earnest looking at the effect of peripheral electrical nerve stimulation (PENS) for various conditions. Despite this early work the evidence for PENS was still inconclusive. From 1996 to 2004 there were a whole slew of papers looking in peripheral nerve stimulation for variety of conditions including chronic migraine, mixed types of headache, chronic low back pain, and one RCT each for chronic neck pain (PENS), diabetic neuropathic pain, sciatica, chronic non-bacterial prostatitis /chronic pelvic pain syndrome, osteoarthritis of the hip and of the knee (temporary Peripheral nerve field stimulation (PFNS)), and hyperalgesia associated with various neuropathic condition which lead to the 2013 NICE recommendations (Interventional procedures guidance [IPG450]).
Aims
Following these recommendations, we started using the PENS machine to treat refractory chronic neuropathic pain conditions at the Royal London Hospital in 2014. We were keen to see the benefit or efficacy for these patients following the treatment.
Methods
We have done a retrospective case series of patients treated with PENS. We have collected 12 patients over a 2-year period. They attended a day case procedure during which a microstimulator needle was placed subcutaneous over the field of pain. We then proceed to administer PFNS to the affected area. Our patients were then followed up 1 to 2 months’ post treatment. The outcomes we were looking at were best pain reduction scores, medication reduction, functional improvement and interval for next treatment.
Results
We collected 12 patients during this study. Of these 12 patients. Out of these 12 we are still awaiting follow up data from 3 patients. So far we have had successful treatment of 78% of patients listed for PENS treatment. Out of these patients the pain reduction score was 77% less with PENS treatment. These patients had either failed to respond or couldn’t tolerate a Qutenza 8% patch application. Out of the responder group we had 71% of patient reducing their intake of pain medications with 90% of patients showing a functional improvement post treatment. The average length of improvement was 4 months before pain levels returned to baseline figures.
Conclusion
Treating resistant chronic neuropathic pain can be very challenging for both patient and pain physician. From our data so far, neuromodulation using PENS treatment for peripheral neuropathic pain shows promise in treating some of these patients who have failed to gain any benefit from established existing treatments and we await further high quality research as to the long term management of this patient subgroup.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Radiofrequency (RF) ablation uses heat to interrupt pain signals in nerves. It generates heat energy from medium frequency alternating current (300-450KHz).
Recent draft NICE guidance, March 2016 on the management of non-specific lower back pain has advocated RF ablation of the medial branch supplying facets joints for suspected facet joint pain. Specifically recommending where non-surgical treatment has been unsuccessful, with a pain score of > 5 on the visual analogue scale and after positive response to a diagnostic block.
It has been shown to be an efficacious treatment for Lumbar Facet Joint and Sacroiliac Joint pain [Leggett et al, 2014]. Furthermore there is level II evidence for Cervical radiofrequency neurotomy [Manchikanti et al, 2016].
Although limited trials assessing RF ablation to Genicular Branch for chronic knee pain it has been concluded this procedure has the potential to decrease pain for those who cannot undergo surgical intervention [Bhatia et al, 2016].
Aims
To assess demographics of patients undergoing diagnostic nerve blocks to Medial Branch of facet joint either in Cervical or Lumbar region and Genicular Nerve Blocks. We analysed the response to these blocks and subsequent uptake of RF ablation.
Methods
Patients were selected by clinical presentation for either Genicular nerve, Lumbar or Cervical Medial Branch block as part of a Radiofrequency Denervation Pathway. This pathway consisted of a pre-procedure pain assessment. All patients were subsequently admitted for day case nerve block under X-ray guidance. The block was performed with 2% Lignocaine and 0.5% Bupivucaine in a 50:50 mix (0.5ml/Joint).
Patients were assessed pre and post procedure and a pain assessment form completed at home (a combination of visual analogue scale and numerical rating score). When pain returned, the patient returned the forms. If the pain score improved by >60% without a significant time lag, regardless of duration and if patient wished to proceed they were booked for radiofrequency ablation. This is in line with current British Pain society guidelines. The data was looked at from 7/1/15-24/6/16.
Results
A total of 46 patients, 32 Female and 14 Male were enrolled into the RF pathway. The mean age was 48.26 (Female - 47.4, Male - 50).
37 patients underwent Lumbar median Branch Blocks (25 Female, 12 Male). 26 (70.27%) had an adequate response and had RF ablation. The average reduction in pain score was 50.62% (60.13% in patients who have RF, 44% in patients who did not). This was maximal 1 hour post procedure.
7 patients underwent Genicular Branch Blocks (5 females, 2 males). 4 (57.14%) had an adequate response and had RF ablation. The average reduction in pain score was 58.6% (55% in patients who went on to have RF, 63% in patients who did not). This was maximal 1 hour post procedure.
2 patients underwent Cervical Facet Joint Injection. Neither had an adequate response and opted against RF ablation. The average reduction in pain score was 55%, immediately post procedure.
Conclusion
These responses were significant judged by the reduction in pain scores. Lumbar median branch block (50.62%), Genicular Median Branch Blocks (57.14%) and Cervical Median Branch Blocks (55%). This implies that we are picking the correct patients for this procedure.
The successful conversion to RF denervation was positive both for Lumbar Median Branch Blocks (70%) and Genicular Branch Blocks (57%). This uptake was not shown in the cervical median branch blocks however may have been consequence of a small population number. Overall there was good compliance and satisfaction with this pathway allowing patient autonomy in decision making for their condition.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Osteoarthritis (OA) is the most widespread chronic joint disease worldwide. Symptomatic knee OA is observed in approximately 12% of individuals over the age of 60 years. OA knee pain is often not effectively managed with current non-pharmacological or pharmacological treatments. Injections (genicular nerve block (GNB)) or pulsed radiofrequency (PRF) neurotomy of the articular branches to the knee offers a potential therapeutic alternative for chronic knee pain. Buckinghamshire Healthcare Pain Management Service offers diagnostic GNB and therapeutic PRF to patients referred with poorly controlled chronic knee pain, particularly in those considered unfit to undergo surgical intervention or in whom previous surgical interventions have failed.
Aims
This retrospective survey reviews the efficacy and outcomes of GNBs and PRFs performed by our pain service over a 21 month period to determine the usefulness of these procedures. If possible, identification of patient subgroups in whom such interventions are most beneficial would be useful in expanding this service.
Methods
Patients that received a GNB or PRF between August 2014 to April 2016 were identified from theatre records. 19 patients were identified during this 21 month period, in whom a total of 27 procedures were performed; 2 PRFs and 25 GNBs of 14-20ml of 0.25% bupivacaine with 3.3-6.6mg of dexamethasone. Follow up was not possible for 2 patients following GNB, so they were excluded.
The patients’ clinical notes were retrospectively reviewed to ascertain the subjectively perceived effects of the procedure. The patients’ reported pain symptoms, as documented during nurse led telephone follow up at three months and consultant review in pain clinic at four to six months post-procedure, were classified as an ‘improvement’, ‘no significant improvement’ or ‘worse’. Duration of effect and further management following the procedure were also reviewed. Age, gender and previous interventions/surgeries were noted.
Results
Of the 17 patients included, 12 received a unilateral GNB, 3 received bilateral GNBs and 3 received a repeat unilateral GNB, giving a total of 23 GNBs. 15 resulted in a reported improvement, no significant improvement was reported following 6 and transiently worse pain was reported following 2. This demonstrates a patient reported improvement following 65% of GNBs.
Following the 15 effective GNBs; 6 were booked for PRF, 3 were booked for a repeat procedure, 3 remain under review and 3 were discharged from pain management services.
The reported duration of improvement ranged from 1 to 4 months in those booked for further procedures, and longer still for those discharged or who remain under review.
The average patient age was 64 years. The male to female ratio was 1:3. 11 patients had previously undergone knee surgery; of these, improvement was reported following 71% of GNBs.
Conclusion
These findings indicate that GNB results in an improvement in pain symptoms as reported by patients in 65% of cases. Although a small sample size, this figure is as high as 71% in post-surgical patients. A temporary ‘flare’ up of pain symptoms was reported in 2 cases, but GNB is relatively simple to perform and no long term adverse outcomes were observed. This data supports the continued use of GNBs by our pain service in the management of chronic knee pain, particularly in patients experiencing intolerable side effects from pharmacological agents or in whom other therapies have failed.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic orofacial pain affects up to 7% of the population (Aggarwal et al., 2006) having a significant impact on physical and psychosocial wellbeing (Zakrzewska, 2013). Research indicates that CBT is effective in managing a range of chronic pain conditions (Williams et al., 2012). More relevantly to this evaluation, a nascent body of evidence suggests that CBT is also an effective treatment for orofacial pain conditions specifically temporomandibular joint disorder (TMD). A recent systematic review by Rhandhawa et al., (2016) of non-invasive interventions for TMD suggests that both self-care management and CBT lead to improvements in pain and disability. In addition CBT is effective in reducing pain interference on activity levels and depressive symptoms (Rhandhawa et al., 2016). While these findings are promising, the current authors were unable to identify a published paper that examined the effectiveness of group-based CBT for a range of orofacial pain conditions in routine clinical practice.
Aims
This service evaluation aimed to assess the efficacy of a group-delivered, six-week pain management CBT programme for patients with diverse chronic orofacial pain diagnoses, whose pain severely impacted on a variety of physical and psychosocial factors.
Methods
This evaluation adopted a cohort design and was conducted at the Eastman Dental Hospital (London). Data were collected from 113 adults (n=82 female) with chronic orofacial pain (mean age=50.1 years; SD=14.5; range 19 to 59) between November 2014 and December 2016. Patients with a range of diagnoses were included (e.g. TMD, neuropathic facial pain, atypical odontalgia and idiopathic facial pain). Participants attended six weekly sessions of 3.5 hours’ duration, facilitated by a clinical psychologist and physiotherapist. Topics included: dealing with distress; challenging unhelpful thoughts; mindfulness; pain science; importance of movement; pacing of activities; communication; and flare-up management. Participants’ level of pain, physical functioning and distress were assessed pre and post-treatment, at one and nine months using validated psychometric self-report measures: Brief Pain Inventory (BPI), Pain Self-Efficacy Questionnaire (PSEQ), Depression, Anxiety and Positive Outlook Scale (DAPOS), Pain Catastrophizing Scale (PCS), Illness Perception Questionnaire (IPQ), and Chronic Pain and Acceptance Questionnaire (CPAQ).
Results
A total of 14 groups, consisting of six to 10 members, were conducted during period encompassed by this evaluation. However, uncollected data meant that only 26 individuals’ BPI scores were used in the analyses. Following the testing of appropriate assumptions, a series of one-way Analysis of Variance repeated measures tests were conducted on the data using the BPI, PSEQ, DAPOS, PCS, IPQ, and the CPAQ as dependent variables. The analyses found statistically significant changes, in the desired directions, for all of the dependent variables: i.e. the BPI (facial: F(3)=6.27, p=.001, n=26), the PSEQ (F(3)=47.51, p<.001, n=113), the DAPOS (F(3)=65.11, p<.001, n=113), the PCS (F(3)=96.86, p<.001, n=113), the IPQ (F(2.83)=121.52, p<.001, n=113), and the CPAQ (F(3)=52.12, p<.001, n=113).
Conclusion
This preliminary basic analysis provides evidence that suggests the group-based CBT pain management programme was an effective treatment for chronic orofacial pain, insofar as we found that scores on all of the psychometric measures showed a significant reduction across all four time point (pre, post, one month and nine months). These findings appear to be in line with already established literature base for chronic pain and CBT and the evidence base for TMD alone. Our data expands the evidence base to include a wider orofacial pain clinical population.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Use of ultrasound in performing pain procedures is relatively new and gaining importance. Most of the pain procedures are done under fluoroscopy which exposes staff and the patients to the radiation. Radiation can cause burns, blood dyscrasias and alteration of DNA causing mutations. The use of ultrasound in regional anaesthesia has gained tremendous success because of the safety. The benefits include good resolution, lack of radiation, real time imaging and requires minimal personnel. There is lack of information about the extent of training in the usage of ultrasound techniques in chronic pain procedures. The purpose of the survey was to assess the usage of ultrasound in pain procedures among the pain physicians.
Aims
The purpose of the survey was to assess the usage of ultrasound in pain procedures among the pain physicians.
Methods
A paper questionnaire of 8 questions was given randomly to the pain physicians attending a pain meeting. The questions related to the grade of the operator, their experience of using ultrasound and the procedures performed under ultrasound. Questions were also asked about how they learnt about the ultrasound guided procedures and how were they keeping update with the knowledge. Further information was gathered about the possible factors for not using ultrasound.
Results
A total of 47 responses were received. The experience ranged from trainees (23) to consultants(14) to non-consultant grade(10). None of the respondents had gone through a formal training in ultrasound for the pain procedures. The training was obtained through attending conferences, workshops and practising on the patients. Most of the procedures performed were peripheral nerve blocks, stellate ganglion block, occipital nerve block and trigger point injections. Only 4.7% (n=8) of respondents were using ultrasound guidance for axial pain procedures (mostly lumbar facets and lumbar epidural). The most common reasons for not using ultrasound was lack of training and proper equipment. Most of the respondents(n=37) agreed that ultrasound usage should be taught during pain medicine fellowship. A small sample may limit the generalisability of the findings but our survey covered the target population adequately well.
Conclusion
Ultra-sonographic pain procedures are not only safe but also provide a cheap and more handy way of doing procedures. The other advantage is guided joint and tendon injections along with avoidance of intravascular injections (Bhatia A et al 2013). The survey highlighted the problem of adequate teaching and lack of equipment as noted similarly in an earlier survey (Asaad BO et al 2014). Cadaveric training has been the most useful in learning the procedures as has been previously found by Kessler J et al (2014). In conclusion, mandatory use of ultrasound in pain fellowships and training of faculty will significantly.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Randomised controlled trials (RCTs) are essential to delivery of an evidence-base for pain management. Success of trials depends on adequate and timely participation of eligible participants. Within recruitment processes, information provided to and discussed with patients must be presented in a way that accurately and fairly describes what participation will involve, including advantages and disadvantages. Written information is supplemented by recruitment consultations, during which the recruiter discusses what participation would mean and answers questions. To ensure that trial recruitment is optimal and that consent is fully informed, it is important to understand what information patients need to make decisions about whether to take part. Recent research into clinical trial processes has focused on recruitment consultations and demonstrates the benefit of qualitative research in optimising recruitment. This project examines recruitment consultations with patients eligible to participate in a RCT of a new care pathway for chronic post-surgical pain after knee replacement.
Aims
To explore content of recruitment consultations in an RCT evaluating an intervention for chronic post-surgical pain after knee replacement. Findings will inform refinements to trial recruitment processes during the internal pilot phase and help to ensure that consent is fully informed.
Methods
During the 6 month pilot phase of the randomised trial, all recruitment consultations are audio-recorded with consent from patients. The audio-recordings are transcribed and anonymised before being imported into QSR NVivo software where they are coded and analysed using a thematic approach. Analysis was conducted by an experienced qualitative researcher in collaboration with one recruiter from the coordinating centre. Codes were discussed and agreed upon, before being reapplied to the data set, with ongoing refinement to the coding framework as needed.
Results
To date, seven recruitment consultations have been carried out by two recruiters at two study sites. Five consultations took place at participants’ homes and two took place within a private room at the local clinical research centre. Key findings are: the recruiter explained each element of the study and each section of the patient reported outcome questionnaire to ensure that patients were aware of the commitment and time involved. Patients were willing to be involved and often had altruistic motives for taking part, or hoped that involvement might improve their clinical outcomes. Some patients expressed dissatisfaction with their previous experiences of usual care before they received the invitation to participate in the RCT. Patients understood the trial questionnaires and were willing to complete them. Patients’ understanding of the randomisation process was checked multiple times in the consultation by the recruiter, and all patients understood this process.
Conclusion
Our ongoing analysis suggests that, to date, the current recruitment processes are effective and that patients are fully informed at the point of consent. At the end of the pilot phase we will make recommendations about refinements to the recruitment consultation processes. This work demonstrates the value of embedded qualitative research to optimise recruitment to trials in pain.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Failed back surgery syndrome (FBSS) is the persistence of back and or leg pain 6 months following on from an anatomically successful surgery Patients with FBSS typically experience pain, disability and reduced quality of life.
The initial management of FBSS is conventional medical management (CMM). This includes pharmacological management through the use of oral opioid, NSAID, antidepressant, and anticonvulsant/antiepileptic. There are many problems associated with long term use of these medications. These include dependence, misuse, organ toxicity, cognitive impairment, depression and hyperalgesia.
Aims
RCT evidence has demonstrated spinal cord stimulation (SCS) is superior to CMM in pain reduction, quality of life, patient satisfaction and functional capacity. Whether SCS reduces pharmacological use in real life remains equivocal.
We aim to determine if SCS and the timing of therapy initiation reduces patient medication use.
Methods
Data was analysed from primary care (Clinical Practice Research Datalink) and secondary care (Hospital Episode Statistics).
A retrospective cohort study was undertaken identifying 10,901 patients with at least 24 months of follow up data. 20.8% of these patients had FBSS with 85 patients receiving SCS therapy.
FBSS patient’s criteria included:
Additional lumbar surgery (6-24months post-index)) AND/OR
Pain-related physician visits (spanning 6 months from 6-24 months post-index) AND/OR
Another surgical intervention to address pain (any time post-index)
SCS patients were identified using OPCS codes. Codes were used to identify pain medication use. Drugs were classified into 4 categories: opioids, NSAIDs, antidepressants and compound analgesics.
The impact of SCS on medication use was measured in pre- and post SCS patients between a 2 and 4 year period.
85 patients were sorted by time to treatment. In order to obtain two distinct cohorts 30 extreme patients were selected for each group.
Results
SCS demonstrates a declining drug use at 2 and 4 years post implant:
Opioid’s
2 years prior to SCS = 81% patients
2 years post SCS = 79.6%
2-4 years post SCS = 71.1%
NSAID’s
2 years prior to SCS = 60.8%
2 years post SCS = 43.8%
2-4 years post SCS = 37.8%
Anti-neuropathic’s
2 years prior to SCS = 74.7%
2 years post SCS = 63%
2-4 years post SCS) = 65.6%
Compound analgesics
2 years prior to SCS = 44.3%
2 years post SCS = 39.7%
2-4 years post SCS = 37.8%
Early SCS therapy shows a significant declining drug use when compared to late implant. Taken over a 1 year period prior to SCS to between 1 and 2 year post SCS:
Opioid’s = 8.3%
NSAID’s = 27.5%
Anti-neuropathic’s= 16.7%
Compound analgesics = 16.7%
Conclusion
This study has shown SCS therapy reduces medication use in SCS patients. There is a steady rate of decline in use over the 4 year period proving a sustained impact of SCS therapy. The long term use of analgesics is of concern especially opioids and its impact not on the individual and society
Evidence has shown SCS long-term success rate increases with early intervention. This was reflected in our early SCS therapy cohort showing marked and sustained decline in all 4 analgesic groups.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Computer modeling of transverse tripolar configurations has shown preferential activation of dorsal column over dorsal root fibers (Struijk & Holsheimer, 1996). Clinical evaluation of a transverse tripole using a 3 column, 4 contact lead suggests an improved usage range in which shielding from lateral anodes was thought to increase dorsal root thresholds compared to dorsal column thresholds (Oakley, et al., 2006). We hypothesize that transverse fields can enable many paresthesia states at a single level on the lead, which may increase ability to optimize coverage. Here we characterize transverse steering in a 4-column, 32-contact lead with an SCS system using multiple independent current sources.
Aims
To characterize transverse steering in a 4-column, 32-contact lead with an SCS system using multiple independent current sources.
Methods
This study is an institutional review board (IRB) approved, prospective, on-label, multi-center, non-randomized, exploratory, single-arm study, single visit study. All subjects were previously implanted with an SCS system and 32-contact paddle, and had low back and/or leg pain. The lead level closest to midline was selected for programming and paresthesia distributions were collected. A finite element model with a surgical lead was constructed based on spinal cord anatomy. The spinal cord finite element model was coupled with dorsal column and dorsal root fiber models to predict neural excitation. Computer modeling was used to predict anode and cathode configurations that would produce unique stimulation in the transverse direction of the spinal cord.
Results
Early data analysis includes 9 subjects from 2 US centers and is not powered to detect statistical significance. Eight subjects had a tightly-spaced lead (36mm span) and 1 subject had a wide-spaced lead (52mm span). Paresthesia drawings from each configuration were collected and converted to binary images for analysis. When comparing configurations within patients at a single rostral-caudal level, paresthesia area changed at least 17% and up to 100%. When anode-cathode assignment was constant, but percentages of current were changed, paresthesia area changes of at least 37% and up to 100% were observed. Amplitudes calculated by the spinal cord computational model are consistent with clinical amplitude trends when comparing configurations within patients.
Conclusion
Initial observations show a large range of possible paresthesia coverage using transverse current steering, and are consistent with the hypothesis and published theory.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Living with chronic pain can have a major impact on wellbeing, quality of life and productivity. In England alone, up to eight million people (15%) live with such pain. Despite limited data supporting the effectiveness of long-term use, prescription data from the UK show substantial increases in the use of opioids for non-cancer pain with a 466% increase in the number of strong opioid users between 2000 and 2010. However, adverse effects including sedation, decreased concentration and memory, drowsiness, changes in mood, constipation, dry mouth, abdominal pain, nausea and hormonal changes with consequences such as sexual dysfunction often outweigh any treatment benefits. Moreover, long-term recipients often develop a tolerance resulting in reports of inadequate analgesia. Despite growing recognition of the importance of seeking to reduce long-term opioid use, formal UK guidelines for opioid reduction do not exist and there is limited support for people wishing to reduce their intake.
Aims
I-WOTCH will evaluate the effectiveness and cost effectiveness of a patient-centred multicomponent self-management intervention for people living with chronic non-malignant pain, that targets withdrawal of strong opioids on activities of daily living and opioid related adverse events.
Methods
A definitive randomised controlled trial recruiting 468 participants from primary care, pain clinics and pharmacies. Eligibility criteria; chronic non-malignant pain, aged ?18, using strong opioids (defined by the British National Formulary) for at least three months and on most days in the preceding month and fluent in written and spoken English. Those randomised to the I-WOTCH intervention will receive a three day group facilitated course, based on cognitive behavioural principles and led by a trained nurse and a lay person with chronic pain and experience of opioid withdrawal/tapering. In addition, participants will also receive one-to one sessions (face to face and telephone with the trained nurse) to develop a tapering plan. Participants will also receive a copy of (My Opioid Manager (anglicised); a self-help guide for people using opioid drugs for chronic pain)). Those in the control intervention will receive (My Opioid Manager (anglicised) and a relaxation CD only.
Results
The primary outcome measure is ‘activities of daily living’ measured by the Patient-Reported Outcomes Measurement Information System, Pain Interference Short Form (8A)(PROMIS-PI-SF-8A).
The main secondary outcome is opioid use defined as mean difference in morphine equivalent dose in the four weeks prior to one-year follow-up expressed as mg of morphine per day. Other secondary outcomes include: adverse events, health related quality of life, sleep quality, emotional wellbeing, self-efficacy and resource use.
Data will be collected at base line, four, eight and twelve months. A comprehensive cost effectiveness and model based economic evaluation will be completed. A process evaluation will also track how: the intervention is delivered, staff experiences of delivery, possible mediating processes and patients’ perceptions and experiences of participation in the intervention.
We will present data from the pilot phase of the trial.
Conclusion
The findings from this trial will inform clinical practice on the identification and management of patients with non-malignant chronic pain, seeking to support a reduction in/withdrawal from opioid use. It will help address the current need to change prescribing behaviours as well as empowering and motivating patients to undergo behaviour change and engage in self-management of long term pain without the reliance on long term use of opioid drugs.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Non-theatre injection procedures are an important part of the multimodal strategy to manage persistent pain in a biopsychosocial model. Non-X-ray interventional procedures can be performed in a dedicated clean room to improve the efficiency of patient turnover. This designated area allows the admission and discharge of the patient with minimal disruption to the demands on hospital beds. Performing an increased number of cases as compared to a theatre setting and also ensuring high standards are met have to be assessed (1, 2); we audited these clean room injections in 2014-15. Informed consent, patient review and patient outcome are key areas that were assessed in this audit.
Aims
To audit the clean room interventions in the chronic pain service at the University Hospitals of Leicester NHS Trust with the following standards:
All procedures should have informed consent (1,2)
All procedures should be reviewed by telephone follow up (target: 90%) (2,3)
Efficacy of more than 30% pain relief (target: 60%)
Methods
40 patients were retrospectively audited from September 2014 to October 2014. All these patients had clean room injection procedures done under aseptic precautions. All patients had telephone reviews as per our standard protocol at six weeks after the injection; these clinical records were retrieved from the ICE computerised system. The data was inputted and analysed using Microsoft Excel.
Results
The data demonstrated a range of procedures performed in the Clean room. Trapezius trigger injections were the most common procedure performed. Other injections included: Occipital nerve blocks, Trigger injections in abdomen, Botulinium toxin injections, Knee trigger injections, Lumbar trigger injections, Facial injections and other simple injections. 100% of patients had informed consent with 100% of patients being reviewed by telephone consultation following the procedure. The mean time following the procedure for a telephone consultation was 10 weeks. 69.23% of patients had successful pain relief with pain relief lasting greater than 6 weeks.
Conclusion
Clean room injections have very good efficacy and are an important part of the multidisciplinary chronic pain management. Our audit demonstrated that all procedures received informed consent and had follow-up telephone consultations. 69.23% of patients had successful pain relief proving the effectiveness of our clean room interventions. The audit also demonstrates that our structure and process adheres to the Royal College standards.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The diverse patient population suffering from chronic pain suggests that a single treatment approach unlikely will benefit everyone. Indeed, spinal cord stimulation (SCS) trials often fail to provide adequate pain relief for many trialed patients, suggesting that what works for some may not work for others. Many short- and long-term changes can complicate treatment efficacy, resulting in difficulty sustaining effective stimulation even after a successful SCS trial. The variability and plasticity inherent in chronic pain disorders suggests that SCS systems must be flexible to modify targets, provide alternative stimulation patterns to the same target, or both. Some SCS systems provide targeting capabilities using advanced technologies such as anatomically-guided (3D) neural targeting. Yet, even appropriately identified neural targets must be stimulated optimally as well.
Aims
To evaluate the extent chronic pain patients take advantage of the availability of multiple neurostimulative waveforms provided from a single device, we performed a real-world device utilization registry study of patients implanted with a device capable of delivering multiple waveforms in addition to standard rate stimulation.
Methods
We collected data from a large aggregated database of clinical programmers from an unbiased cohort of 250 patients. The database consists of variables collected during programming sessions including: stimulus amplitude, frequency, current fractionalization, patient program usage, and program changes. Patients had access to three non-standard waveform programming types in addition to standard rate stimulation. Non-standard stimulation programming included the following: at least 1000 pulses per second (1 kilohertz stimulation), fractionalizing the cathodic current away from target while intensifying the anodal current near the target region (anodal intensification [AI]), and burst stimulation.
Results
Approximately 60% of patients utilized multiple, non-standard waveforms at least 20% of the time, with 11 different waveform combinations observed. Not all patients used standard rate stimulation when using available non-standard waveforms, as some reported using 1 kHz stimulation combined with AI as well as1 kHz stimulation combined with burst stimulation, both in the absence of standard rate stimulation. We also observed sustained usage of multiple waveform programming, as patients on average reported using 3 programs out to 1 year, with twice as many programs early on.
Conclusion
These results demonstrate that many patients utilize non-standard waveforms for notable proportions of stimulation time if provided the opportunity. This supports the notion that patients are likely to benefit using a single device that can provide multiple stimuli and programming options when using SCS to treat their pain.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Spinal Cord Stimulation (SCS) trial outcomes can have a profound effect on the decision to proceed with permanent implantation or not. Enabling chronic pain patients within a trial to experience a single device delivering multiple stimulation frequencies and waveforms (multiple waveform SCS) coupled to an algorithm allowing for precise anatomically-guided neural stimulation field targeting (3D Neural Targeting) may provide for more definitive identification of the neurostimulative approaches optimally suited to each individual.
Aims
To begin investigating the effect of a system capable of multiple waveform SCS, patients were evaluated who, after enduring a trial failure using an SCS system that holds stimulation constant at 10 kHz only, were subsequently switched to a system capable of 3D Neural Targeting and delivering multiple neurostimulative waveforms.
Methods
Patients who failed an SCS trial using a system capable of 10 kHz stimulation only (Senza, Nevro Corp.) were analyzed after interchanging to a trial stimulator providing standard rate stimulation, anatomically-guided 3D neural targeting, and available programming capabilities using multiple stimulation waveforms such as 1 kHz stimulation, burst stimulation and anode intensification (Precision Spectra, Boston Scientific). Percent pain relief (PPR) as calculated using baseline and post-trial pain scores is reported following trials using both systems.
Results
So far, data obtained and analyzed is from 11 patients. Results from up to 9 more patients will be presented. Forty-five percent of the patients analyzed to date reported experiencing back pain only. In addition, 45% of patients evaluated reported undergoing 1 previous back surgery (36% percent reported 2 or more prior back surgeries). Following a trial using 10 kHz stimulation only, 64% of the assessed patients reported no pain relief (0% PPR), 27% reported minimal pain relief (0-25% PPR), and 9% reported moderate pain relief (25-50% PPR). Of the patients who reported no or minimal PPR after a trial using 10 kHz only, 45% reported a conversion to either high PPR (36%) or very high PPR (9%) following a subsequent trial using a multiple waveform SCS system.
Conclusion
Providing patients with options in the event of a failed SCS trial is of importance given that most trials are typically conducted using only one system with a limited range of available neurostimulative approaches. An SCS system capable of multiple waveforms and precise targeting capabilities offers the potential for more personalized optimization of stimulation thereby helping to improve trial outcomes.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Technical advancements designed to enable better targeting of paresthesia-based neurostimulation have been thought necessary to facilitate improvement in treating chronic pain using spinal cord stimulation (SCS). One novel method to enable specific targeting is called Anatomically-Guided (3D) Neural Targeting. This approach combines multiple independent current control (MICC) with 32 available electrodes and a unique programming algorithm based on a 3D anatomical model that takes into account the conductivity of spinal column structures, relative lead location, and vertebral level of the leads. In addition to fractionalizing current between electrodes, this technology allows for precise steering of stimulation to targets by generating a central point of stimulation.
Aims
To assess whether 3D Neural Targeting SCS can provide effective treatment for chronic pain, we performed a real-world, observational clinical study. Moreover, we examined patients utilizing 3D Neural Targeting SCS versus those using a previous generation system not equipped with this novel targeting technology.
Methods
LUMINA is a retrospective, multi-center, consecutive study across 13 clinical sites of 213 trialled patients treated out to 2 years post-implant using a 3D Neural Target SCS system equipped with up to 32 contacts, MICC, and a patient specific, model-based algorithm to adjust for lead position (Precision Spectra, Boston Scientific). In addition, 213 patients from these same participating sites using a previous generation system and software (Precision Plus, Boston Scientific), without the model-based algorithm, were selected for matched cohort analysis.
Results
Mean overall pain prior to treatment in the 3D neural targeting cohort was 7.17 ±2.06 (n=213). The overall mean pain score was reduced and sustained out to 24 months post-implant at 2.94 ±2.62 (n=169, p<0.0001). Severe pain patients, defined as those with a baseline NRS score of 8 – 10 (n=108) were analyzed. In these patients, the overall mean pain of 8.75 ±0.78 (n=108) at baseline was reduced and sustained out to 24 months post-implant with an overall mean pain score of 3.41 ±2.33 (n=91, p<0.001). Responder rates were greater than 70% for overall and low back pain. Compared to a previous generation SCS system, statistically significant increases in response rates were observed using 3D Neural Targeting SCS.
Conclusion
The results demonstrated long-term evidence of significant overall and low-back pain relief out to 2 years using a novel 3D Neural Targeting algorithm. Based on this study’s design and implementation, the observed clinical outcomes are reflective of what clinicians and patients can expect in the real-world clinical setting.
Conclusion
Sedation for pain procedures should be reserved for carefully selected patients. Our survey has shown one third of pain physicians routinely offer sedation to their patients. This we consider is still a high number and we plan to disseminate our findings and guidelines to pain professionals to create awareness. Patient Educational materials can assist in making informed decisions. We plan to create a patient information leaflet and include this in patient appointment letter.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The general perception during pain interventional procedures is that sedative and analgesic agents are safe and improve patient satisfaction. However, sedation can be associated with significant risks, particularly when administered to patients with other co morbidities, specially in the prone position. A review of literature and guidelines revealed that most routine minor pain procedures, do not require anaesthesia care other than local anaesthesia. The use of sedation and anaesthesia must be balanced with the potential risk of harm from doing pain procedures in a sedated patient, especially those undergoing cervical spine procedures.When performing epidural injections in the cervical, thoracic, or high lumbar segments of the spine, direct needle injury to the spinal cord is a potential risk. Needle contact with the cord is likely to elicit a strong paresthesia. The use of moderate or deep sedation may block the patient’s perception of a needle induced paresthesia.
Aims
Our aim was to determine the current practice of providing sedation during pain procedures in the Northern England Region. Also, we were interested in knowing as to the adherence to the International Spine Intervention Society(ISIS) guidelines for sedation during pain procedures.
Methods
We performed a paper based survey provided to attendees at the Northern England Annual Pain Meeting. The survey proforma was prepared after reviewing ISIS guidelines on sedation for interventional procedures. Our survey included a total of twelve questions looking at the grade of responders, current practice in providing sedation during pain procedures, type of drugs used for sedation, extent of monitoring, knowledge about existing guidelines, availability of patient information leaflets in their institution and patient satisfaction rates. The questionnaires were collected at the end of the meeting, collated and analysed.
Results
We received responses from 56 attendees, which included forty five pain consultants, five pain fellows and six non career grade doctors. The survey revealed sixteen (28%) respondents would offer sedation routinely to their patients. Only six responders felt anxiety as an automatic indication for providing sedation. Pulse Oximetry was the most common monitor during sedation followed by Blood Pressure, ETCO2 and ECG. Midazolam, Midazolam with Alfentanyl and Propofol with Alfentanyl were the most commonly used followed by Nitrous oxide and Remifentanyl. Thirty Six respondents (65%) responded they wouldn’t use sedation in neuroablative procedures. Remifentanyl was popular in patients having radiofrequency ablation. Thirty Two respondents (57%) were not aware of any guidelines. Eight (14%) responders provided written information to their patients.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic pain of moderate to severe intensity occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives (1). This is a substantial health care problem. Mechanical low back pain due to a combination of vertebral osteoarthritic changes and/or degenerative disc disease (bulge, protrusion, dehydration) is a major social issue and has been extensively investigated to find any predictive risk factors and its possible prevention. A literature review of published studies in patients with low back pain (LBP), conducted between 1966 and 1998 had shown a wide range of 1-year prevalence (22% to 65%) and lifetime prevalence (11% to 84%) of LBP, underlying the complexity of the problem (2).
Aims
To evaluate the effects of a course of three spinal injections (lumbar root, LRI; epidural, ESI) in patients suffering from chronic mechanical low back pain with unilateral/bilateral radiculopathy in the lower limbs for more than 6 months
Methods
We treated 112 consecutive patients suffering from chronic mechanical low back pain with unilateral/bilateral radiculopathy in the lower limbs for more than 6 months with a course of three spinal injections (lumbar root, LRI; epidural, ESI) at 12 weekly interval. Each injection consists of depomedrone (methylprednisolone) 120 mg (3 mls) and chirocaine 2.5 mg/ml (5mls). Each patient was asked to complete a Pain Numeric Scale (PNS, 0-10) at baseline (prior the injection) and each following week for the entire 12 weeks. A total number of 98 patients returned a completed PNS. They were 61 female and 37 male patients. The average age was 59 (41-84).
Results
The mean baseline pain score was 7.93. Mean weekly pain intensity showed reduction. The highest pain reduction was reached at week 4 (PNS=5) after the first injection. Pain consequently increased weekly and reached 6.90 at the time of the 2nd injection. It gradually decreased again, reaching the best pain reduction at week 5 (PNS=5.53) starting increase again after. The average PNS at week 12 was 7.12. The outcome after the 3rd injection was very similar.
Conclusion
Our case study shows that a course of three consecutive spinal injections (ESI or LRI) at 12 weeks interval was beneficial and provided improvement in chronic mechanical low back pain. The outcome was very similar between the 1st, 2nd and 3rd injection, with the severity of pain returning toward baseline at the time of the next injection, showing that there was not a cumulative effect. No side effects were reported.
We conclude that a course of lumbar root or epidural injections produce a satisfactory but temporary pain relief.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
A 2012-2013 hospital-wide report found 50% of inpatients (n=381) had chronic pain which complicated their treatment, and that specialist pain input and integration between hospital and community were lacking. In response, a Complex Pain Team of nurse educator, nurse specialist, physiotherapist, clinical psychologists and medical consultants, all pain specialists, was established.
The team provides multidisciplinary assessment and treatment to referred patients. They must have complex to manage pain, and/ or take >120mg morphine equivalent /day or opioid doses that are rapidly escalating; have visited A&E more than twice or been admitted more than once, for pain, in the last year.
Crucially, the team works with the admitting teams and wards around the patients’ medical needs. Inpatient treatment is followed up in community and/or outpatient services. In addition to disseminating pain management skills through joint working, the team delivers an educational programme to hospital medical and nursing staff and community GPs.
Aims
To evaluate the effects of the Complex pain Team (CPT) intervention on patient pain, quality of life, and (dis)ability. Interim data from January 2016 to October 2016, is below, and will be extended to February 2017.
Methods
Patient recorded outcome measures via questionnaires are completed by the patient at initial assessment (baseline) and repeated at six month follow up. The validated outcomes include measures of quality of life: pain severity (British Pain Inventory Items 1-4, BPI); depression screening (Patient Health Questionnaire-9, PHQ-9); catastrophising (Pain Catastrophising Scale, PCS); and pain self-efficacy (Pain Self-Efficacy Questionnaire, PSEQ). Baseline and follow up data are used to estimate extent of change.
Initial follow up data from the first four months of participants has been analysed to estimate extent of change. Change is expressed in terms of the number of patient scores that have stayed the same, improved or worsened by more than one standard deviation (SD) from the group mean score for that variable from baseline.
Full appropriate statistical tests will be employed when the follow up data is complete.
Results
Thus far 40 inpatients (7 males: 33 females; mean age 41.1 years), have provided baseline data, and 15 have completed follow-up. One patient declined to complete all of the outcome measures hence n=14 for PHQ-9, PCS and PSEQ.
For BPI severity, PCS and PSEQ, 5 patients reported an improvement at follow up by at least 1 SD from the baseline mean. Only one patient worsened by at least 1 SD in each domain. The remaining patients reported no changes greater or less than 1 SD at follow up.
Four patients reported an improvement at follow up by at least 1 SD from the baseline mean for the PHQ-9 whereas 7 stayed the same and 3 worsened by more than 1 SD.
Conclusion
The Complex Pain Team may be the first truly integrated UK inpatient-community-outpatient service for patients with persistent pain. Initial outcomes provide encouraging evidence of clinically relevant change in terms of pain severity, depression, catastrophising and self-efficacy.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
In Britain, approximately 10 million people live with pain; the limited data on prescribing patterns in the UK show that there were 16 million opioid prescriptions in 2015, costing over £200 million. Yet evidence suggests that opioids are only effective in the short term, after which most patients experience tolerance and some develop opioid induced hyperalgesia. Opioid side effects and withdrawal symptoms can be devastating to patients, their family and society: very little support and advice is available for patients wishing to stop their opioids. People with typically spend less than 1% of their time in contact with health professionals; the remainder of the time they, their carers and families, manage by themselves. Structured, group-based, psycho-educational self-management interventions help people to better manage their daily lives with a long term condition, including persistent pain, but few of these have specifically targeted patients considering opioid withdrawal.
Aims
The Improving the Wellbeing of people with Opioid-Treated CHronic pain (I-WOTCH) study aims to enable those with persistent non-malignant pain to self-manage their pain better, reduce opioid use and improve their quality of life. We report the complex intervention-development approaches, the pilot process evaluation, and the patient-facing material required.
Methods
The I-WOTCH intervention is based on a previous trial (COPERS study) of a self-management approach for people with persistent non-malignant pain; opioid use was not targeted. Using Medical Research Council guidance, we applied our learning from the COPERS study to inform a new intervention, including additional material on opioids, and an opioid tapering regime.
The development of the multi-modal intervention materials will be adapted in response to feedback from the nurses and lay facilitators, who are delivering the intervention in the pilot studies. We are working with our patient and public involvement (PPI) advisers who are represented on the Trial Management Group, and at the pilot site. We describe the iterative development and the formative process evaluation results of the pilot phase (see separate poster for pilot findings) that have led to the further refinement of the new intervention and the final materials.
Results
The I-WOTCH intervention uses the biopsychosocial model of health and wellness, drawing upon the psychological theories of self-efficacy, social learning, and cognitive behaviour-change.
It comprises three, full-day sessions, co-delivered by a nurse and a lay facilitator with experience of opioid withdrawal, and who have been specifically trained to deliver I-WOTCH. Sessions cover pain and opioid pathways, working in partnership with health professionals, communication skills, relaxation tools, action planning and problem solving (including managing setbacks), all of which aim to increase self-confidence and motivation. Participants are offered a tailored one-to-one session with the nurse to agree an opioid tapering programme, and three follow-up telephone calls. Participants will additionally receive course handouts, a DVD and a mindfulness CD (or access to electronic downloads).
Both active and control arm participants will receive a My Opioid Manager book – a patient education tool (untested in the UK) - and relaxation CD.
Conclusion
In conclusion the key elements we consider necessary for ideal implementation are to:
highlight the context-specific theoretical considerations that are necessary in behaviour-change interventions;
outline the pragmatics of designing appropriate content involving several delivery media (paper, electronic, audio-visual), in collaboration with multiple stakeholders.
present examples of our intervention materials.
Insights that we have gained from this process can be used by other intervention developers to anticipate, implement and succeed in creating or modifying their intervention to optimise its persuasiveness, feasibility, relevance and benefit to users.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Pain of lumbar facet-joint origin is a common cause of low back pain in adults, and may lead to chronic pain and disability. At present, there are no diagnostic criteria for lumbar facet-joint pain, and no definitive research to support the use of targeted lumbar facet-joint injections to manage this pain. There is no standardised technique for facet-joint injection, and no consensus of what would constitute a suitable sham procedure.
Due to the lack of high quality clinical evidence, the National Institute for Health and Care Excellence (NICE) guidelines published in the UK in 2009 did not recommend injections of therapeutic substances into the back for non-specific low back pain, despite their potential to reduce pain intensity and rehabilitation, and NICE called for further research to be undertaken.
Aims
The aim of this pilot study is to examine the feasibility of undertaking a definitive fully powered double-blind randomised controlled trial to evaluate the clinical- and cost-effectiveness of facet-joint injections compared to a sham procedure, in participants with non-specific low back pain of more than 3 months’ duration.
Methods
Patients with non-specific low back pain of more than 3 months’ duration (who have failed 2 elements of non-specific back pain treatment) were to be recruited from clinics at 3 hospitals in the UK. Of 1000 patients screened, it was anticipated that 250 would be eligible to enter the study and proceed to have a diagnostic test for facet-joint disease. Those with a positive response would be randomised to receive either:
4 intra-articular facet-joint injections through a spinal needle at 2 bilateral lumbar levels, using 0.5ml 0.5% bupivacaine and 20mg methylprednisolone per joint (active group), or 4 peri-articular injections through a spinal needle at 2 bilateral lumbar levels, using 0.5ml normal saline per injection (sham group).
A combined physical and psychological programme (CPP) would be delivered to all participants by physiotherapists trained to deliver the Back Skills Training programme.
Results
Recruitment took place at a single centre, at Barts Health NHS Trust, between January and September 2016. Of 628 patients screened, 50 were considered eligible to enter the study and 16 participants were consented to take part; 5 participants dropped out following consent. Following diagnostic injections for facet-joint disease, 9 out of 11 participants had a positive response and were randomised to receive either lumbar facet-joint injections or a sham procedure.
All participants were invited to attend 6 sessions of the Back Skills Training programme after their injections.
Outcome measures were collected at baseline, then 6 weeks, 3 months and 6 months after injections, using questionnaires to assess pain, functioning, health-related quality of life, anxiety and depression, health care resource utilisation, complications, and adverse events.
Conclusion
The preliminary results demonstrate that the number of participants recruited and considered eligible to take part were lower than expected, in part due to the strict inclusion and exclusion criteria. Many patients referred to the pain clinic with low back pain had already received previous facet-joint injections, or had radiculopathy and other dominant pain.
Proposals for a future trial will include a discussion between including a highly selected population (with a high response rate to the diagnostic test, as demonstrated) compared to a less selective population, with potentially more diagnostic test failures, in order to improve the recruitment rate.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Non-specific chronic low back pain (NSCLBP) (low back pain lasting longer than 3 months without an identifiable patho-anatomical cause) is a common problem. It requires a disproportionate amount of healthcare resources and a primary care research priority is to determine strategies for educating and empowering individuals to successfully self-manage this condition. During face-to-face consultations valuable time is often spent on addressing bio-psychosocial barriers to self-management and the internet offers the potential for further support.
Aims
The objective of this review was to evaluate whether web-based interventions positively influence bio-psychosocial issues related to having NSCLBP which act as a barrier to self-management.
Methods
A narrative literature review was conducted in November, 2015 using electronic databases, OVID Medline, Embase, AMED (Allied and Complimentary Medicine), PsycINFO and Cochrane Library (Cochrane collaboration). In order to capture contemporary studies, and considering the relatively recent advent of the World Wide Web, the search was limited to those published from 2005 and onwards.
Results
From examining the trials in this review some online interventions showed short term improvements in bio-psychosocial issues which act as a barrier to self-managing NSCLBP. A variety of interventions were found with many using a cognitive behavioural therapy approach. Some websites focused on exercise, postural education and supporting helpful lifestyle changes. Varying levels of interactivity were found with each intervention.
Conclusion
There is limited evidence to make firm conclusions regarding the long term efficacy of web-based applications used to support self-management of NSCLBP. Isolating the differential effects of each component used in web-based applications complicated the process of deciphering which type of approach is best. Also, research on the subject has been mostly restricted to limited comparisons with waiting list control groups along with limited sample sizes. Additional research would help to identify best practices for internet-based support.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Over 90,000 primary total knee replacements are performed annually in the NHS. People undergo knee replacement with the hope that surgery will improve their pain, but approximately 20% of people experience chronic pain afterwards. There is a pressing need for better management for patients who experience this pain but there is little evidence about how to improve care. To address this gap we have developed a complex intervention in keeping with Medical Research Council guidance. The intervention comprises a clinic-based assessment to identify potential causes of a patient’s chronic pain after knee replacement and to provide onwards referral to appropriate services. Earlier stages of work to design this complex intervention included a survey of service provision, focus groups with healthcare professionals, systematic review, expert deliberation, and patient involvement activities. Previous development work involved consensus work and meetings with healthcare professionals. This abstract presents the final stages of intervention refinement.
Aims
The aims of this work were twofold. The first aim was to test and refine the processes and procedures for intervention delivery and assess patient acceptability. The second aim was to evaluate the perceived implementability of the intervention within the future trial.
Methods
Testing procedures for intervention delivery
Ten patients with chronic pain after knee replacement provided informed consent to participate. Chronic pain was defined as a score of 0-14 on the 7 items of the Oxford Knee Score. Patients were invited to attend a clinic on two occasions and to see an orthopaedic surgeon and a physiotherapy Extended Scope Practitioner, separately, at each clinic. The clinic involved a medical history, self-report questionnaires, x-rays, a blood test and structured clinical examination. Patients also completed a questionnaire about the acceptability of the clinic process.
Evaluating the perceived implementability of the intervention
To evaluate views about implementability of the intervention in the future trial, 10 health professional stakeholders completed a 23-item online questionnaire based on the NoMAD instrument. This instrument measures implementation processes from the perspectives of stakeholders involved in the implementation work.
Results
Testing procedures for intervention delivery
This work highlighted the need for a number of changes to the assessment clinics. These involved an additional screening tool for neuropathic pain, standardisation of technique and goniometer usage to improve reliability of range of motion assessment, further training on the assessment of Complex Regional Pain Syndrome, and the need for standardised radiographs for the assessment of limb alignment. Patients thought that the content of the clinic was acceptable and appropriate. This work also informed the content of a comprehensive training manual and one-day training event for healthcare professionals who will deliver the trial intervention.
Evaluating the perceived implementability of the intervention
Stakeholders understood the intervention and could see how the intervention would affect the nature of their own work. They were aware of the proposed benefits of the intervention for patients and were keen to engage with the new practices.
Conclusion
We have undertaken a comprehensive programme of research to develop and refine a complex intervention prior to evaluation in a randomised trial. Our study provides an example of the methods that can be used to address key questions within intervention design. The next stage is to evaluate the clinical and cost-effectiveness of the intervention in a definitive multi-centre randomised trial, which will include an internal pilot phase.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The Enhanced Transtheoretical Model Intervention (ETMI) aimed at increasing physical recreation activity in people with chronic low back pain. The primary outcome was disability at 12 months. The intervention was compared to physiotherapy as usual. The result from the trial1 indicated that ETMI was significantly more effective than physiotherapy, and that this difference was clinically meaningful.
Aims
The aim of this analysis was to explore whether both intervention and control perform equally well for patients with depression.
Methods
We carried out a sub-analysis on the data from the trial (N=220). We considered patients to be ‘depressed’ if their SF-12 score was below 45.6, which is the cut-point recommended by the authors. We compared outcome at 12 months on disability on the Roland Morris Disability Questionnaire (RMDQ), average and worst pain, and rates of physical activity at 12 months in patients with and without depression between the two interventions using Analysis of Variance, with pain and disability at baseline entered as covariates.
Results
More than half of our sample were defined as ‘depressed’ (57/109 in the ETMI group and 62/111 of the control group). For non-depressed participants, ETMI was superior only on disability scores at 12 months, but not on pain ratings or increases in physical activity (PA). For participants with depression, ETMI was superior on disability, average pain and increases in PA at 3 months, and superior on disability and PA at 12 months. The change in disability on the RMDQ was clinically meaningful, shifting from 10.7 ± 5.2 to 3.1 ± 5.0 at 12 months, compared to 10.8 ± 5.3 at baseline, to 7.4 ± 7.0 at 12 months in physiotherapy.
Conclusion
Both interventions were effective at improving outcomes, but ETMI was more effective than physiotherapy for all patients. Of importance, within the ETMI arm, patients with depression improves as much as those without depression, but in physiotherapy as-usual, depressed patients had significantly worse outcomes.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The increased complexity of pain aetiology involving chronic pain, co morbidities and bio psychosocial factors for hospital inpatients is an important consideration for resource availability for Inpatient Pain Services (IPS). In a major trauma centre additional issues including psychological impacts of injury on rehabilitation and types of pain require multimodal analgesia, poly-pharmacy and the need for an increasing array of skills. This requires new strategies for managing the efficiency of the IPS. It is acknowledged that specialist skills are required owing to pain complexity along the continuum (Upp et al, 2014). Tools measuring case complexity, such as INTERMED (Lobo et al, 2013) exist but a specific tool for measuring pain complexity which is reliable and simple to use for inpatients in a hospital setting has not been published.
Aims
The aim is to assess the value of a newly developed pain complexity grading tool by auditing the relationship between pain complexity and incidence of neuropathic pain, referring speciality, time taken with patients and number of assessments in order to predict input required, prioritise and risk stratify, therefore increasing efficiency.
Methods
A thorough literature search yielded no results for published works on the measurement of pain complexity specifically. A pain complexity grading system was developed for use by the IPS for use on hospitalised patients who met the existing referral criteria. A holistic approach was used in development to account for the varied impacts on pain. The grading tool takes into account injuries, pharmacological, social, psychological, medical and historical factors in quick and easy to use criteria. Patients scored Complexity Grade (CG) either 0, 1 or 2. 406 referrals over a 6 month period were audited. Patients’ pain complexity was graded and the amount of time taken for and number of assessments for each referral, type of pain, reasons for referral and referring speciality were recorded.
Results
Of referrals who were not complex (CG0) 10% had multiple reasons for referral. 27% of CG1 had >2 reasons for referring compared to 48% of CG2. Of 125 referred with chronic pain 107 (86%) had additional complexity, making them CG2. 52% of CG2 patients had chronic pain compared to 16% of CG1. The referral number for chronic pain alone was similar- 4% and 5% of referrals respectively. 100% of referrals by Cardiac, Haematology and Renal were CG2. 3 visits was the median across all CGs. The range was 0 to 27 visits for CG2; 1 to 12 for CG1; 1 to 8 for CG0. CG2 patients had a median duration 5:30 longer than CG0. Visit duration range was greater by 2:10. 67% of referrals with neuropathic pain were CG2, 27% CG1, 6% CG0. 62% of CG2 patients had neuropathic pain compared to 44% with CG1 and 50% CG0 respectively.
Conclusion
Those with neuropathic pain were more likely to be complex and complex pain patients were more likely to have neuropathic pain, chronic pain and more than one reason for referral. Increased pain complexity required longer reviews and referrals from certain specialities were more likely to have greater pain complexity. The conclusion can be drawn that the pain complexity grading enables prediction of requirements and therefore could improve efficiency through better informed allocation of resources. Further audit into reasons for complexity would further enable prioritisation for resources and assess the need for more resources.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The Inpatient Pain Service (IPS) found referrals were becoming increasingly complex with multiple injuries, psychological impacts of injury on rehabilitation, types of pain requiring multimodal poly-pharmacy and an increasing array of skills. The IPS developed to meet the demands of a busy major trauma centre with a caseload including chronic pain patients with chronic pain, psychiatric diagnoses, social issues and immediate medical needs in addition to acute pain resulting from trauma and associated surgeries. To ensure complex needs were met, a satisfaction outcome question and a pain complexity grading tool were devised as the IPS grew to meet demand at a busy trauma centre hospital.
Aims
The aim of the audit is to determine if pain complexity requires more interventions from the IPS with a secondary aim of auditing whether outcomes are better for patients with greater pain complexity or for whom.
Methods
A validated outcome question format was used to audit IPS outcomes. A pain complexity criterion for grading patient’s pain complexity was developed for use by the IPS for use on hospitalised patients who met the existing referral criteria of the IPS. A holistic approach was used in development to account for the varied impacts on pain. The grading tool takes into account injuries, pharmacological, social, psychological, medical and historical factors in quick and easy to use criteria. Patients scored Complexity Grade (CG) 0, 1 or 2. 406 referrals over a 6 month period were audited. Patients’ pain complexity was graded and type and number of interventions made for each complexity grade were analysed. The relationship between interventions, pain complexity and outcomes was analysed.
Results
61% of referrals were CG2, 33% were CG1. Only 6% did not have complex pain (CG 0). More complex patients were more likely to require more interventions. Of those requiring >5 interventions none were CG0, 8 were CG1 and 23 were CG2. Of the latter 4 required >10 interventions. The median number of interventions was universally 2 across all CGs but in the CG2 cohort the range was 0-13, 0-6 for CG1 and 0-5 in CG0. Across all complexity grades nobody responded strongly disagree. Of the referral graded complexity score 2, 66% strongly agree, 30% agree 3% neither agree nor disagree and 1% disagree. Of CG 1 patients 73% strongly agree, 24% agree 3% neither agree nor disagree and nobody responded disagree. Those with CG score 0 responded 58% strongly agree, 33% agree 8% neither agree nor disagree and nobody responded disagree.
Conclusion
Despite 94% of referrals having complex pain grades outcomes were still very positive. The strong correlation between pain complexity and the number of interventions means the conclusion can be drawn that more input, more diverse interventions and a wider variety of knowledge and skill is required where pain is more complex but this yields positive outcomes. On-going audit of service outcomes is required to maintain patient satisfaction for management of complex pain.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Pain is often under-recognised and under-treated in children. Effective pain management is an important part of paediatric in-patient hospital admissions. Not only is there an ethical duty to treat pain; it can help prevent anxiety, fear avoidance, delayed discharge and the possibility of developing chronic pain in the future. Proper assessment of pain is crucial especially in those patients who find it difficult to communicate. A multimodal approach to pain management is recommended.
Aims
A snapshot audit to survey pain assessment and treatment of all paediatric inpatients including medical and surgical wards at the Great North Children’s Hospital: a large tertiary referral paediatric teaching hospital.
Methods
Data were collected from 104 inpatients at the Great North Children’s Hospital on 8th September 2016 by a team of Anaesthetic trainees and consultants along with acute pain and theatre recovery nurses. Patients on SCBU were excluded. The data collected on paper forms included:
Age
Gender
Specialty
Pre-existing pain
Length of hospital stay
Recording pain scores
Pain tools used
Pain severity
Satisfaction with pain management
Pain management offered: pharmacological, regional, physical or psychological methods.
These results were compared to NICE guidelines updated in 2009 which outlined the recognition and assessment of acute pain in children. Four key recommendations were made including the use of validated pain tools, assessment and recording pain levels at regular intervals and getting children to report their own pain where possible.
Results
A total number of 104 audit forms were completed with equal distribution (50%) of male and female children. About 40% of both male and female had their pain scores recorded. Lack of recorded pain scores were more prevalent on medical wards compared to surgical wards. Numerical rating scale was used in 20% for both male and female children. FLACC was used for 15% of male and 10% of female children. Majority of pain scores during the audit were between 0-3/10 in both male (30%) and female (25%) children. Majority of overall pain experience ranked between 1 to 2 in both male (36%) and female (30%) children (1 = very happy, 5 = not at all happy). Physical and psychological strategies to manage pain were only used sparingly despite being valuable tools in pain management. There was more scope for the use of regional anaesthesia techniques at our institution.
Conclusion
As compared to similar pain audits at other paediatric institutions our results compare favourably. We plan to provide specific pain education to areas where pain assessment and scores fell below standards. In most areas pain management is reasonable and this is reflected in patient / carer satisfaction scores. A reliance on the use of pharmacological pain management only has been shown. The importance of incorporating non-pharmacological strategies and regional techniques in optimising pain management needs to be made clear. After implementing a programme of pain education we plan to repeat this snapshot audit to gauge quality improvement.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Opioids are effective in providing analgesia but their safety and efficacy in chronic non cancer pain management is debatable (1). The British Pain Society (BPS) has issued guidance on use of opioids for persistent pain (2). ‘Opioids aware’ is a Public Health England funded project providing advice on prescribing opioids to both health care professionals and patients (3). North East of England has the largest number of opioid prescriptions according to the NHS Business Services Authority regional variations in spending on opioid analgesics.
Aims
To evaluate the pattern of opioid prescribing in chronic non cancer pain in general practice in the North East region of England, among patients attending out-patient pain clinics at the Royal Victoria Infirmary in Newcastle-upon-Tyne.
Methods
Data was collected from 138 patients (both new and review) with chronic non cancer pain attending the out-patient pain clinics at the Royal Victoria Infirmary. This prospective survey was carried out between November 2014 and February 2015. All patients attending the pain clinic were given a simple form to fill out indicating their pre-existing opioid and anti neuropathic medication use, prior to their consultation. The data was validated at the time of consultation in the clinic.
Results
Opioids were being used by 75% of patients attending the pain clinics. Majority (58%) of the patients were using at least one opioid and 17% of patients were using 2 or 3 different opioids at the same time. The daily oral morphine equivalent dose varied from 3 mg. to 1620 mg., with an average of 112.45 mg. oral morphine equivalent per day.
Conclusion
There is a wide variation in prescribing of opioid and anti-neuropathic medication among General practitioners and Pain physicians in chronic non cancer pain. Most patients attending the pain clinics were already on opioids with some of them using high doses. There is an increasing need to prescribe opioids in a safe and effective manner as highlighted by the ‘Opioids aware’ project. Improving awareness of BPS opioid prescribing guidelines among health care professionals and patient education are important in achieving uniformity in prescribing opioids.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Pain management programmes (PMP) are an established part of care for patients suffering with chronic debilitating pain in the UK. (RCA, 2015). The Evidence suggests that a multidisciplinary team (MDT) with a Pain Physician, Specialist Nurse, Psychologist, Physiotherapist and Occupational Therapist provide effective pain management using a biopsychosocial model and can prevent further physical disability (Nelson & Weir, 2001). PMP uses rehabilitative strategies, which aim to change behaviour and promote self well-being through education, goal-setting, exercise and replacing fixed and unhelpful beliefs. After assessment of the patients by the multidisciplinary team, PMP is delivered in a group setting at the Dudley Group of Hospitals. Each group consists of ten patients who meet with the MDT for three hours every week for a ten week period. Patients are then reviewed at 3 months with a view to reinforcing the aims of PMP and continued use of strategies to maximize functional
Aims
The objectives of our PMP are to improve patients’ understanding of pain and increase their level of physical functioning despite ongoing pain and promote self-management to decrease their reliance on medical management. We carried out our service evaluation to see whether the current PMP format is meeting our service standards.
Methods
63 patients from seven PMP groups completed an anonymous questionnaire issued at their 3 month review. The questionnaire consisted of six questions based on symptoms and experiences, and used a ten point numerical Likert scale (−5 to +5); where 0 is no change, -5 to 0 is negative response and 0 to +5 being positive. Questions were:
Overall is your pain better?
Are your symptoms are better?
Are you able to do more on a day-to-day basis?
Are you able to cope better with your pain?
Are you able to control the severity of your pain symptoms better?
Are your feelings about the future more positive?
The aim of this analysis was to demonstrate areas of improvement; decline or where aspects remained unchanged. The results were analysed and are discussed below.
Results
The results for each question are as follows.
30% showed an improvement in their pain compared with 24% who reported worse pain. The majority of patients (46%) reported their pain was same.
49% reported their symptoms have remained the same whilst 29% felt an improvement. 22% had their symptoms worsening.
63% reported an increase in activity levels whereas only 10% felt worsening and 27% remained at the same activity level.
79% patients reported an improvement in their ability to cope, 6% had worsening and 14 % felt the same.
60% of them felt that they were better able to control the severity of pain symptoms with only 10% seeing a reduction in control and 29% remained the same.
A more positive outlook on the future was reported by 68% of the patient where on 10% reported negative feelings and 22% remained the same.
Conclusion
Majority of patients (82%) demonstrated that they benefited from attending PMP. As we expected there was minimal improvement in pain symptoms because PMP aims mainly at coping skills and strategies for dealing with chronic pain, disability, distress and life changes. The above results meet the service aims of the PMP to support patients to self-manage their pain better and current evidence (Scascighini et al, 2008). A detailed assessment of patients by the multidisciplinary team and an assessment prior to starting the PMP to check for patient suitability is essential for good outcomes for the individual as well as the group.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
In the past few years, there have been significant changes in the commissioning of pain services in the UK. Various regions have seen changes in terms of how, where and what various CCGs are commissioning. This has led to significant speculation in terms of the future of pain services across some parts of the UK. Although the number of consultant posts advertised for posts in Anaesthesia and pain medicine has not decreased, there has been a steady decline in the number of anaesthetic trainees taking up higher and advanced training in pain medicine in the past five years. This survey was performed in order to try and clarify how well CCGs understood what is currently being delivered by pain services across the UK and what their future intentions are in terms of ongoing provision. The survey was done prior to the introduction of the current sustainability and transformation plans.
Aims
To ascertain CCGs perception of delivery of their pain services and plans for the future provision of pain services.
The authors believe to that speculation regarding the future of pain services is having a negative impact on the number of anaesthetic trainees pursuing higher and advanced training in pain medicine.
Methods
218 Clinical Commissioning Groups were sent a survey electronically by Dr de Gray on behalf of the Faculty of Pain medicine. The survey included nine questions – whether pain services were being funded in primary or secondary care, whether the CCG believed it was important to continue delivering these services. The question was posed as to whether the current budget allocated was thought to be sufficient and whether budget cuts were anticipated in the forthcoming years. The CCG was also asked if there was a set pathway that had to be followed before a patient could be referred into a secondary care pain clinic, and how many new and follow up patient consultations had been funded in the past financial year. Finally the CCG was asked specifically which aspects of multi-disciplinary pain management were they funding within their region. The survey was sent out on four occasions over a period of three months.
Results
67 of a total of 218 CCGs responded. 92% reported it was important to continue funding pain services. 67% were funding secondary care services, 23% both primary and secondary care, and 8% primary care alone.
With regards to anticipated changes to future budgets, 52% answered yes, 41 % answered no, 5% answered they did not know, whereas 2% declined to answer. In those that predict budget changes, 18% predict an increase, 21% predict a decrease, 5% did not answer whereas 56% do not know.
With regards to current budgets, 10 % thought them sufficient, 14% insufficient, 11% thought it excessive, 58% did not know, 7% declined to answer.
65% of CCGs had specific pathways that GPs had to follow before referral to a pain clinic. The number of patient consultations funded ranged from less than 1,000 to over 20,000. Over 85% were funding multidisciplinary services.
Conclusion
The response rate was low at 31%. It is however reassuring to hear that 92% of respondents believe that continued funding of pain services is important. Only 10% believe current budgets to be adequate, a significant number 58% did not know, which either reflects poor understanding of the needs of the local population or services delivered. A similar percentage of 56% could not predict whether budgets would need to increase or decrease. The authors speculate that this may reflect the uncertain times we live in – will this change with the transformation and sustainability projects – only time will tell.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Shoulder pain is one of the common complaints to physicians in general practice. Pain in shoulder region can originate from various structures, including the subacromial-subdeltoid bursa, the glenohumeral and acromioclavicular joint, the long head of biceps, and the rotator cuff.
Suprascapular nerve block (SSNB) has historically been used to reduce pain and improve range of movement (ROM) in patients with shoulder pain. The suprascapular nerve (SSN) innervates nearly 70% of the shoulder joint, and therefore its blockade is a commonly accepted mode of pain therapy in acute and chronic settings.
Traditional practice of chronic pain procedures relies mainly on the use of landmark techniques, nerve-stimulation, fluoroscopy, and occasionally computed tomography (CT). The above techniques require a range of specialist resources and personnel and carry risks including radiation exposure and contrast allergy. The use of ultrasound (US) in chronic pain management is relatively new.
Aims
The aim of this audit was to identify the practices within our institution where shoulder pain syndromes of different aetiology were offered diagnostic or therapeutic SSNB.
As a secondary outcome, we attempted to evaluate the efficacy of the various techniques undertaken, in terms of the quality and duration of pain relief achieved.
Methods
This retrospective audit covered a 4-year period, from September 2012 until September 2016, when the use of US for chronic pain blocks became routine in our department.
We identified patients from a locally held database, including all the patients who had SSNB for diagnosis and/or treatment of chronic shoulder pain, regardless of aetiology or diagnosis.
The modality of the block (landmark, nerve stimulator and US), the dose of steroid and the volume of local anaesthetic was documented on a separate form.
The efficacy of the block was established by asking the patients if they were satisfied with the pain relief they got and if it was felt to be worthwhile to repeat the block.
Patients were reassessed after the SSNB treatment at 3,6 and 12 months at the outpatients clinic to establish the duration of the pain relief.
Results
53 patients underwent SSNB between September 2012-2016.The mean age of the patients was 62.8 (range from 33-86 years old).17 patients were male and the rest (36) female.
Different modalities were used to conduct SSNB in our institution; 20 patients had SSNB using landmark technique, 23 had SSNB under nerve stimulator and 10 patients under US-guidance.
All the patients received steroid (triamcinolone acetonide (Kenalog) 40 mg for each side) plus different volumes of local anaesthetic, 0.25% levobupivacaine. The mean volume of levobupivacaine 0.25% was 9.75ml for the landmark technique, 9.17ml for the nerve stimulator and 8.8ml for the ultrasound technique.
Pain reduction to the extent that it was considered worthwhile to repeat the block was reported by 60% (12/20) under landmark, 78%(18/23) under nerve stimulator and 70%(7/10) under US.
No difference was found in terms of duration of pain relief when comparing the different modalities.
Conclusion
Our audit revealed the use of several techniques for the performance of SSNB. It was notable that fewer SSNBs were performed under US perhaps reflecting a lack of experience and a significant learning curve.
We acknowledge the bias of heterogeneous causes of shoulder pain and cannot account for different causes of shoulder pain, for which SSNB alone might not be the most effective therapeutic treatment.
In conclusion, while several techniques may be used to provide effective pain relief with SSNB, US may improve the specificity and diagnostic accuracy whilst reducing the costs and risks associated with the use of ionizing radiation.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Opioids remain a mainstay of acute and chronic pain management despite known toxicities, particularly in the frail elderly. The use of prescribed dose and interval ranges adds flexibility to administration but also gives potential for higher than intended initial doses. This audit was precipitated by a number of opioid related adverse incidents within our organisation.
Aims
To assess whether patients prescribed a dose range opioid receive an initial high or low dose. The setting was a medium sized district general hospital.
Methods
Two investigators (AF, ML) accessed all available drug charts on medical and surgical wards in Frimley Park Hospital over 4 days. The hospital only uses paper charts on these wards. Chart data was included if it included a dose range opioid prescription.
Results
113 charts were reviewed. Mean age 68 yrs. 56% female. 84% of the patients were on surgical (53%) or orthopaedic (31%) wards. The most commonly prescribed opioid was morphine sulphate (62%), followed by codeine (18%). In 59 patients (52%) initial dose was at the higher dose; in 45 (40%) it was the lower dose. (8% in between). For morphine sulphate in the over 65 yr age group 52% were given the higher dose, and 47% the lower dose; in the under 65s, 58% were given the higher dose; 41% the lower. In the small medical patient group there was an equal split between higher and lower initial doses. Qualitative discussions with nursing staff suggests that the decision to give a higher or lower dose is made on general impression, and therefore may not always include real time knowledge of other important factors such as current renal function.
Conclusion
Opioids are a two edged sword: effective analgesics but also associated with a risk of respiratory depression, particularly in the frail elderly - the group most likely to be prescribed them acutely in secondary care. This audit suggests that in more than 50% of cases the highest of a dose range is initially given, even in an older age group. Prescribers should be aware of this and consider single dose regimes with regular review in high risk patients.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Most best practice standards for Specialist Pain management services for long term pain recommend delivery is by multidisciplinary and multi-professional teams. However, there is little empirical evidence for this as the optimal model of care. The National Pain Audit found wide variation in service delivery. Less than half the specialist clinics had sufficient skills mix to be fully multidisciplinary. It is not known how this impacts patient care.
The aim of this project was to investigate whether those with the greatest severity of pain or high impact were referred to multidisciplinary clinics and whether clinic type affected patient outcomes. Patient level data was used from the National Pain Audit and clinic type as defined by the International Association for the Study of Pain based upon treatments offered and skills mix.
Aims
To investigate
Whether patients with severe pain or severe impact of pain are referred to multidisciplinary clinics
Whether being a clinic that is multidisciplinary affects patient outcomes
Which patient characteristics are related to patient outcomes
Methods
Patient level data was gathered of the audit was gathered over 2011-13. 106 specialist pain clinics in England and Wales entered 9588 patients into a case mix tool. 9071 patients returned detailed questionnaires repeated at 6 months (N=4014) and 12 months (N=1800) .The follow -up groups formed two outcome datasets.
Clinics were categorised into the four IASP Clinic Types. The Brief Pain Inventory two subscales were used to describe need, grouped into mild, moderate and severe.
Multivariate modelling techniques were used to investigate the relationship between the Clinic Type that patients were referred to and patient characteristics including age, sex, diagnosis and level of need.
Regression analyses were used to examine relationships between Clinic Type and patient outcome (discharge, A& E attendance, Minimal Clinically Important Difference in pain scores, sufficient advice and guidance provided to manage pain) with selected patient variables as confounders and predictors.
Results
No single modality clinic returned patient level data. Forty-seven percent had severe pain and interference with life. Needs did not predict Clinic Type referred to.
Those less than 20 years old were 2.5 times more likely to access multidisciplinary care than someone aged over 80 years. Those with post-herpetic neuralgia were twice as likely to be referred for multidisciplinary care compared with those with a non-specific diagnosis.
In term of outcomes those who attended Non-Multidisciplinary Pain clinics were less likely to feel Advice and Guidance was sufficient. Younger patients were most likely to attend A&E and have poorer outcomes. Those with moderate to severe anxiety/depression were half as likely to be discharged by one year and more likely to attend A&E.
Conclusion
A significant minority of patients were referred to clinics which were not well matched to need. If this was addressed there may be significant benefits to both patients and health economies. Only multidisciplinary pain clinics seem to provide patients with sufficient advice to self-manage pain. The presence of anxiety/depression seems to be the main barrier to discharge. Young people seem to fare poorly.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
It’s very important to ascertain patients’ experiences when they are attending pain services as these experiences can help to shape a service that better meets their needs. Patient-centred care is known to provide the best outcomes, however, all too often, services appear to be designed for the convenience of clinicians and not the patients who actually use the service. Surveys are regularly used in the NHS to determine patient satisfaction with services but can be poor at communicating what patients actually think and feel about the services they use. Experience Based Co-Design is an innovative approach to improving healthcare provision in which staff and patients work in partnership to re-design services. This technique has been used before in oncology and emergency medicine but there is very little research into its use in chronic pain.
Aims
This aim of this study was to improve the outpatient clinic for patients using chronic pain services at a teaching hospital. The Experience Based Co-Design methodology was used to gain a greater understanding of patients’ experiences and to produce a list of priorities for change when improving the experience.
Methods
Seven patients were recruited with the aim to find the most diverse group possible based on time spent using the department, pain condition, age and sex. Video recorded patient interviews (2-3 hours) were conducted. A range of patient experiences of using the chronic pain service were captured. The interviews were analysed to identify ‘touchpoints’ which are areas in which patients experienced a heightened emotional response to their interaction with the service or staff. Staff were also interviewed to gain their views on how the service could improve. A patient experience event was held at which patients discussed the touchpoints and identified the most significant areas for change that would improve their experiences of using the chronic pain service. From the recorded interviews a short 20 minute trigger film was compiled to illustrate these touchpoints to staff and gain their commitment to improve patients’ experiences when using the service.
Results
Twenty touchpoints were identified via the interviews with problems in communication a major theme. There were many positives identified by the patients, for example they valued the development of good relationships with clinic staff and feeling properly listened to for the first time. The lack of information provided before attending their first appointment and arriving for procedures was described as a cause for raised anxiety levels by a number of patients. The need for a short debrief after clinic as they described feeling overloaded with information in the clinic room were prioritised for improvement. The patient experience event allowed a group discussion about what was most important to them. At the event they produced a list of points that that they would have liked to have known before attending procedures. This could be used by the staff when producing new information leaflets for the service.
Conclusion
This study featured collaboration between patients and staff to improve patients’ experiences of using chronic pain services. Through patient participation a comprehensive list of recommendations for service improvement were produced, with possible solutions identified; something that could not have easily been completed with the use of patient satisfaction surveys, which are more commonly used. Presenting these findings to staff stimulated a lively debate about how to implement the desired changes. The involvement of patients in driving change and re-designing services is shaping a more patient-centred chronic pain clinic and improving the experience for all the patients who use the service.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The draft NICE guidelines (2016) for low back pain have indicated pain self-management advice and information should be made available at the point of assessment. However, even with wider availability of this information some people will still struggle to incorporate this advice into everyday life. A public forum has highlighted barriers and enhancers to people becoming self-managers of their persistent pain. Four chairs of local and national support groups were asked by the public about their experience of persistent pain. From this initial event, themes emerged and were used to form an on-line questionnaire completed by those in persistent pain across the UK.
Aims
The aim has been to understand the experience of pain via those who are chairs of local and national support groups and related to this determine both key enhancers and barriers to pain self-management.
Methods
A public forum was established with a chair who directed questions from the audience to the panel. Selected panel participants all had persistent pain with 3 chairs of pain support groups and a patient consultant for a NHS pain service. This event was recorded, uploaded to YouTube (https://www.youtube.com/watch?v=YazQ4jNLR30) and transcribed. Two researchers independently read the transcript and identified themes via repetitions, transitions, and similarities/ differences. These themes were reviewed and a final list agreed. Based on the themes identified, a follow up online questionnaire was designed, posted (https://www.dur.ac.uk/wolfson.institute/sig/pain/coping/) and promoted via email and Facebook. The online questionnaire was assessable to the public and intended for those with persistent pain. In terms of ethics, the research design was approved by Durham University. The recording and potential use of the public forum for research purposes was announced to all contributors and responses to the online questionnaire were collected anonymously.
Results
220 questionnaires were completed over a 2 month period. The top three enhancers and barriers for >5% of people (n=96) completing the online questionnaire are reported herein. Enhancers were: learning new ways to self-manage pain (13%), pain medication improving function (12%), being listened to and believed (11%), knowing more about pain and the causes (9%), GP who listens and supports (8%), my family/ friends taking part and supporting me (8%), referral to pain management services (7%), less fearful of the pain or its effects on my life (6%), connecting to social media/ IT resources (6%). Barriers include: depression, low moods, loss of hope (14%), other people not understanding about my pain (13%), my pain is invisible to others (12%), side effects of pain reducing medications (10%), unable to work/ contribute to society (8%), lack of GP’s knowledge on pain management (7%), medication as the only treatment plan (6%).
Conclusion
This pilot study has gained insight into the enhancers and barriers of pain self-management and identified those most important for further research. The complexity of various issues impacting on pain self-management engagement is noted with many responders (n=>120) unable to limit their selection to only three questionnaire options. Future events and analysis of those with >3 responses could add to this body of evidence (https://www.bna.org.uk/meetings/bna2017/public-programme/). Our approach has meant further research is focused on public set agendas. This follow-up study is likely to be specific to one significant impact enhancer/ barrier for one pain condition in one locality.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Neuropathic pain is often deemed more severe than nociceptive pain, with greater interference on activities of daily living, whilst being harder to treat effectively. There is evidence that neuropathic pain is under-diagnosed, in particular within the population of patients with cancer and those who have survived cancer. A systematic review suggested that a liberal estimate of incidence within this patient group would be approximately 40%.
Aims
Amongst the population attending the Royal Marsden outpatient Pain Management clinics:
Determine the prevalence of neuropathic pain.
Establish the specificity and sensitivity of the Douleur Neuropathique-4 Questionnaire (DN4).
Identify whether neuropathic pain is associated with greater pain intensity, greater pain interference or is more difficult to treat.
Methods
After gaining ethical approval, patients attending Pain Management clinics between 01/01/2016 and 30/11/2016, who consented to providing data, were included. Exclusion criteria:
No documented pain diagnosis
Failure to complete Brief Pain Inventory (BPI) or DN4
Two groups were identified; those with a clinician diagnosis of neuropathic pain or mixed neuropathic/nociceptive pain (‘neuropathic’ group) and patients with a diagnosis of nociceptive pain (‘non-neuropathic’ group).
These groups were compared to determine:
Proportion of patients reporting severe pain (BPI severity?7), severe pain interference (BPI interference?7), likely anxiety (Hospital Anxiety and Depression Scale [HADS] ?11) and likely depression (HADS?11).
True negative and true positive rates of the DN4.
Of those who attended Pain Management clinic more than once, the fraction who responded well to treatment (identified by Patient Global Impression of Change Scores [PGIC] of definite improvement or better).
Statistical analysis was performed using chi-squared testing.
Results
256 patients were included (187 within the neuropathic group and 69 in the non-neuropathic group). The BPI identified similar numbers with severe pain intensity (18.2% in the neuropathic group vs. 18.8% in the non-neuropathic group) and a higher percentage of patients in the non-neuropathic group with severe pain interference (47.8% vs. 34.8%). Neither demonstrated a statistically significant difference.
The sensitivity of the DN4 Questionnaire in our patient cohort was 80.2%, the specificity 69.6% and accuracy 77.3%.
The likely prevalence of anxiety and depression was estimated at 34.4% and 56.1% respectively in the neuropathic group. Similar figures were seen in the non-neuropathic group (27.9% and 57.4% respectively).
185 patients were seen more than once. Of these, 171 patients (135 in the neuropathic and 46 in the non-neuropathic group) completed a PGIC. 29.6% of patients in the neuropathic group reported improvement compared to 23.9% in the non-neuropathic group.
Conclusion
The proportion of patients with neuropathic pain diagnoses was higher than figures seen in a recent systematic review. A possible explanation for this could be the patient population attending our hospital, many of whom have undergone surgery.
Amongst the two groups, there was no difference in the proportion of patients reporting severe pain intensity, severe pain interference or improvements in their pain. No difference between the likelihood of anxiety or depression was identified between the two groups. Confounders not accounted for include underlying diagnosis requiring presentation to a cancer centre, which may significantly influence anxiety and depression incidence.
Conclusion
The aim of this qualitative analysis of clinical decision making pre ONS implant, patient expectations of ONS and patients’ post ONS implant experiences will inform the development of this budding service. Further research of outcomes is ongoing and includes the collection of pain and wellbeing measures to be evaluated at a later date.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The Walton Centre is a tertiary referral centre for pain management, situated in the North West of England. We receive referrals from across the country, in addition to our immediate area; North West of England and North Wales. We are currently the largest users of High Concentration Capsaicin (8%) patch in the UK. The service is currently led by a Clinical Nurse Specialist with experience in treatment with High Concentration Capsaicin and chronic pain management.
Aims
The following is intended to illustrate our experiences of treatment responders within a cohort of 123 patients, treated with high concentration capsaicin (8%) patch, between December 2014 and October 2016.
Methods
Patient were assessed for evidence of clinical improvement at clinic visits and also via telephone consultations. Clinical improvement was classed as a 30% reduction in the size of the painful area or a 30% reduction in NPRS score, or both, with or without evidence of functional improvement. Those patients who did not demonstrate clinical improvement were discharged back to their referring consultant.
Of the 123 patients; 7 had neuropathic stump pain following a limb amputation, 33 suffered with Postherpetic Neuralgia (PHN), 25 had a range of Peripheral Neuropathies, 43 had post-surgical neuropathic pain and 15 has suffered a traumatic nerve injury.
Results
Overall 37% (45) of the entire cohort demonstrated a clinical improvement. Of these, 7% (3) demonstrated significant improvement and did not require further repatch. Those who demonstrated clinical improvement continued to receive repatches every 90 to 180 days.
Of those who demonstrated clinical improvement (45); 2.2% (1) had Neuropathic stump pain, 17.8% (8) had Postherpetic Neuralgia (PHN), 22.2% (10) had a range of Peripheral Neuropathies, 46.7% (21) had post-surgical neuropathic pain and 11.1% (5) had suffered a traumatic nerve injury.
Further analysis demonstrated the percentage responder rates within each sub categories; Neuropathic Stump pain 14.3%, Postherpetic Neuralgia 24.2%, Various Peripheral Neuropathies 40%, Post-surgical neuropathic pain 48.8% and Traumatic Nerve injury pain 33.3%.
Responders within the sub category of Peripheral Neuropathy were further sub divided demonstrating the following; 30% (3) had Chemotherapy induced Neuropathy, 40% (4) had Painful Diabetic Peripheral Neuropathy and 30% (3) had Idiopathic Painful Small Fibre Neuropathy.
Conclusion
The most influential variables that may influence responder rates is length of time from onset of symptoms to initiation of treatment with high concentration capsaicin. As The Walton Centre is a tertiary referral centre, many patients may experience a delay before obtaining referral, this may account for the lower than average response in certain painful conditions and would warrant further audit and analysis.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Spinal cord stimulation (SCS) often loses effectiveness in chronic pain treatment over time based on assessments of pain location, extent, and/or intensity. However, pain assessment resolution is limited by the fact that many different locations are often grouped in the same category. For instance, “low back pain” may refer to many different points or extents within the lower back. Thus, it is possible that long term increases in pain ratings may not be due to increasing pain in the same initial location(s). To address this issue, we sought to determine the extent to which existing pain patterns change over time as well as the extent to which new patterns develop.
Aims
To evaluate the extent to which existing pain patterns change over time as well as the extent to which new patterns develop in patients with neuropathic pain.
Methods
Patients with permanently implanted Boston Scientific SCS systems are followed for up to 36 months after a pre-implantation baseline evaluation in order to gauge long-term pain relief. At baseline and each follow-up visit, patients use a highlighter to mark all areas on a standardized anatomical template where they have experienced pain within the past 7 days. We performed analyses on these drawings for more than 100 patients to explore whether there were any shifts over time in the areas denoted as painful. Specifically, we compared each patient’s drawing at the 6 or 12 month follow-up visit to their drawing at baseline. Since all drawings were completed using a standardized template, we could make pixel-by-pixel comparisons to see where in the body pain remained
Results
We determined how frequently new areas of pain arose within our patient sample. We also characterized the spatial distribution of this new pain, including its distance from areas of preexisting pain, in order to determine how often treatment of new pain would require re-targeting of therapy provided by SCS.
Conclusion
New pain areas occurred within a year after baseline for a subset of patients. This would therefore suggest that such patients are likely to benefit from SCS systems that allow for flexible post-implantation adjustment of targeted therapy locations in order to achieve long-term maintenance of pain relief.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
All drugs currently available for the treatment of neuropathic pain (NP) are clinically useful in only a minority of patients1. Lidocaine given systemically via the intravenous route has been shown to be effective in treating NP 2. Experience in our unit over twenty years indicates that it is very well tolerated by comparison with mainstream oral pharmacotherapy in NP (such as tricyclic antidepressants and gabapentin/pregabalin) and in many cases a single infusion may be followed by prolonged pain remission, lasting several weeks. However, in other cases, pain relief may be dramatic but of too brief duration for i.v. infusions in a specialist unit to be practicable as a means of providing continuous pain relief.
A perceived practical obstacle to the use of systemic lidocaine (and other local anaesthetics) for treating NP is that they are ineffective when administered via the orogastric route due to a high level of hepatic first-pass metabolism.
Aims
Having established treatment of NP with i.v. lidocaine as routine practice in our unit, we set out to establish whether administration of lidocaine via the subcutaneous route could provide a therapeutic effect comparable to i.v. infusion, enabling domiciliary treatment by self-administration (or administration by a carer) and to assess patient acceptability.
Methods
Patients were selected from those already managed within our unit who had received at least two prior i.v. lidocaine infusions, one of which incorporated a saline placebo, and had reported a substantial and consistent reduction in pain intensity without troublesome side-effects.
All patients received their first two administrations of subcutaneous lidocaine in our unit. The first administration was performed by one of the authors (PN) and the second by the patient, or a specified other (usually carer or spouse) under observation and following detailed instruction and assessment of competence. A printed instruction sheet was provided.
The anterior abdominal wall was selected as the site for injection on the basis of ease of access and lack of potential to injure major vessels or nerves. Patients received the same dose as their previously established intravenous dose (usually 3mg / kg) given as four equal boluses of a 1% lidocaine solution at ten minute intervals.
Results
To date ten patients have commenced subcutaneous lidocaine according to our protocol. The range of duration of treatment is 22 months to 6 weeks. In all but one case, patients have elected to persist with subcutaneous lidocaine treatment. The dose interval range is 2 - 8 weeks. There have been no reports of major adverse effects and patient acceptability has been high. No difficulties have been reported with the process of self-injection. Some individuals have reported enhanced benefits from the change from intravenous to subcutaneous domiciliary treatment, not only because of greater convenience but because it has enabled individual experimentation with optimal dose frequency. One patient (an academic scientist) reported a better result if the injections were spread out over the course of one and a half hours rather than thirty minutes.
Conclusion
In our small series, systemic lidocaine administration via the subcutaneous route has so far produced results comparable to intravenous infusion and has proved well tolerated with good patient acceptability. The widespread and long-established use of subcutaneous lidocaine for the provision of local anaesthesia attests to its safety and the experience in our unit of administration intravenously in patients with chronic NP has demonstrated the drug to be remarkably well tolerated with the dose regimes we use.
We conclude that subcutaneous lidocaine is deserving of further evaluation as a treatment for chronic NP.
References
- 1. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015; 14: 162 – 173 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Challapalli V, Tremont-Lucas IW, McNicol ED, et al. Systemic administration of local anaesthetic agents to relieve neuropathic pain. Cochrane Database Syst Rev2009: CD 003345 [DOI] [PMC free article] [PubMed] [Google Scholar]
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
According to the World Health Organisation 245,000 Libyan people (population ~6million) will have diabetes by 2030. Painful Diabetic Neuropathy (PDN) is a very common complication of diabetes affecting up to 50% of diabetic patients. There is a need to estimate the prevalence of PDN in Libya so that health care authorities can plan effective pain management programmes. The self-report version of the Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) scale is used to identify pain of neuropathic origin. Previously, we translated and linguistically validated the self-report version of the Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale for use in Libya.
Aims
To estimate the point prevalence of PDN in adults in Eastern Libya.
Methods
We approached patients attending the Benghazi Diabetes Center who had diabetes for >5 years to take part in the study. The Benghazi Diabetes Center is one of the largest diabetes centers in Libya, providing services to Eastern Libya for approximately 100000 patients per year. Patients provided consent and completed the Libyan S-LANSS. Anthropometrics, marital status, socioeconomic and education information was recorded and blood glucose level determined. Sample size was calculated to be 400 individuals with diabetes (SoftStat) so a target of 450 participants was set to account for potential withdrawals.
Results
Four hundred and fifty participants completed the study (age = 19 to 87years, BMI = 17.6 to 44.2 kgm2, 224 females). One hundred and ninety five (43.3%) participants reported pain in their lower limbs in the previous 6 months and 190/195 participants reported S-LANSS score of >12. Thus, 42.2% of participants with diabetes had PDN and 97.4% of participants experiencing pain also had neuropathic pain characteristics. Participants with PDN had diabetes for 20.4±6.5years (mean+SD) compared with participants without PDN (11.1±4.6 years, p=0.0001, t-test). Participants with PDN smoked tobacco for more years (7.9±12.3 years versus 1.1±3.9 years for those without pain, p=0.001). Blood glucose levels were higher for participants with PDN compared with participants without pain (143.6±29.3 mg/dl versus 120.0 ±17.3 mg/dl respectively. Participants without PDN had a higher level of education (x2=79.4, p=0.001) and higher employment status (x2=13.0, p=0.001) than those with PDN.
Conclusion
The point prevalence of PDN in Libya was 42.2% and higher than estimates in UK populations (34%). This may be due to more effective glycaemic control interventions in the UK. Risk factors for developing PDN were high blood glucose, long duration of diabetes, and low educational and employment status. We speculate that more educated patients tend to have better control of blood glucose.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Mindfulness is a practice of attentional training that has been recommended to improve quality of life in chronic pain, though the 2015 Mindful Nation UK Report (commissioned by a cross-party APPG) called for more definitive research, including cost-effectiveness.
Mindfulness for Health is an 8-week course developed using personal experience of pain to tailor mindfulness to the needs of people with chronic pain. Previous qualitative studies have shown significant quality of life improvements sustained for almost a decade after taking part in a programme.
Aims
To investigate changes in acceptance of pain, quality of life, fatigue, mood, anxiety, mindfulness, and self-compassion following participation in the Mindfulness for Health (MfH) course, as well as changes in health resource use.
Methods
MfH course participants completed online questionnaires at baseline, post-course, and during follow-up at 3 and 12 months post-course.
Pain and pain impact were measured using the Brief Pain Inventory; distress by the Hospital Anxiety & Distress Scale; catastrophising by the Pain Catastrophising Scale; acceptance by the Chronic Pain Acceptance Questionnaire; fatigue using a scale adapted from the BPI; quality of life using the WHOQOL-5; mindfulness by the Five Facet Mindfulness Scale ; and compassion by the Self-compassion Scale. Questions on health resource usage and quality of sleep were also completed.
Results
Interim baseline and post-course data is presented here from 35 (28 female) participants with LTCs. Within this sample, 21 (16 female) participants were currently experiencing chronic pain and therefore completed specific pain-related questionnaires.
For chronic pain, while pain severity was essentially unchanged post-MfH, catastrophising decreased by 47% (p< 0.001) and pain interference by 23% (p=0.01).
In the whole sample, fatigue severity decreased by 19% (p=0.017) and fatigue interference with daily activities by 42% (p<0.001), anxiety scores by 24% and depression by 32%. Further, quality of life improved by 66% (p<0.001), with gains also in self-compassion and mindfulness. Sleep improved, with reduced difficulty falling asleep (33%), staying asleep (37%) and waking too early (33%).
We are now investigating how changes in mindfulness mediate these outcomes.
Conclusion
Although pain itself did not change significantly, these interim results indicate worthwhile improvements in key areas of life and quality of life from the Mindfulness for Health programme. Further data collection and analysis is in process, in order to illuminate the specific effects of mindfulness as well as impacts on health resource usage.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Kinesiology taping is a therapeutic technique of application of elastic adhesive tape to the skin which was developed in 1970s to facilitate rehabilitation of sports-related musculoskeletal injuries. It is claimed that kinesiology taping facilitates blood and lymphatic microcirculation by creating convolutions of the skin, and that it modulates pain by stimulating low-threshold cutaneous mechanoreceptors (in line with the Gate Control Theory of Pain). Evidence from systematic reviews suggests that kinesiology taping is useful as an adjunct to mainline therapies for managing short-term musculoskeletal pain and cancer-related lymphedema (Banerjee et al., 2016). It is suspected that healthcare practitioners including physiotherapists, nurses, occupational and lymphedema therapists working in oncology and/or palliative/supportive care settings in the UK may use kinesiology taping to manage symptoms in cancer; however to date very little information is available as there have been no surveys examining the self-reported use of kinesiology taping in cancer settings.
Aims
The aim of the questionnaire survey was to gather information from registered healthcare practitioners in the UK on the use of kinesiology taping in cancer including treatment regimens, adverse effects and barriers to its use.
Methods
This was a cross-sectional web-based questionnaire to survey the use of kinesiology taping by UK-registered healthcare practitioners working in oncology and/or palliative/supportive care settings using non-probability self-select sampling technique. The questionnaire which consisted of a screening question, 5 questions on demographics and 16 questions on self-reported use of kinesiology taping, was designed and piloted in Leeds Beckett University’s Snap Surveys software. Gatekeepers of the following professional bodies were contacted to seek approval for dissemination of the questionnaire to their members: Association of Chartered Physiotherapists in Oncology and Palliative care, College of Occupational Therapists Specialist Section - HIV, Oncology and Palliative Care, United Kingdom Oncology Nursing Society, Faculty of Pain Medicine, and British Lymphology Society. Upon approval, the weblink of the questionnaire was sent to the gatekeepers. The survey was conducted between August 2015 – September 2016. Follow-up emails were sent to all gatekeepers on one occasion for increasing responses.
Results
24% of respondents (29/123) that participated in the survey reported that they use kinesiology taping in their oncology and/or palliative/supportive care practice within the NHS (59%), voluntary and third sector (31%) and private settings (10%). 29 respondents included nurses (45%), physiotherapists (42%), lymphedema therapists (10%), and clinical massage therapists (3%). The use of kinesiology taping was reported ‘often’ or ‘always’ in primary cancer diagnosis of breast (69%), prostate (32%), gynaecological (17%), head and neck (17%), and for the management of lymphedema (73%), oedema (71%), scar tissue (post-radiotherapy) (56%), pain (20%), breathlessness (19%) and abdominal discomfort (15%). Its effectiveness for improving symptoms for which kinesiology taping is used was rated ‘effective’ or ‘very effective’ by 90% of respondents. Adverse effects reported were skin-related allergy and sensitivity. Commonly reported precautions include skin-patch testing, fragile/post-radiotherapy skin, active cancer site while contraindications include broken skin, open wound/fungating lesion, skin infection, cellulites, and DVT/thrombosis.
Conclusion
Kinesiology taping could be a useful non-pharmacological adjunct to the current package of therapies available for mitigating some of the symptoms related to cancer including oedema and pain. Adverse effects, precautions and contraindications are predominantly skin-related implying emphasis on skin assessment prior to selecting cancer patient for kinesiology taping. Barriers to using kinesiology taping are mainly related to its lack of evidence base, scepticism and cost. Findings of this study are not generalizable; more research is needed to judge its usefulness in the continuum of cancer care.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The majority of chronic pain patients are managed in the community, with only more complex cases accessing specialist multidisciplinary pain services. Pharmacological management is often unsatisfactory (Breivik et al 2006), with variable pain relief and adverse effects. Nonpharmacological approaches including education, advice, physical activity, and exercise are also important.
Exercise may have specific benefits in improving chronic pain, as well as the more general benefits associated with improved physical and mental health, as depression, deconditioning, and obesity are commonly observed in these patients. Lack of mobility in chronic pain patients is associated with increased all-cause and cardiovascular mortality (Nuesch et al 2011).There may be many perceived barriers to physical activity such as fear avoidance (Vlaeyen et al 1995) in this particular group. Physical exercise can be very safe and cost-effective, but inappropriately-advised exercise could potentially be harmful in this population.
Aims
To identify self-reported activity levels, attitudes, beliefs, and perceived barriers to increasing physical activity among a sample of patients referred to chronic pain services.
Methods
Following ethics approval, a prospective survey was carried out of patients attending their first appointment at the Lothian Chronic Pain Service (Edinburgh, Scotland) between March and June 2015. Basic demographics (gender, age, living alone, GP visits, hospital intake, emergency call-outs, pain duration (months), employment status, education level) were collected.
Validated patient self-report questionnaires routinely used in the clinic assessed general aspects:
Brief Pain Inventory (BPI);
Hospital Anxiety and Depression Scale (HADS);
Self-report Leeds assessment of Neuropathic Symptoms and Signs (S-LANSS);
Tampa Scale of Kinesiophobia (TSK);
Pain Self-Efficacy Questionnaire (PSEQ);
Pain Catastrophising Scale (PCS).
Additional questionnaires focussed on exercise and physical activity:
International Physical Activity Questionnaire – short form (IPAQ-s);
The Physical Activity Stages of Change Questionnaire;
Physical Activity Questionnaire (originally designed for Diabetic Patients, focusses on attitudes towards exercise using the Theory of Planned Behaviour (TPB) [PAQ-DP]).
Results
Surveys were distributed through three hospitals: 143 from 400 were returned (36% response).
Physical activity levels were low (IPAQ-s, n=142, median 0 METs, IQR 0-0), reflecting that the majority were in the early stages of change (Pre-contemplation [n=25, 17.5%], Contemplation [n=61, 42.7%]), compared to later (more active) stages (Preparation [n=4, 2.8%], Action [n=7, 4.9%], Maintenance [n=20, 28.0%]).
Catatrophising was high (PCS helplessness, n=105, 13.3 SD 6.3, magnification, n=109, 5.1 SD 3.5, rumination, n=108, 9.5 SD 4.7, total, n=106, 27.8 SD 12.7); self-efficacy was low (PSEQ, n=114, 25.1 SD 14.3); fear avoidance was moderate-high (13-item TSK, n=107, 32.2 SD 8.4). Measurement based on TPB (normalised PAQ 0-100 scale) showed low perceived behavioural control (n=130, 28.2 SD 17.9) and self-identity (n=131, 38.6 SD 20.6), moderate intention (n=130, 54.1 SD 32.1) and subjective norm (n=133, 51.5 SD 22.6), and moderate-high instrumental attitude (n=133, 70.0 SD 25.1) and affective attitude (n=130, 60.4 SD 16.4).
Conclusion
Patients attending the Pain Clinic for the first time are largely sedentary; only a very small number are regularly active. The large proportion of patients in the Contemplation stage of physical activity participation indicate they require additional support in progressing to participation in regular exercise, and were therefore appropriately referred to the pain service. The low scoring within perceived behavioural control is reflected in the limited movement through the stages of change, as the individual perceives the level of difficulty of participating in physical activity. Strategies to address potential barriers to engaging in exercise need to be developed.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Pain management is a particular challenge for combat casualties repatriated to the UK with complex, life-changing injuries, particularly during ward-based wound care and dressing changes. Despite the Military Acute Pain Service providing multi-disciplinary support with multimodal analgesic regimes and epidural/regional nerve catheters, a significant number of patients experience distressing pain.
A stakeholder group of NHS and military clinicians, engineers and human factors specialists was established to investigate the feasibility of introducing virtual reality (VR) to provide distraction therapy during wound care. VR was selected for appraisal due to its contemporaneous use by the United States for military casualties and its potential “high-tech” appeal to injured soldiers.
A formal, human-centred design (HCD) framework was adopted for the development of the prototype VR system. The first phase of this process was a comprehensive assessment of the user capabilities and capacity of complex trauma patients, in order to ensure device usability and utility.
Aims
To investigate appropriate technologies to support interaction with customised virtual environments (VE) by UK military combat casualties, including those with full or partial limb loss. This included establishing user capabilities, user satisfaction and technology acceptance in relation to commercial-off-the-shelf input devices, such as hand controllers and displays.
Methods
The stakeholder group produced descriptors of the user capabilities of battle-injured inpatients. Heuristic principles were applied to select ostensibly appropriate hand controllers for formal usability appraisal by a sample of the target patient population. Using a within subject, repeated measures, randomised design, each participant trialled each of four controllers:
Keyboard and mouse.
Xbox controller.
Joystick.
Thumb controller.
An integrated user tracking system, measuring VE navigation trajectory and time to task completion, was developed to provide objective measures of user performance.
Subjective data were also collected including:
Usability of the input device based on the VRUSE questionnaire; a tool designed specifically to assess usability of VR based systems.
Ratings of workload based on the NASA Task Load Index (TLX).
Discomfort rating using Borg Numerical Rating Scale.
Results
Twelve patients completed all four device assessments. The Xbox controller was rated as the most usable device overall, although the joystick was awarded the highest usability scores by hand-injured patients. One-way ANOVA testing shows a significant main effect on ratings of usability of the devices [F(3,33) = 4.177, p=0.013). There were significant differences on usability ratings between the Xbox and each of the other controllers (joystick p=0.018, keyboard and mouse p=0.033, thumb controller p=0.002), but no significant effects between the remaining three.
The user preference results were seemingly influenced by disability; in particular the joystick was least favoured by those without and most preferred by those with hand injury. All controllers caused discomfort in the hand-injured group.
NASA TLX workload ratings were highest for the keyboard and mouse, although one-way ANOVA testing failed to demonstrate a statistically significant difference ([F (1.445,15.899) =2.246, p>0.05).
Conclusion
This study demonstrates the validity of using a formal HCD approach to inform prototype design for VR-based distraction therapy. It is essential that all elements of prototype systems are usable and acceptable by the target user population, particularly those with complex injuries. The HCD process allows objective and subjective ratings of device components. Despite high technology acceptance by combat casualties, the usability of devices was influenced by patient injury pattern. All tested devices caused some discomfort. This is an important consideration when designing a pain management system and requires disclosure to patients prior to involvement in clinical trials.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Interdisciplinary pain management is the treatment of choice for patients with persistent pain causing significant distress and disability. (1) The efficacy of interdisciplinary pain management programmes, in terms of improved functional status, work retention and health-related quality of life is supported by a wealth of evidence. (2) Interdisciplinary treatment is necessarily time and resource intensive, and ensuring that eligible patients access the treatment they are offered as early as possible is paramount in improving the efficiency of the service.
Patients referred to the Newcastle Pain Management Programme team by their pain consultant are sent an opt-in letter, requiring them to contact the team to arrange an initial assessment. Up to thirty percent of patients referred either did not arrange an assessment, or did not attend, resulting in patient and clinician frustration and delays in treatment.
Aims
On initial analysis with all team members, a number of potential barriers to accessing Pain Management Programme Team assessments were postulated. The subsequent patient survey was carried out with the intention of exploring these hypotheses, to identify possible means of improving the opt-in rate and reducing the number of missed appointments.
Methods
All referrals to the Newcastle Pain Management Programme team during a 3 month period from April to June 2016 were reviewed to identify patients who did not arrange an initial assessment with the team, and those who arranged an appointment but failed to attend. An eight question telephone questionnaire was devised in consultation with the whole team, and patients were contact by a single investigator. Responses to open questions were recorded verbatim, and these responses were coded to identify key themes. Arrangements were made to ensure that patients indicating administrative difficulties as the reason for non-attendance, or wishing to rearrange an appointment, were able to do so. Data was also collected regarding the timing of clinic correspondence, other interventions offered at the same time as referral, information about the PMP team referral recorded in the clinic letter, and information given to the team in the referral letter.
Results
Thirty patients were identified, of whom 27 did not opt in, and 3 did not attend an appointment. 18/30 were referred at their first pain clinic attendance. 7/30 were also offered interventional treatment. Twenty patients answered the questionnaire by telephone.
16/20 patients had received their clinic letter, but only 8 recalled having received the opt-in letter for PMP Team assessment. Regarding barriers to attendance, 2 patients indicated an active decision not to engage. 4 responses referred to physical or social barriers to attendance, including family commitments, time pressures or the need for additional support.
“I don’t remember” was the most frequent response to a question regarding understanding of the role of the PMP team, not necessarily well correlated with the amount of information in the clinic letter. Six patients had clear and positive understanding, but there was lack of clarity regarding the process required to be assessed.
Conclusion
Patients attending the Newcastle Pain Unit are generally offered interdisciplinary care at an early stage. However the survey suggested that information given during consultations about the role of the team and the means of arranging an assessment may not be received, despite being frequently supported by information contained in a clinic letter. This may represent a modifiable factor for improving opt-in rates and reducing patient and clinician frustration. An information leaflet detailing the roles of the team and the referral process is being developed to accompany clinic letters for patients referred to the team.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
There is a growing body of evidence supporting the effectiveness of web-based cognitive behavioural interventions. However, the evidence for web-based treatments for chronic pain is still developing (Eccleston et al., 2014).
Aims
The aims of this evaluation were: 1) to determine whether Pathway Through Pain (an online PMP) leads to improved clinical outcomes in people with chronic pain; and 2) to evaluate whether health care costs were reduced following completion of this PMP.
Methods
This study employed a pre/post test design with clinical outcome measures including disability (ODI), depression (PHQ-9), anxiety (GAD-7), quality of life (EQ-VAS). Health care costs (from inpatient, outpatient and A&E services) were extracted for the year pre- and post-intervention for people receiving the intervention and a comparison group of people who were referred but did not receive the intervention.
Between 2012 – 2016, 1245 patients were referred for consideration for the web-based PMP. Pre- and post-intervention clinical outcomes data has been analysed for 237 people and one year pre- and post-intervention health care cost data has been analysed for 621 people.
Results
Significant improvements were reported for all of the outcomes measured. A series of paired samples t-tests were used for outcome analysis. People completing the web-based PMP showed significant improvements in disability (ODI; p <.001; d = -.54) mood (PHQ-9; p = <.001; d = .41) anxiety (GAD-7; p = <.001; d = -.40) and quality of life (EQ-VAS; p = <.001; d = .42).
Preliminary analysis of health care cost data suggested that the group who used Pathway Through Pain had reductions in combined health care costs (across inpatient, outpatient and A&E services) in the year after the intervention (average reduction of - £414.77 per patient) and the group who did not use Pathway Through Pain had increased costs during this period (average increase of + £127.01 per patient).
Conclusion
For patients completing the web-based PMP there was evidence suggesting significant health gains. However, a minority of patients referred entered treatment (46%) and, of these, a minority completed treatment (45%).
Despite this, for some patients, a web-based PMP may provide an acceptable low-intensity treatment choice and web-based programmes could widen access for those unable to attend traditional group PMPs. Furthermore, results suggest that this web-based PMP could lead to substantial reductions in health care costs.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
A common exclusion criteria for Pain Management Programmes is participants with a limited life-expectancy or rapidly deteriorating disease or condition, this effectively excludes Hospice patients.
The 2013 VOICES survey of 21,320 bereaved people reported that pain relief was inadequate for 53% of people who died at home, 32% of people who died in hospital, 26% in Care Homes and 13% in hospices. The management of pain in these patients remains primarily pharmacological, the fact that pain is inadequately managed coupled with the side effects of analgesics negatively impacts upon patients quality of life.
PMPs are tailored to patients with chronic conditions, we looked at all the elements and adapted them to be more pertinent for patients with a limited life expectancy e.g. removing the emphasis on pain not being an indicator of harm. We called our modified programme a Palliative Pain Management Programme (PPMP).
Aims
To test the feasibility of using a modified PMP in the Hospice setting.
Specific objectives:
To reduce dependence on pharmacological interventions.
To identify specific goals for each patient.
To introduce techniques for self-management of pain.
To reduce the distress associated with pain.
Methods
Patients with a life limiting illness, complex pain, a Pain Score greater than 5 and a Karnofsky Performance Scale greater than 50% were eligible for enrolment.
Patients were referred by the Hospice Community team and the Day Hospice.
Patients were initially assessed by a Palliative Medicine Consultant and a Pharmacist. The tenets of the programme were explained, a pain history and a medicine review were undertaken and participants were given a pain diary.
Participants attended the hospice for one afternoon a week for six consecutive weeks.
The PPMP was delivered by a doctor, a physiotherapist, a psychologist, a spiritual care advisor and Peter Moore who modified his Pain Toolkit for use by palliative patients.
Participants were also coached in Mindfulness, Relaxation, Cognitive Behavioural Techniques and Seated Exercise.
Feasibility testing of structured questionnaires, the Hospital Anxiety and Depression Scale (HADS), Pain Scores and the Pain Toolkit Questionnaire.
Results
18 patients met the inclusion criteria and 9 patients agreed to take part.
Age range of participants 35 to 74 years. 1 male,4 females.
Four deteriorated prior to starting the study and were too unwell to participate. 5 patients completed the programme.
Diagnoses: Four cancer, one neurological condition.
Participants reported moderate to severe anxiety and depression at the start. HADS at week 1, 3 and 6 showed category improvement.
Pain scores did not change significantly but participants reduced their use of breakthrough medication.
Patients were able to employ techniques to self-manage pain and used these before resorting to opioids.
Mindfulness and Relaxation were rated as the most beneficial elements.
Patients reported group working supportive.
Participants comments: ‘more hope of moving forward’ ‘ I can try to control my pain instead of it controlling me’ ‘ I take less medication’.
All participants said they would recommend the programme.
Conclusion
This feasibility study demonstrated that it is possible to deliver a PPMP in the hospice setting and to achieve the objectives set out above.
Future modifications of the programme:
Better data collection.
Increase recruitment numbers at beginning of programme to allow for expected hospice patient attrition.
Allow adequate time at the start of each session to review goals and the Pain Toolkit.
Offer mindfulness, behavioural management, exercise and relaxation in bite sized chunks each week as opposed to blocks of time for each element.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Severe pain experienced following major burns is exacerbated during wound care and dressing changes. Virtual Reality (VR) distraction therapy has been exploited, with some success, for procedure-related pain management particularly in adult burns and trauma settings. Functional Magnetic Resonance Imaging studies undertaken during VR distraction from experimental pain have demonstrated enhancement of the descending cortical pain-control system.
Viewing natural environments, both real and virtual, can have therapeutic benefits; including improved psychologic wellbeing, pain relief and post-operative recovery.
The Human Interface Technologies Team, a collaboration of engineers, human factors experts and clinicians, have developed a novel system called “Virtual Restorative Environment Therapy” (VRET) to be used during ward-based painful procedures. VRET combines commercial-of-the-shelf components with custom-built gaming software, incorporating views of a virtual natural scene with passive and active-distracting gameplay.
A human-centred design approach has been used to consider context, ergonomics and task completion, to increase the usability and utility of the intervention.
Aims
To assess the feasibility of VRET as an adjunct to standard analgesia during inpatient burns dressing changes, determined by:
Successful safe completion of passive and active VRET interventions.
The effects of VRET on pain and anxiety compared to standard analgesia alone.
User acceptance and experience by patients and staff.
Methods
The study was a single-centre, block randomised trial. All patients with burns who required at least three in-patient dressing changes, requiring opioid-based or inhaled nitrous oxide analgesia, were screened.
Participants underwent one dressing change using a standard analgesic protocol. Two further dressing changes used passive VRET (video) and active VRET (game) in addition to standard analgesia. The order of intervention was randomised using computer-generated block allocation.
Using a Monte Carlo method, we estimated that a sample size of 25 patients would provide 99% power to detect a clinically important effect of a 33% reduction in pain scores (Numerical Rating Scale 0-10).
A non-blinded assessor interviewed patients and staff after each intervention, collecting pain (worst, average, before and one hour after dressing change) and anxiety scores. Usability, nausea, patient satisfaction with VRET, and overall pain management scores, using five-point Likert items, were supported by free-text comments.
Results
Two hundred patients were screened over an 18-month period, with 42 approached, of whom eight were enrolled. Seven patients completed all interventions.
Reasons for the low accrual rate included patient refusal (28/34) and a change in practice whereby physiologically stable patients were more likely to be managed as outpatients.
In the seven patients studied, there was no significant difference in satisfaction with analgesia, or in worst, average and post-procedure pain scores between interventions. Anxiety was significantly reduced following active VRET, compared to standard analgesia (p=0.04, paired t-test).
All patient and staff users reported that VRET was “somewhat” or “very” easy to use. Patient satisfaction with VRET was mixed, although all but one reported that they enjoyed using the system. Only one patient experienced “immersion” or “feeling part of” the virtual world. There were no adverse events or nausea during or after VRET exposure.
Conclusion
The trial was closed with incomplete recruitment due to variable factors including change in clinical practice and patient refusal. Patient contextual factors, including psychosocial status, appeared to adversely effect enthusiasm for research activity. From data collected VRET appears acceptable and safe and may be non-inferior to standard analgesic techniques. It may be most useful for patients in whom anxiety is heightening their pain experience. Further work is being undertaken to improve the prototype design process to accommodate patients’ physical abilities and capacity. This, combined with more pragmatic trial design, will contribute to future feasibility studies on refined prototypes.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Ai Chi which can be considered as T’ai Chi in the aquatic environment bringing attention to posture and breathing while positioning the body in optimal alignment (Sova, 2009). Centres in Australia and USA are using Ai Chi to treat a wide range of conditions including chronic pain. It has been demonstrated to have benefits in terms of reduction in anxiety and pain in the fibromyalgia population and improved balance in the chronic stroke patient (Calandre et al 2009, Noh et al 2008). The physiotherapy sessions on a Pain Management Programme (PMP) help patients engage in physical reconditioning and maximisation of physical function (BPS Guidelines for PMP’s for adults, 2013). At the Walton Centre, Liverpool, Ai Chi was integrated to established hydrotherapy sessions on the 16 day (100hrs +) PMP in view to enabling greater variety of exercise within the hydrotherapy pool which is promoting both mindful and enjoyable movement.
Aims
To evaluate the patient perceived impact and utility of Ai Chi within the Pain Management Programme in order to evaluate current and future development of session content.
Methods
An 8 question satisfaction survey was conducted following an introduction to Ai Chi between 2015-16. The data was collected upon two separate time points. The Questionnaire used was a combination of both qualitative and quantitative data. A 5 point Likert scale was used to rate satisfaction and relevance. Further questions facilitated qualitative data regarding specific therapeutic benefits, how session could be improved, and patients plans for independent implementation of AI Chi. The treatment included a verbal educational introduction to Ai Chi, two 20 min sessions of the sequenced exercises and an optional 3rd session. Like all PMP exercise groups, patients were encouraged to pace the exercise sequence to their individual capabilities and were supported by illustrated patient information leaflets. The patients themselves carried out the exercises in the hydro pool while the instructor demonstrated each posture on the pool side. Questionnaires were collected following completion of treatment.
Results
59 anonymised questionnaires were issued and returned. 98% stated they were satisfied or very satisfied with the Ai Chi classes. 100% stated that it was relevant or highly relevant to the management of their chronic pain. 89% stated that they had plans to use Ai Chi following completion of the PMP (of these 70% reported 1-2 times/week, 21% 3-4 times/week, 9% 5-6 times/week). From the qualitative data common terms reported as therapeutic benefits included, ‘improved movement’, ‘Improved flexibility’, ‘relaxing’, ‘improved balance’, ‘mindful’, ‘calming’ and ‘easy’. Common feedback for suggestions on future practice included more frequent classes and to be delivered from earlier on in the programme. A limitation noted regarding future implementation of Ai Chi is that there are no group classes available as yet in the community.
Conclusion
Results demonstrate patients are highly satisfied with the inclusion of Ai Chi exercise classes and they state intent to continue the practice beyond our programme. Qualitative feedback consistently reported patients felt they were more flexible, had improved balance and able to move better. It would be interesting in future to assess whether these reported changes correlated with measured objective changes in function, balance and falls risk. The results strongly suggest that the inclusion of Ai Chi is a relevant addition to our PMP. Continuation of Ai chi practice beyond the context of the programme requires further assessment.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic intractable testicular pain, of 3 months’ duration or longer, is common, particularly occurring after recurrent epididymitis or testicular surgery and commonly idiopathic. Microsurgical denervation of the spermatic cord, epididymectomy and vasovasostomy are treatments shown to provide relief, however these carry the cost of being invasive procedures. Sacral nerve and ilioinguinal and genitofemoral nerve stimulation have been reported in case studies to be effective for chronic testicular pain. PTNS is a treatment for overactive bladder, and has also been reported to have beneficial effects for chronic pelvic pain. We therefore considered that PTNS may also be an effective treatment for intractable testicular pain.
Aims
To evaluate the success of peripheral tibial nerve stimulation (PTNS) in the treatment of chronic intractable testicular pain.
Methods
We surveyed 11 men with intractable testicular pain using the National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) before and after a course of twelve PTNS treatments. The NIH-CPSI is a validated questionnaire about pain, urinary symptoms and quality of life.
Results
9 out of 11 men had an improvement in their NIH-CPSI score after treatment. The median total score decreased from 20/43 to 13/43. Median pain score reduced from 11/21 to 7/21, median urinary symptom score reduced from 4/10 to 3/10, median effect on quality of life score reduced from 7/12 to 3/12.
Conclusion
These preliminary results suggest that PTNS could be a helpful treatment for chronic testicular pain. As a non-invasive technique with minimal side effects, used in a context where other measures have been unsuccessful, there would be a high benefit:risk ratio if further studies prove it to be effective. PTNS is a promising technique for treating previously intractable chronic testicular pain. Further studies are necessary to confirm its effectiveness.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Mindfulness meditation-based interventions (MMBIs) are an increasingly popular approach to self-management of long-term conditions. The interventions generally take the form of an eight-week course, providing participants with a range of tools, including meditations, with which to respond to their condition with greater awareness and acceptance. There is growing evidence that MMBIs benefit people with many long-term physical and mental health conditions, particularly in terms of psychological wellbeing. In chronic pain populations, systematic reviews of MMBIs have identified positive changes in depression, coping, quality of life and perceived pain control, although findings are still inconclusive, particularly with regard to physical outcomes. Most evidence for MMBIs however relates to short-term outcomes, with few studies providing follow-up of more than three months. Limited information exists about how people use mindfulness in the longer-term, how they integrate it into their daily lives and how this affects their experience of living with their condition.
Aims
This study aimed to explore how practising mindfulness affects people’s experiences of living with a long-term condition. In particular, it focused on the perceptions of people who had learnt mindfulness at least six months previously, and how it had affected the way they related to and managed their condition.
Methods
A qualitative approach using constructivist-informed grounded theory was adopted. People with long-term conditions who had attended Breathworks “Living Well with Pain and Illness” mindfulness course at one of three UK locations at least six months previously were invited to participate, as were local Breathworks trainers. A two-phase data collection process between 2011 and 2012 enabled theoretical sampling. Firstly, two consecutive, in-depth, face-to-face interviews, lasting between 1 – 1.5 hours, were conducted at recruitment and then, where possible, 4.5 - 9.5 months later (47 interviews in total). Participants completed diaries which were used to prompt exploration of key incidents and experiences. Secondly, two focus groups were conducted to enable further exploration of emerging themes. Field notes and memos informed the data analysis. Data were analysed concurrently using Charmaz’s two-stage coding strategy. Trustworthiness was supported by a clear audit trail and a coding frame developed with input from a team of researchers.
Results
The final sample comprised 41 adults with diverse physical and/or mental health conditions, many with multi-morbidity. Over 50% were living with chronic pain, and over 40% had been practising mindfulness for more than two years. Participants reported predominantly positive experiences, almost all identifying significant changes in thinking and behaviour. Many had integrated mindfulness into how they managed their condition and, for a significant minority, it also provided short term relief of pain and other symptoms. A core process of ‘Starting where I am’ was formulated, highlighting how people became more aware and accepting of their condition and thus able to self-care more effectively. The process was encapsulated in five themes: Getting a new perspective; Feeling equipped to cope; Doing life differently; Seeing a change; and Finding mindfulness difficult. Strong resonances were identified between participants’ experiences and the process of transition through which people come to terms with challenging life events.
Conclusion
Living with a long-term condition such as chronic pain presents significant challenges to people, both in practical terms and in its impact on their identity and wellbeing. The results of this study suggest that mindfulness can be conceptualised as a facilitator of transition, enabling some people to adapt to these challenges more effectively. Transition is associated with improved, self-directed self-management, which was evident in many participants’ accounts, and is significant to patients, carers and healthcare providers. This study provides new insights into the long-term value of mindfulness in enabling people to become skilled and responsive in managing their health condition.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Axial Spondyloarthritis (AxSpA) is a chronic inflammatory disease predominantly affecting the spine, causing back pain and stiffness. A significant issue for the treatment of AxSpA in the UK is the management of pain and stiffness both before and after diagnosis. For people with AxSpA, an often lengthy delay in diagnosis (Sykes et al., 2015) can lead to poor pain management. This delay is partly due to the difficulties that health care professionals experience in identifying inflammatory back pain (Mansour et al., 2007). Previous research has shown that up to 40% of 276 AxSpA patients attending a tertiary care rheumatology service had used at least one form of complementary and alternative medicine (CAM) therapy prior to diagnosis to manage their symptoms (Sengupta et al., 2014). It is not yet known which therapies or aspects of CAM therapies people with AxSpA find most beneficial in managing their pain and why.
Aims
This study aimed to further understand CAM use by people with AxSpA through exploration of their views and experiences of using CAM therapies to manage their pain and other symptoms.
Methods
Ethical approval was received from the Department of Psychology Research Ethics Committee at Bath Spa University. Eight individuals (5 female) with a diagnosis of AxSpA, were recruited to take part in the study through a public engagement event and/or completion of a previous online survey. The study involved a semi-structured telephone interview. Interview data was transcribed verbatim and analysed using thematic analysis (Braun & Clarke, 2006) to identify initial codes and subsequent themes to represent participant experiences.
Results
Participants reported using a range of CAM therapies (e.g. hydrotherapy and acupuncture). Two themes were identified: (1) ’a pain in the neck’; where participants’ narratives highlighted that symptoms appear in painful bouts and flares, that diagnosis is prolonged and that they have become experts on their own bodies, and (2) ‘suck it and see’; that CAM is generally a positive experience, despite many difficulties and concerns that some therapies might make things worse. Participants made many distinctions between CAM and mainstream care, but suggested that an integrative approach may be best for pain management, particularly to enable them to access therapies that greatly reduced their pain and reliance on pain medication (e.g. hydrotherapy) on the NHS. AxSpA symptoms vary greatly throughout the patients’ journey and a client-led approach appears to be optimal for pain management, as without this, patients feel they are not being listened to.
Conclusion
This study explored the use of CAM therapies as symptom management, prior to and after receiving a diagnosis of AxSpA. CAM therapies provide useful pain relief for patients with AxSpA. This may be improved with greater accessibility to CAM therapies through the NHS and healthcare providers. The usefulness of CAM in supporting AxSpA individuals in pain symptom management should be better acknowledged and could be implemented into an integrative approach to empower patients to manage their pain in addition to mainstream care. Future research could usefully explore CAM practitioner’s experiences of treating symptoms of pain in individuals with AxSpA.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The physiotherapy sessions on a PMP aim to help those living with chronic pain develop skills and knowledge enabling them to engage in key components of rehabilitation such as increased movement and maximisation of physical function (BPS Guidelines for PMP’s for adults, 2013). These guidelines recommend that PMPs should continue to refine their method and processes as an ongoing concern.
At the Walton Centre, Liverpool, it was noted despite statistically significant improvements (Twiddy, PMP Audit 2014/16) in various measures of physical function, patients were not necessarily enabled to move better. Frequently, antalgic movement patterns prevailed over normal movement (NM) patterns. To address this, two NM exercise sessions were introduced onto our 16 day (100+ hours) PMP. Within these sessions, NM patterns such as sit to stand are deconstructed into components which are then practiced before reconstructing them into their whole, with the aim of normalising and improving function.
Aims
To evaluate patient perceived impact of normal movement sessions, thereby gaining insight into the value of its inclusion and allowing evaluation of our delivery to date.
Methods
A 10 question questionnaire using a mix of quantitative and qualitative statements was designed and then provided to patients once both NM sessions had been completed. 5 point likert scale questions were used to measure: satisfaction, understanding of rationale, perceived relevance to living with chronic pain, value of sessions, ability to pace, enjoyment and plans for future use. Patients were also given the opportunity to provide associated qualitative responses.
Questionnaires were collected over 4 cycles of the programme.
Results
43 anonymised questionnaires were issued and returned.
93% agreed or strongly agreed that NM principles were relevant to the management of their chronic pain.
98% agreed or strongly agreed that the NM sessions were a valuable component of our PMP.
85% agreed or strongly agreed that practice of NM will enable better function in daily life.
84% agreed or strongly agreed they were able to pace effectively and respect their pain levels when practicing normal movements.
98% agreed or strongly agreed they plan to regularly use NM exercises as part of their independent pain management beyond our programme. 58% of this group reported intention to use on a daily basis.
Common themes that emerged from the qualitative feedback were:
development of better movement
ability to use in daily life
plans for continued use
Conclusion
Results demonstrate patients value the inclusion of NM exercise sessions and they state intent to continue regular use beyond our programme, envisaging improved physical function as a result.
These results strongly suggest that the inclusion of NM sessions is a valuable addition to our PMP.
Although patients reported a strong intention to continue NM principles and practice, currently we have no measure of practice beyond the PMP and no objective measures of changes in quality of movement. This is likely to guide the direction of future research, which could enable further development of both session content and delivery.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Temporomandibular Disorders (TMD) are extremely common, with myofascial pain representing the largest subgroup, accounting for up to 96% of patient cases. (1)
In recent years, there has been a shift in the management of TMDs with greater emphasis on identification of patients’ opinions and attitudes towards their diagnosis and management. (2) Expectations are considered an important psychological factor that can influence treatment outcomes, patients’ compliance to treatment, as well as satisfaction. (3)
As part of our management of myofascial pain in Guy’s Oral Surgery Department, we have developed an interactive group session to deliver education and conservative advice, which are key management strategies for TMD. Feedback questionnaires are used before and after each session to evaluate patient satisfaction, capture attitudes and expectations regarding their myofascial pain.
Continuously obtaining patient feedback has allowed us to develop a dynamic care pathway to meet the patients’ needs, priorities and expectations.
Aims
To identify patients’ expectations of treatment.
To discuss how these can potentially influence the patients’ experiences as they undergo treatment.
To discuss how awareness of patients’ expectations can affect the clinician’s approach in delivering care to this patient group.
Methods
Since April 2015, patients with myofascial TMD have been managed in an interactive group education session. All patients are required to have attended an initial oral surgery consultant clinic, where a clear working diagnosis is made and an explanation given. If a bite-raising-appliances is indicated, the impressions are taken at the initial consultation for fitting at the group session.
Feedback questionnaires are used before and after each session in order to evaluate patient satisfaction and capture their attitudes and expectations regarding their myofascial jaw pain. There is a specific section for recording expectations of treatment and all patients are encouraged to complete this prior to starting the clinic. Following the interactive sessions patients are asked to record whether their expectations have been met.
Written informed consent is obtained for each patient to approve the use of these results and comments.
Results
115 patients attended between April 2015 and November 2016 and a total of 252 expectations recorded. A summary of the patients’ expressed desired outcomes is as follows:
The most frequently desired outcome was to gain advice on “how to better manage, eliminate or prevent the pain from getting worse ” (112/252, 44%)
In addition “gaining reassurance, more information and understanding about the jaw structure, jaw pain and elements associated with jaw disorders” was the second most common expectation (67/252, 27%)
Approximately 20% (48/252) of the patients’ expectations were related to “receiving the mouthguard” and “understanding its use in management”
Information on “management strategies (physical, medical, psycho-social)” accounted for 8% of expectations (20/252)
The remaining priorities were associated with “restoration of normal jaw function”, “rebuilding confidence” and “meeting others with similar pain” (5/252, 2%)
Following the group session 96% of these expectations were met.
Conclusion
Establishing patients’ priorities before commencing management of myofascial TMD pain enables the clinician to target their treatment, as it encourages consideration of the full range of relevant issues.
Tailoring care-pathways to address these expectations, leads to high patient satisfaction. It allows management to be based on patients’ own priorities rather than on what the clinician perceives to be important.
Our interactive group session provides a clinical setting in which patients’ expectations can be identified, recorded and addressed as part of their management strategy.
Further research is required to improve understanding of the impact patients’ expectations have on the treatment.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
An estimated one in ten women of reproductive age experience endometriosis (Rogers et al, 2009). The symptoms range from mild to severe, and include pain, infertility, and bladder and bowel issues. Multidisciplinary treatment, which may include surgery, medical management and/or therapeutic interventions such as cognitive-behavioural therapy, is increasingly seen as the most effective pathway for endometriosis patients (e.g. Cambitzi & Nagaratnam, 2013).
A small minority of women with endometriosis-related pain syndrome will reach the pain clinic. Studies estimate that approximately one-third of female patients with chronic pelvic pain (CPP) have a diagnosis of endometriosis (e.g. Guo & Wang, 2006). Pain management programmes (PMPs) are a well-established intervention for those with all types of pain, and as such may be an appropriate treatment for endometriosis. There is currently a lack of evidence for efficacy of PMP-based treatments for women with endometriosis.
Aims
Our service offers a specialist multidisciplinary PMP for patients with CPP known as ‘Link’. Seventeen percent of the 318 female patients who have completed Link have a diagnosis of endometriosis-related pain syndrome. We sought to determine efficacy of a CPP PMP specifically for women with endometriosis.
Methods
Clinical outcome data were collected from 55 patients who completed Link from September 2009 to September 2016. All patients had a diagnosis of endometriosis-related pain syndrome and were referred internally by a pain consultant or clinical nurse specialist. Mean age was 38 years old with mean pain duration of 12 years.
All outcomes were collected pre- and post-treatment, at one-month follow-up and at 12 month follow-up, using validated self-report questionnaires and a test of physical performance. Percentage change and pre-post effect sizes were analysed using Cohen’s d. Minimum benchmarks for effective treatment effect sizes (Cohen’s d) for pain experience (d=0.41); cognitive appraisal and coping (d=0.08), emotional functioning (d =0.27), pain behaviour in terms of health care use (d=0.32) and physical performance (d=0.29) were derived from Fenton & Morley (2013). Calculated Cohen’s d values that exceed these minimum benchmarks suggest clinically effective outcomes for Link.
Results
Link outcomes showed that patient pain severity exceeded the benchmark with reported reductions of 17% at post- (d=0.64), 20% at one month (d=0.79) and 30% at 12 month follow-up (d= 0.57). There were consistent increases of between 32-35% for self-efficacy at post- (d=0.57), one month (d=0.88) and 12 month follow-up (d=0.63). Similar findings were reported for emotional functioning with improvements between 24-32%, which exceeded the benchmark at post- (d=0.74), one month (d=0.88) and 12 month follow up (d=0.63). Physical functioning showed the largest percentage change by 85% at post- (d=0.63) which remained above benchmark at one (23%; d=0.53) and 12 month follow up (33%; d=0.45). GP pain-related visits reduced by 35% at post- (d=0.35) and 12 month follow-up (d=0.31) but not at one month.
Conclusion
The outcomes show that a CPP-specific PMP yields clinically significant outcomes for women with endometriosis. This suggests that multidisciplinary pain management work is a helpful intervention for endometriosis-related pain syndrome, either alongside, following or instead of standard gynaecological interventions. Pain management is potentially a valuable tool for women to help them to cope well with one of the main symptoms of endometriosis, and we hope that the study outcomes will help to facilitate referrals to a pain clinic.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic Pain is often very debilitating, dramatically affecting all aspects of people’s lives and society around them, yet medical interventions aimed at pain relief are often ineffective. There is some evidence to support the use of multidisciplinary interventions which aim to improve self-efficacy and quality of life and reduce distress for patients with chronic pain who have severe and complex difficulties. The degree to which patients with neuropathic and non-neuropathic pain conditions differentially benefit from multidisciplinary interventions remains largely unexplored.
Aims
The objectives of the study were to assess the prevalence of neuropathic pain (NP) in a cohort of patients attending a pain management programme (PMP) and evaluate the effectiveness of the PMP in patients with neuropathic and non-neuropathic pain conditions.
Methods
This study used assessment and outcome data routinely collected from patients participating in a PMP by the clinical team as part of the treatment process. The PMP was delivered by Health Professionals specialising in pain management; Physiotherapists, Clinical Psychologists, Occupational Therapists and Nurse Specialists. The programme consisted of psycho-educational sessions administered within a cognitive behaviour therapy (CBT) framework intended to identify and change negative thought patterns and beliefs about pain, and included an exercise programme to restore and maintain fitness, strength and flexibility. The group-based programme was undertaken intensively all day for 13.5 days in 3 weeks and data collected over 6 years. Patients completed the PainDETECT questionnaire at an initial assessment to determine their NP status. Effectiveness of the programme was measured via standardised questionnaires relating to pain experience, psychological and physical functioning at initial assessment (before the PMP), on completion of the PMP and at a 4-month follow-up.
Results
Data was available for 327 (71.9%) of 455 patients with chronic pain who attended the PMP during the study period. The mean age of the sample was 48.9 years (range=20-83), and the majority (70.4%) were female. There was a high prevalence of NP in the PMP cohort; 60.9% of patients scored in the ‘neuropathic component is likely’ range on the PainDETECT and 22.3% scored in the ‘unclear’ range. Patients indicating ‘likely NP’ had more severe pain, and elevated depression and disability levels at assessment compared with patients without NP. Patients both with and without NP made significant improvements in pain experience and physical function over the course of the PMP, and these were largely maintained at follow-up. However, compared with patients without NP (after accounting for pre-treatment differences), ‘likely NP’ and/or ‘unclear’ patients evidenced lower self-efficacy at both post-treatment and follow-up and higher anxiety and disability levels at post-treatment.
Conclusion
This study indicates that many patients attending PMP interventions are likely to have neuropathic elements to their chronic pain condition and these patients are more functionally impaired across a range of domains. While PMPs offer improvements in pain experience (reduction) and physical function for both patients with and without NP, patients with NP appear to benefit less when considering psychological well-being and decreased pain-related disability. This suggests a need for adaptation of PMPs to better accommodate the psychological needs of patients with NP attending CBT-based multidisciplinary PMPs.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
An estimated 15% of the adult population in the UK have CP impacting on their quality of life.
Opioid medication is a mainstay of treatment, with prescription rates increasing in recent years. Although opioids can be very effective in the short term they have little effect on CP. In the long term opioids may lose their pain relieving effects completely; or even cause a paradoxical increase in pain. There are concerns about the adverse health impact of strong opioids, with approximately 50% experiencing side effects such as constipation, sleep disturbance, reduced mental capacity, fractures and risk of death.
There is a need to target opioid use to reduce the risk of side effects and potentially improve quality of life of patients with CP. Offering patients a structured approach to managing opioid reduction maybe a safe and effective way to address this major healthcare problem.
Aims
To investigate whether patients can reduce opioid medication in a tapered withdrawal with support from a MDT community pain service.
Methods
Following MDT assessment patients agreed to reducing their opioid intake with clinical nurse specialist (CNS) and bio-psychosocial support.
Patients were seen initially face-to-face by a CNS to agree a structured reduction of their opioid medication. A detailed plan was sent to the patients’ GP to facilitate this. GPs were asked to prescribe medication in doses that enabled small incremental reductions. The CNS managed the reduction via face-to-face appointment and telephone reviews.
The target reduction rate was set at 10% per week for the first 70% of the original dose followed by 10% per week of the remaining dose until reaching 10mg daily (morphine equivalent), then discontinued.
Depending on withdrawal side effects some patients’ reductions were slowed to enable recovery from withdrawal symptoms prior to further reductions.
Results
Twenty patients (16 female), average age 47 years (range 28-81) with CP (>3months) were referred to a community pain clinic for medication management. Of the 22 patients who expressed an interest in discontinuing their opioid based medication 17 were able to discontinue it, 3 were able to substantially reduce,1 stopped and re-started and 1 withdrew from the process without reducing. The average starting dose was 146mg (morphine equivalent) per day (range 40mg to 545mg). The average time to stop was 5 months (range 2-13 months). The initial dose of opioid medication was a contributing factor to the time taken for withdrawal.
Patient comments following their reduction on subsequent follow-up include:
“Thank you for giving me my short term memory back”
“My family have noticed that I am becoming more active and interested in things around me”
“I am awake and out of bed at 8 o’clock on a morning where previously I struggled to get out of bed before lunchtime”
“My pain is no worse than when I was taking the morphine”
Conclusion
This service evaluation shows that patients with CP are able to reduce their opioid intake if done in a structured supported way. Factors effecting the time taken to reduce were the starting dose and side effects associated with withdrawal. More research is required to establish if reduction in opioid medication can be maintained in the long term and to evaluate the cost effectiveness of this service.
physiotherapy for all patients. Of importance, within the ETMI arm, patients with depression improves as much as those without depression, but in physiotherapy as-usual, depressed patients had significantly worse outcomes.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic pain is a major health problem associated with multiple psychological challenges. Mindfulness has been described as “reperceiving”, which permits self-regulation of attention in a non-reactive manner; it has also been associated with various improvements, including pain experience, distress and disability. Mindfulness programmes have found significant improvements in pain intensity, psychological symptoms, coping ability, and participation in daily activities. However, high drop-out rates, potentially reflect unwillingness to participate or the impact of the patients’ condition are also common. Within a UK Jersey-based pain centre offering intensive multidisciplinary pain management programmes, the pilot of a Breathworks Mindfulness for Health (MfH), was piloted to establishing the potential contribution to the use of resources, outcomes and patients’ experience.
Aims
By piloting a direct selection and subsequently introducing a self-selection process, this study aimed to:
Track differences in attendance and outcomes, when comparing direct selection and self-selection groups;
Evaluate the benefit of MfH for managing pain experience, interference and distress, and worthwhile differences between the two Cohorts.
Methods
A continuous sample of chronic pain patients (N=57) were allocated or signed-up to an 8-week (2.5 hours per week) MfH Breathworks Accredited courses. The participants in first three courses (‘direct selection’; DS) agreed to attend and were allocated a place. Participants in the latter three courses (‘SS) opted-in from a broader group, during a pre-requisite taster session with explicit presentation of course requirements, required reading and required home-practice. MfH courses were co-facilitated by one consultant clinical psychologist and one pain specialist nurse. Subjective and standardised data was collected at baseline and at the end of treatment and analysed utilising database and statistical analysis packages.
Results
The three DS groups (n=15) reported 100%, 29% and 71% retention respectively. The three SS groups (n=24) all had 85% retention.
DS groups reported significant improvement in pain interference (p= <.001), quality of life (p= <.001) and self-compassion (p= <.001). SS groups reported improvements in resilience (p=.001), intensity (p=0.29), interference (p= <.001), chronic pain acceptance (p= <.001), depression (p=.001), mindfulness (p=.001), and pain catastrophizing (p= <.001).
Subjective reports with a Visual Analogue Scale (possible range = -100% to + 100%), showed improvements in pain intensity, interference and resilience respectively (DS, M= 8%, 22% and 24%; SS, M = 30%, 32% and 40%). However, there was a trend for greater improvement in the SS group and, whilst the range of change for the DS group included cases of clinical significant deterioration in intensity and resilience, this was not the case for the SS group.
Conclusion
It appears that a pilot to implement a mindfulness intervention specifically designed for pain and long term difficulties, had twofold benefits: firstly, it allowed to improve the initial communication, engagement and thus the consistency of retention of the patient group. Secondly, it also improved statistical significance when improving communication of expectations, thus self-selection for the package. Additional potential mediators and confounders of the observed change are discussed as are findings around less expected reductions in pain intensity and catastrophizing.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Explain Pain education aims to inform patients with chronic pain about pain neurophysiology and the biopsychosocial model of pain management. Explain Pain purports to work by aiding pain reconceptualisation; that is to impart the knowledge chronic pain is maintained by sensitisation of the nervous system rather than being faithful representation of tissue damage and that psychosocial factors can modulate pain perception. A growing body of evidence supports its’ effectiveness.
All patients referred for therapy within our service are invited to attend Explain Pain. In 2015 our service was commissioned to provide a pain service at 2 Community Hospitals within our region.
Therefore, we aimed to deliver Explain Pain at these setting. Explain Pain is delivered to groups of patients with chronic musculoskeletal pain (CMP) by experienced therapists with training in pain neurophysiology. Sessions last 2 hours and are supported by Power-Point slides and visual aids.
Aims
To investigate if Explain Pain delivered in community settings can improve patients’ knowledge of the neurophysiology of pain and evaluate patient satisfaction with the service.
Methods
Sixty-six participants (41 female), with average age 51 years (Range 20-78 years) with CP (>3months duration) were referred to Explain Pain in one of two community settings between 01-11-12 and 30-09-16.
Explain Pain sessions (2hr duration) were delivered by senior physiotherapists with over 5 number of years delivering Explain Pain material to pain patients and post graduate training in pain-neurophysiology education. The average patient group size was 5 (range 2-8) Sessions had a set format supported by Power-Point slides and visual-aids.
The primary outcome measure was the Neurophysiology of Pain Questionnaire (NPPQ), a 19-item questionnaire/quiz on pain neurophysiology completed pre and post intervention. Participants respond by answering; true, false or unsure to all items.
The secondary outcome was patient satisfaction, collected using a questionnaire with 7 items assessing satisfaction with the; therapist, material, facilities etc. and was completed post intervention. Agreement was rated on a 5-point Likert scale; excellent – poor.
Results
Of the 66 participants attending Explain Pain 56 (36 female) completed pre and post NPPQ and 58 participants completed the Patient Satisfaction Questionnaire (38 female). Reasons for not completing included; literacy or vision issues (3) or time constraints (7).
The mean pre and post NPPQ score was 7.8 (SD 3.3 (n=56)) and 12.3 (SD 2.6 n=56)) respectively, with a mean improvement of 4.5 (95% CI 3.7 to 5.3) p<0.001).
Regarding patient satisfaction, over 93% of participants rated each item as ether excellent or good
Comments provided in the free text section of the patient satisfaction questionnaire included:
“I was really unsure about today but it was outstanding. Really well presented”
“Pain explained in an easy to understand wording and diagram”
“Easy to understand very helpful in understanding pain not always being physical”
Conclusion
This study found that following Explain Pain delivered within a community setting patients have significantly improved knowledge of pain neurophysiology and they have high levels of satisfaction with the service. Our work has the following limitations; the lack of control group as well as the involvement of the therapist in data collection/analysis. Further work is needed to establish if these improvements are maintained over time. Additionally, the clinical impact of the Education needs to be investigated within this setting.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The Highlands of Scotland has only had a pain management service for the last six years and has a catchment area that covers 32,518km², of rugged coastline, remote countryside and many small islands with an adult population of 254,634 of which 19% suffer chronic pain. Due to the difficult terrain, distances involved, and limited transport our initial consultations are held by telephone and audits presented at previous Pain Conferences have demonstrated their efficacy and an extremely high level of patient satisfaction.
We have consistently struggled with managing patients expectations of the service due to poorly informed patients by GP’s and consultants.
Aims
The aim of introducing an ‘Introduction to Pain Management’ session prior to their initial telephone consultation was to correct misconceptions, decrease DNA rates and start to educate patients on the importance of self management from the very beginning de-emphasising the medical model.
Methods
Sessions were set up in Wick, Fort William and Inverness covering various aspects of the service and treatments offered. All patients who attended were then provided with the date and time of their initial telephone consultation and those who failed to attend were sent a letter asking them to ring in if they wish to receive another appointment.
Satisfaction questionnaires were given to patients attending.
Results
354 patients were booked within the audit period and satisfaction questionnaires were obtained from 200 patients identifying
Whether the class was useful and which aspects were most useful
Patients expectations
Whether there were any changes they would instigate having attended the class
Outcomes for the patients who had failed to attend the class were identified as some of these had very valid reasons for being unable to attend the class going straight to telephone consultation. Overall DNA rate was very low at 5%.
Conclusion
The introduction of a pain management education session has been well received by both patients and the staff involved with undertaking telephone triage appointments. This has decreased our DNA rate for initial telephone consultations but more importantly has encouraged patients to look more at acceptance and the importance of long term pain management strategies right from the beginning with less emphasis on the medical model.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The Pain Management Service in The Highlands of Scotland had been running an eleven week pain management programme (PMP) with a three month review since the service was set up six years ago. It has a catchment area that covers 32,518km², of rugged coastline, remote countryside and many small islands with an adult population of 254,634 of which 19% suffer chronic pain. The programme takes place in Inverness and a previous audit had demonstrated that patients found it difficult to attend due to a variety of reasons resulting in poor take up of places, high dropout rates and sporadic attendance.
Aims
By introducing an introductory session and making alterations to the way the programme was accessed and structured we aimed to decrease waiting times, improve attendance and make learning pain management techniques available to a wider cohort of patients.
Methods
All patients identified as being suitable for a pain management programme were provided with an appointment for an introductory session which covered a variety of topics around pain management with discussion around both their expectations of a PMP and ours. Alongside this the programme was completely rewritten and condensed into six weeks with a three month review. Outcome measures were kept the same to allow comparison.
Results
Ten introductory classes have now taken place involving 117 patients. Take up for the programme has been excellent with a small proportion of patients transferring to the pain management plan (delivery of pain management utilising a workbook and telephone support). Those that failed to attend were sent letters asking them to ring in if another appointment was required but take up of this was low though some did ring in to say they no longer required this treatment.
Satisfaction questionnaires were obtained from 86 patients identifying whether they had found the session helpful, which topics had been of most use and how likely they were to attend a programme.
So far we have run 5 PMP’s successfully filling the majority of places. Attendance rates have been excellent and outcomes so far have been comparable or slightly better than those from the longer programme.
Conclusion
Patient’s satisfaction with the introductory session has been high and figures show that utilisation of the PMP has improved with attendance rates greatly increased. There appears to have been no negative impact due to the decreased number of hours in terms of outcomes though numbers for comparison at three months are presently quite small.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
People aged 65 and over are the fastest growing segment of the population in the UK and chronic disease occurs far more commonly in older people than in any other age group. Chronic pain is known to impair quality of life and affect wellbeing. Studies of older people have tried to establish prevalence of chronic pain, the physiological effect of ageing on pain and associated polypharmacology of co morbidities of the ageing body. To understand and support the needs of the ageing population with chronic pain, it is important to consider the multidimensional effect of chronic pain on older people’s lives from their personal account.
Aims
To conduct a critical narrative review of the literature regarding the lived experiences of older people affected by chronic pain. To establish, from the older person’s narrative account, the experience of chronic pain, and to describe the presented sequelae of chronic pain on older people’s psychological, spiritual and social well-being.
Methods
A search was undertaken utilising the Cochrane Database of Systematic Reviews, Medline, Embase, PsychINFO and CINAHL for primary research papers published between 2006 and October 2016. The search terms ‘Chronic Pain’, Older People’ ‘Experience’, associated MESH terms were applied. Experience was defined as the personal expression or account of older people, and related to studies of people who were able to freely communicate their experience of living with non-cancer pain. From the search, 287 papers were identified and were assessed against inclusion criteria. Retrieved papers were hand-searched and assessed for suitability and methodological quality. Due to the heterogeneous nature of the identified research, a narrative synthesis and thematic approach was taken to analysis.
Results
There is limited research relating the narrative experience or story of living with chronic pain in old age. The review only identified nine studies, including a range of qualitative methods. The studies were of older people in residential care, supervised living or living independently at home. Commonly occurring themes, noting the effects of chronic pain, included sleep disruption, effects on mobility, constrained daily activities, loneliness, depression and other existential effects. The negative effects of chronic pain were compounded with loss of independence, isolation and limited opportunities for social interaction.
Conclusion
From the findings of this review it is difficult to make generalisations; older people are not homogeneous and each person’s pain is individual which generates personal consequences. The experience of living with chronic pain is difficult to extract from the physical and social context of being old, possibly dependent, isolated and experiencing other comorbitities. Nonetheless, each description of pain is no less significant because of its unique, complex and often existential nature. However, the destructive effect of older people’s experiences of chronic pain must be fully understood in order to develop appropriate support and interventions in whichever context of care.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Safe, effective, quality driven Pain Management is important. Historically the In-Patient Pain Service collected data in paper format (activity, patient demographics, analgesic system and drug delivered data) to demonstrate how resources were being utilised. However, very little clinical data was captured.
The In-patient Pain Service, in collaboration with the Clinical Effectiveness Unit for the Trust, developed an electronic database, as a tool to safely store and manage patient information data and to monitor pain management strategies and patient outcomes. The database is a replica of the daily audit form the service uses in clinical practice but was redesigned to incorporate the key patient and service outcomes that could be used as a benchmark for quality improvement. The data is collected from the first patient to the last patient visit from the In-patient Pain Service.
Aims
The aim of the present study is to explore the data the In-Patients Service has collected a year after the development of the database.
Methods
Historically the In-Patient Pain Service collected activity data and limited clinical data in paper format (patient demographics; number of patients seen; number of visits and time spent; pain scores at time of visit; type of analgesic system and amount of drug used). We collected and stored paper audit forms and periodically inputted this information into a spreadsheet. However, data was often not inputted or analysed. The database includes demographic information; reason for admission; surgical or medical intervention; pain scores; psychological co-morbidities; treatment interventions pre and post pain service involvement; system based interventions for acute pain; treatment related side effects and adverse events; patient satisfaction and clinical review free text.
Routine data is collected using the audit form and data entry is performed retrospectively.
The database was piloted in order to identify any weaknesses in the design and test its usability. The project was finalised in December 2015.
Results
From December 2015 until April 2016 the In-patient Pain Service reviewed n=929 patients.
The majority of the patients were female n=572, and n=352 male (n=2 blank entries).
n=439/929 patients were admitted through one of the four hospital’s Emergency Department (ED).
whilst n=457/929 for a scheduled elective surgical procedure (n=33 blank entries).
n=682/929 patients underwent a surgical procedure.
The In-patient Pain Service reviewed n=80 patients with an epidural infusion, 291 patients with a PCA.
Tramadol was the most commonly used/recommended weak opioid (n= 96) and Oxycodone Modified Release (n=163) was the most commonly/recommended strong opioid, reflecting our enhanced recovery programmes which advocates the use of this within its pain management protocol. The most common opioid side effect was constipation (n=102).
Regarding patients’ overall satisfaction with the pain management, n= 289 were ‘Satisfied’, n=96 were ‘Completely Satisfied’, n= 34 were ‘Neither satisfied nor dissatisfied’, n= 3 were ‘dissatisfied’ (n=507 were not recorded).
Results from December 2015 to December 2016 will be presented at the time of the conference.
Conclusion
The electronic database has already been used to benchmark the quality of the care we provide related to the safe and effective discharge from hospital of patients requiring strong opioids following surgery. It has enabled us to identify the strengths and weaknesses of the acute pain management interventions used and to redesign the service to implement improvement strategies.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The use of regional blockade has significantly increased in the last 10 years. NICE guidelines for the management of hip fractures which states ‘Consider intra-operative nerve blocks for all patients undergoing surgery’ .
There are no suggested standards for documentation of regional blocks. AAGBI Core Topics in Anaesthesia (2015) states ‘detailed documentation is vital. The antiseptic solution used, type of needle, nerve localisation method, local anaesthetic solution injected (with any additives), and any paraesthesia elicited should be noted.’
Aims
To identify the proportion of patients undergoing fractured neck of femur surgery who receive regional nerve blockade (either central neuraxial or peripheral nerve blockade) and to audit the documentation of theses blocks with reference to the above standards.
Methods
Through liaison with the hospital trauma sister and by use of the electronic patient records system all patients (58) receiving operative intervention for fractured neck of femur (NOF) over a 3 month period were identified and a retrospective review of the notes was undertaken.
Results
40/58 (69%) of procedures involved regional anaesthesia.
33 peripheral nerve blocks were carried out comprising of 27 Fascia Iliaca blocks, four Femoral nerve blocks and two 3in1 blocks.
32 (97%) documented the drugs and dose/volume injected.
32 (97%) documented the nerve localisation method.
24 (73%) documented ‘asepsis’ but only 9 (27%) documented type of skin preparation.
18 (55%) documented needle type.
20 (61%) documented ease/difficulties.
Of note 61% of people documented the side the block was carried out on and no-one documented the position the patient was in for the block.
Only 2/33 (6%) documented all 5 domains.
11/58 (19%) received a subarachnoid block.
All documented the drugs and dose/volume injected
10 (91%) documented interspace used
10 (91%) documented ‘asepsis’ but only 7 (64%) documented the type of skin preparation.
9 (82%) documented needle type.
8 (73%) documented ease/difficulties.
Conclusion
More than two-thirds of our anaesthetics for fractured neck of femur involve some form of regional anaesthesia. We are better at documenting neuraxial blocks than we are peripheral nerve blocks although there are still some areas which could be improved upon. For peripheral nerve blocks we have designed and are implementing a sticker ‘aide memoire’ which can be used on the anaesthetic chart. We are also exploring the possibility of setting up a block room as part of a wider quality improvement project to try and increase the amount and quality of regional anaesthesia we perform.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Frimley Health is integrating the two chronic pain services, historically at Frimley Park Hospital and Wexham Park and Heatherwood Hospitals, into one service. High quality care standards are expected from each area as it becomes a single service over multiple clinical sites. Pain clinic consultations offer the perfect opportunity to communicate with our patients and introduce them to our multidisciplinary team approach.
As described in Core Standards for Pain Management Services in the UK (2015), patients arriving at pain services have complex care needs. Clear, responsive and compassionate communication between clinician and patient is a strong determinant of levels of patient engagement and satisfaction with the service and, as a result, will typically have a strong influence on treatment outcomes. Clinicians can empower patients in learning to manage their own pain by clearly communicating treatment options – including risks and benefits.
Aims
To gain insight into patients’ perceptions of their pain clinic consultation with a variety of clinicians: doctor, nurse, physiotherapist and psychologist.
To gauge patient satisfaction.
To inform service improvement.
To provide feedback to clinicians from their patients for them to reflect on and incorporate into their personal development plans.
Methods
A 12 question single sheet questionnaire was designed by the pain clinicians and clinical audit facilitator. 170, questionnaires together with a pre-paid return envelope addressed to the Clinical Audit Department, were handed out by the clinic nurses or receptionists during June and July 2016. Patients either completed the questionnaire whilst on site and handed it to clinic staff, or completed afterwards and posted it back. Clinics were held at five sites across the Trust and conducted by 17 multidisciplinary clinicians seeing new and follow up patients.
Data from completed questionnaires was entered onto an MS Excel spread sheet for analysis, compared with previous audit data from 2005 and reported in MS Word.
Individual feedback to clinicians was provided in confidence ( delete to) by the clinical audit facilitator. Free text comments from patients were anonymised for the general report.
The audit results were fed back to the pain service.
Results
N=119. Response rate 70%. 94% satisfied/very satisfied (86% 2005), 2% dissatisfied (6% 2005). 98% had enough time and were able to ask questions. 95% understood answers, with 97% understanding explanations. 93% agreed with plan suggested and 97% understood what they needed to do next. Positive comments: ‘Felt very listened to - thank you’. ‘First person to explain my pain to me and care for me.’ ‘Very informative, helpful and kind’. Less positive highlighted parking and clinician lateness. Comments: ‘Collect more accurate information on the patients and to listen to them before changing their pain management programme’ and ‘Letters he sends clearly shows that he is not accurate or listening to them’ demonstrate the need for excellent communication skills and giving accurate feedback. All patients get copies of the clinic letters which previous audits show they are generally very happy with. We continue to work to improve parking/accessibility.
Conclusion
The management of pain is challenging for everyone involved, whether healthcare professional, patient or carer. Effective pain management for most patients will require a collaborative approach where the patient is informed, listened to and actively involved, to the extent that they wish, in decision making. This audit demonstrated that most of our patients find pain clinics easy to get to and are satisfied or very satisfied with their care but that we need to take care to explain pain and its treatment carefully, allowing our patients time to ask questions and reflect on the answers.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Complex Regional Pain Syndrome (CRPS) is a severe debilitating pain syndrome. Pain is usually the leading symptom but there is often associated limb dysfunction and psychological distress. We have been treating CRPS patients for a number of years both as acute referrals from the hand trauma service and as referrals from other pain services for tertiary care. The treatment pathway for CRPS at our hospital offers a multidisciplinary team approach including early specialist physiotherapy, psychology input, medicines management and appropriate interventions where indicated. When offered, interventions run as a series of three of the same procedure, once a week over a three week period.
Aims
To identify our local demographic and complexity of CRPS cases, and to determine if particular interventional treatments have been of benefit.
Methods
Inclusion criteria - diagnosis of CRPS & booked for a procedure/intervention.
Through interrogation of CERNER/CRS, electronic discharge letters and a paper based booking system we identified 30 patients between January 2010 and October 2015 who potentially filled criteria. Following review of their notes, 7 of these patents were excluded (five did not have CRPS, 1 died prior to procedure, 1 refused all treatment including physiotherapy).
For the remaining 23 patients, we carried out a retrospective case notes review. Improvement was accepted as increase in function, decrease in medications and changes in the physical properties of the limb lasting >1year/ongoing).
Results
10/23 (43%) had CRPS present for <1year at time of being seen. 9 (90%) reported almost full resolution of symptoms - 2 with physiotherapy alone, 4 with 1 cycle of intervention, 3 needed 3+ cycles of intervention.
13/23 (57%) had longstanding CRPS (present > 1year: range 13m - 20y). 7(54%) have had good lasting improvement in symptoms. 3 (23%) had short lived improvement in symptoms and 3 (23%) had no symptomatic change.
6 patients had IV Regional Blockade alone, all with lasting improvement.
5 patients had sympathetic nerve blocks alone, 4 had no real lasting improvement.
1 patient had IV pamidronate alone and had lasting improvement in symptoms.
4 patients had sympathetic nerve block plus IV pamidronate, all have shown marked improvement and almost full resolution of symptoms.
5 people had multiple interventions with improvement only being seen in the 2 patients who received IV pamidronate.
Conclusion
Our hospital sees a spectrum of CRPS cases with over 50% being longstanding CRPS. Over the last 5 years we have offered a range of interventional procedures alongside CRPS specific physiotherapy and psychology. We have noticed a benefit from using IV pamidronate, with all patients receiving this showing significant improvement, even in our longstanding CRPS cohort. For patients with early CRPS we saw a large benefit from IV regional blockade using guanethidine, however patients often required multiple courses before having sustained symptomatic and functional improvement.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Alkaptonuria (AKU) is a rare autosomal recessive condition that leads to accumulation of homogentisic acid. This causes onchronotic pigment deposition at connective tissues which leads to the characteristic features of AKU including spondylo-arthropathy and pigmented skin. Joint pain begins at approximately 30 years and is managed using conventional pain control measures with only partial effectiveness. In 2012, the National Alkaptonuria Centre (NAC) was opened at Royal Liverpool University Hospital with the aim of providing annual assessments of AKU patients including review and management by a specialist pain team in addition to access to nitisinone, an unlicensed disease modifying therapy, as part of an international drug trial.
Aims
This descriptive study aims to outline the tertiary centre approach to the management of chronic pain in patients with alkaptonuria. The objective is to describe the patient demographic, the frequency of chronic pain and its characteristics.
Methods
Patients reviewed by the pain specialist team at the NAC between March 2014 and November 2016 were included in this descriptive study. Inclusion criteria were as follows: age >16 year with a confirmed diagnosis of AKU and GP referral to the NAC with initial assessment by the NAC consultant lead. Data was collected prospectively and analysed retrospectively. Parameters collected included the patient’s age, sex, location of pain and the management for each pain. Repeat measures were then collected at subsequent annual clinic appointments.
Results
A total of 56 patients (36 male, 20 female, median age 51 years) were included for analysis. Over 70% of patients reported moderate-severe pain (40/56). The most common type of pain identified was musculoskeletal with the most common locations on initial assessment being shoulder (33%) and lumbosacral spine (32%), knee (25%) and cervical spine (14%). Neuropathic pain was present in 12.5% of patients, the majority being greater occipital neuralgia.
Pharmacological management followed conventional strategies, with no prescriptions of opioid being used. Interventional strategies included suprascapular nerve blocks (25%), trigger point injections (18%) and greater occipital nerve blocks (11%). The effectiveness of these interventions in this subgroup varies. Suprascapular nerve blocks were particularly effective, with 65% of patients reporting excellent pain relief for at least 6 months and managing with suprascapular nerve blocks at each annual assessment. Greater occipital nerve blocks were less effective, with 50% of patients reporting pain relief.
Conclusion
The National Alkaptonuria Centre offers patients a multidisciplinary approach to a rare condition, with significant involvement of the pain team. This condition results in 70% of patients suffering from moderate-serve pain. The main subtype of pain is musculoskeletal, with suprascapular nerve blocks being particularly effective. No opioid medication was started in the patients. Further research is required to categorise differences between this subgroup of patients and the general population who suffer from chronic pain.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Facioscapulohumeral syndrome (FSHS) is the 3rd most common muscle dystrophy first described in 1886. It is an autosomal dominant disorder defined as progressive asymmetric muscular weakness typically of the face, scapular stabilizers, proximal arm and leg. However, clinical presentations may vary from asymptomatic individuals to patients who have complete loss of ambulation. Chronic pain is a frequent and likely under recognized complaint in affected individuals, with a prevalence as high as 77%. The prevalence of FSHD is approximately one in 20,000 individuals. The disorder affects men and women equally. 90% of sufferers notice some weakness prior to 20 years of age. However, FSHD can at times presents during the third or fourth decades of life. Progression is slow and steady affecting one muscle group followed by period of stability. 20% of patients end up in a wheelchair. Life expectancy is not generally compromised probably due spared cardiac and respiratory muscles.
Aims
Widespread pain remains one of the biggest challenges in pain clinics. Inspite of the wide range of differential diagnosis, it is difficult to answer this question in many occasions specially when dealing with uncommon conditions. FSHS is a rare condition difficult to diagnose unless there is enough knowledge and experience with it.
Methods
51 years old male presented 18 years ago initially with wide spread pain, started in his lower back then progressively spread to his shoulders, arms and legs. Only last year when he started to develop progressive muscle weakness affecting his face, shoulders, upper arms and legs with no speech, swallowing or breathing problems. Clinical examination revealed wide spread allodynia with no dermatomal pattern, expressionless face, muscle power of 4/5 on MRC scale in both shoulders, arms, hips flexion and extension as well as knee extension, bilateral scapular winging with anterior rotation and dropping of both shoulders as well as significant bilateral muscle wasting affecting Trapezius, Pectoralis and triceps muscles. He was diagnosed in April 2016 with FSHS based on Genetic and electrophysiological tests. Management adopted biopsychosocial model, patient education, setting realistic expectations along with Supportive and symptomatic measures.
Results
This is a case of FSHS based on genetic testing. Its uniqueness shows in being a rare condition of muscle dystrophy presented un-classically with wide spread pain for 18 years before he started to develop FSHS related muscle weakness. Having a diagnosis and understanding the nature, cause and prognosis of the disease will definitely help with adjusting patient’s expectations, involving the patient in deciding management strategies, motivating the patient to keep active to avoid consequences of disease progression and eventually, overall patient satisfaction.
As many of the widespread pain syndromes, with no curative treatment, adopting biopsychosocial model in management along with symptomatic and supportive is the best way forward and minimize disability due to disease progression.
Conclusion
FSHS is an autosomal dominant muscle dystrophy, classically presented with progressive muscle weakness. However, in this case, clinical presentation was limited to widespread pain before muscle weakness developed. This raises the concern of adding FSHS to the differential diagnosis of widespread pain which comprises significant proportion of pain clinic referrals and highlights the importance of family history in such cases.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic pain often has downstream effects including lifestyle changes and loss of independence. Thus, it is feasible that patient satisfaction would depend on both pain relief and improvements in quality of life. However, many studies report only weak to moderate correlation between pain ratings and patient satisfaction, such that some patients with minimal pain reduction still report treatment satisfaction, suggesting that pain ratings may not account for all facets of the patient experience. In this analysis, we examine the relationships between pain ratings and quality of life responses following spinal cord stimulation (SCS) to identify key factors driving patient satisfaction.
Aims
To examine the relationships between pain ratings and quality of life responses following spinal cord stimulation (SCS) to identify key factors driving patient satisfaction.
Methods
The data analyzed was obtained as part of a prospective, multi-center, global registry (RELIEF, Boston Scientific) that collects patient outcomes for SCS systems utilized on-label to treat chronic pain in routine clinical practice from patients with at least one post-implantation follow-up visit (6 months, 12 months, 24 months, or 36 months). Data was combined across a series of questionnaires (e.g. Baseline Medical History, NRS Pain Intensity, Oswestry Disability Index, EQ-5D-5L Quality of Life, Beck Depression Inventory, Resource Utilization Index, etc). Subjects with less than 20% data missing were retained for analysis (N = 319). Machine learning feature selection algorithms were used to compute the assessment (CART, Relieff, Information Gain) and develop the final model.
Results
This analysis found that while increases in pain reduction are associated with increases in patient satisfaction, roughly half of assessed subjects with > 1 NRS point pain reduction are still satisfied with SCS therapy. The analyzed data further indicates that satisfaction with paresthesia coverage as well as with comfort of stimulation, clinical global impression of change, moderate pain, and simple tasks such as usual activities and mobility were the most influential features for patient satisfaction when pain reduction is > 1 NRS point.
Conclusion
Pain reduction is an important factor for overall patient satisfaction with SCS therapy; however, nearly half of the subjects with low NRS pain reduction are still satisfied. For subjects with > 1 point NRS pain reduction, satisfaction with paresthesia coverage and comfort of
stimulation as well as improvement in the ability to perform simple tasks are the most highly related to patient satisfaction. The way these features interact with subjects’ overall satisfaction warrants future investigation.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The Encountering pain; hearing, seeing, speaking conference emerged from a three-year interdisciplinary project at UCL, Pain: speaking the threshold (PSTT), which assessed the value of images and image-making processes to the management of chronic pain. PSTT brought together a multidisciplinary team to analyse material generated during the face2face project where pain sufferers worked with an artist to co-create images of pain which were subsequently piloted by other patients in NHS clinics.
A recent article by Chu et al in BMJ 2016;354:i3883 argued patients should be more involved in medical conferences. They suggest patient involvement helps delegates understand the problems that matter most to patients and caregivers and that their collaboration aids improvements in conference creation and clinical care.
The Encountering Pain conference brought together those who live with, treat, research and/or represent pain to discuss the challenges of living with pain on an equal playing field, directly addressing Chu’s concerns.
Aims
To: bring together patients, carers, clinicians, academics and artists to share expertise; increase understanding of ways in which the arts and their methods can facilitate pain encounters and breakdown conventional hierarchies; integrate rigorous scientific presentations with creative practice based interventions; collectively generate new knowledge and disseminate to a wider audience.
Methods
The two day conference was planned for over a year by the PSTT team and key patients involved in the face2face project. There were four key note speakers from narrative medicine, pain psychology, basic pain science and history of pain. Patients presented at a plenary session and ran workshops. Abstracts on the topic were invited resulting in short presentations or posters offered alongside creative workshops in writing, movement, photography and drawing. Interventions included poetry reading, performance, dance and music. The conference ended with the screening of a new film Pain under a microscope initiating dialogue between delegates who don’t normally attend the same events. To increase access and dissemination the conference was free and a web site created and maintained. Funds were raised to cover all costs. An interactive feedback session at the end of day one and formal feedback forms enabled evaluation in addition to reviews and publications.
Results
The conference ran to capacity of 200. 98% those evaluated felt the collaboration between medicine and the humanities was valuable, 96% that they had opportunities to participate, 100% had conversations with someone they did not know, 84% that the conference made a difference to how they thought about communication of pain and 98% rated it overall as good or very good (4/5 or 5/5). Pioneer of Narrative Medicine, Rita Charon wrote “The experts in this landmark conference were the patients themselves. We came, unusually quickly, to be able to witness one another’s story and to be able to change our own concepts of patienthood and doctorhood. We broke through into a shared language of pain, finding ourselves partners across the divides of culture and power toward a state of care”. Other comments included: embracing; inspiring; thought-provoking; the interdisciplinarity was illuminating, allowing for broadening of the discourse and promoting deeper understanding.
Conclusion
The conference achieved its objectives and highlighted that patients can play a crucial and active role in designing a pain conference which also benefited from their full engagement in its delivery. This conference went beyond just involving patients but involved the humanities in a variety of different ways and as one GP wrote: embracing humanities is something which is desperately needed in pain medicine. Hearing that GPs are seen as unhelpful non-referrers just hacking away into their computers is very sad. Public awareness of pain was raised. The many calls for this approach to be repeated need to be heard.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Over 94,000 primary knee replacements are conducted each year in the UK, the majority of which are for painful osteoarthritis. While many patients experience good outcomes, around 20% of patients report chronic pain after knee replacement. After knee replacement, average pain severity plateaus at three months, with overall clinical benefit achieved by six months. However, patients with bothersome pain at three months after surgery are often disappointed with their outcome. It is now recognised that a large proportion of adults with chronic post-surgical pain (CPSP), despite having problematic and sometimes constant pain. Given the high prevalence of CPSP, there is potentially a large hidden population with unexpressed needs for care, but who are experiencing ongoing pain and disability after knee replacement.
Aims
We aim to understand why people with CPSP after knee replacement choose not to access formal NHS services. To inform the development of guidance about how best to engage people with CPSP with healthcare services we will utilise the Model of Pathways to Treatment.
Methods
The study comprises in-depth, qualitative, face-to-face interviews with people experiencing CPSP after total knee replacement who make little or no use of healthcare services. Patients are screened at two major UK orthopaedic centres. Those with an Oxford Knee Score of 0-14 who report little or no use of healthcare for their pain are invited to participate. We are purposively sampling up to 40 people with CPSP after knee replacement, aiming to achieve data saturation. Interviews explore participants’ experiences, knowledge and understanding of CPSP, use of healthcare services, and decisions about accessing healthcare. With consent, interviews are audio-recorded, transcribed and anonymised. Once imported into QSR NVivo software, data were analysed using a constant comparative approach, using in-vivo codes and the codes grouped, using inductive methods, into categories. A proportion of the transcripts were independently double-coded by another researcher, and codes discussed, agreed and applied to the data set, with ongoing refinement.
Results
Ten interviews are complete (4 men, 6 women, ages 55-93). Findings already provide key insights into use of healthcare. Participants did not seek healthcare for CPSP because they believed that nothing more could be done. If surgeons were satisfied with the participant’s knee or reassured them their pain would ‘settle’ down, then participants believed they had less reason to re-consult. Participants feared that accessing healthcare could lead to further surgery, or more prescriptions for pain relief medications, which they wished avoid. Some expressed gratitude for their knee replacement and did not wish to complain about or criticise their surgery. Others felt they were no longer deserving candidates for further treatment and thought that others were in greater need. Painful comorbidities could also take precedence over participants’ knee pain when seeking healthcare and could confound their attempts to determine whether pain was related to knee replacement or referred pain from elsewhere.
Conclusion
Our developing analysis suggests that people with CPSP after knee replacement had expectations of physical and social outcomes that contributed to their decisions not to seek further healthcare. Many believed that nothing further could be done about their ongoing pain, or that further attempts to consult for knee pain would only lead to undesirable outcomes such as further prescriptions for pain relief medication or revision surgery, or that they would be perceived as time wasting.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
This qualitative study was conducted to better understand the role of self -management in BPS guideline recommended group chronic pain programmes as delivered within a Bengali community in East London. I place the experience of living with chronic pain and the cultivation of self-management concepts within biomedical discourse in the Bengali pain management program as a paradox. I argue that participants in the program seek medical attention to remove or reduce their pain. However, in contrast to their expectations they may be told that the pain cannot be further pharmacologically or surgically managed entirely and they can then learn to self-manage, often with evidence-based medical guidelines not particular to their community and experience. Therefore, the lived experience of illness and healing as transformative is paradoxical to the chronic pain patient.
Aims
The aim of this study was to better understand the lived experience of persistent pain for our Bengali women patients who participated in our groups. By applying this knowledge, we hope in future to provide more culturally informed programs to assist the women in applying the concepts learned.
Methods
Semi-structured in-depth interviews were conducted with the Sylheti speaking participants through an interpreter, four to six weeks after completion of a Pain Management Programme. This course followed BPS guidelines and was held on a weekly basis for two hours. The group consisted of 17 by the last week. Those who had completed at least 6 sessions were invited for interviews; 10 attended. Although separate groups were held for men and woman, only women were included in this study. The programme was facilitated by a pain specialist physiotherapist and a pain specialist clinical psychologist with a female Bengali interpreter. The Brief Pain Inventory (BPI) was also collected pre-program and at the time interview. The qualitative data were hand coded for themes using a phenomenological framework to answer research questions pertaining to lived experiences of pain.
Results
In this study, the meaning of quality of life to a non- English speaking Bengali woman in London was not consistent with the concepts underlying the principles of self-management as taught in the groups. An improved sense of agency and self-empowerment was not the expectation of our participants. Rather, pain was described in the context of the family and their contribution or inability to participate. Results of the BPI were varied, however, overall did not demonstrate significant improvement. It is felt that we can better assist our patients by managing our understanding of the paradox of self-management within their experience and adapt them to be culturally appropriate.
Conclusion
The understanding of concepts of self-efficacy, acceptance, and empowerment that are promoted in the programs may not be readily accessible and understood. Rather, day-to-day life is an unavoidable need to escape pain rather than transform as encouraged in the program. Further questions are posed for patient-centered care and how this Bengali community may begin to construct meaning towards healing.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic pain affects 1 in 5 young people, causing considerable suffering, disability, disruption to family life, and failure to attain full potential. Many young people self-manage, however a significant minority require the assistance of specialist multi-disciplinary chronic pain management services. Guidelines acknowledge that the role of the Clinical Nurse Specialist in such services is ‘key’ or ‘vital’, but offer little guidance as to what their role entails. There is little empirical evidence of what constitutes effective nursing care in this setting.
Aims
To identify the role fulfilled by Clinical Nurse Specialists, in a chronic pain management service for Young People, in a tertiary London paediatric hospital, adopting a multi-dimensional perspective by seeking the views of clinic staff and service users.
Methods
The study was approved as a service evaluation by the audit department of the Hospital Trust, and ethical approval was obtained from City, University of London. A qualitative approach was adopted, and 10 semi-structured interviews with parent/young person dyads or triads, and 4 multi-disciplinary staff focus groups were conducted. Each grouping constructed images of “Who helps a Young Person with chronic pain?” using labelled tokens. Analysis was undertaken using the six-phase thematic analysis process described by Braun and Clarke (2006).
Results
Five main themes emerged from the data: “Disclosure of pain- or not?”, “Impact of chronic pain for young people”, “Families make adjustments”, “Building on family resilience” and “The role of the Clinical Nurse Specialist”.
The Clinical Nurse Specialist role was perceived as a “bridge” between the family, the specialist MDT and local services. Contact with families served to contain anxiety, build on family resilience and reinforce the multi-disciplinary team clinical message. Clinical Nurse Specialists had most contact with the mothers of Young People, perceiving them as the ‘gateway to the child“. Clinical Nurse Specialists acted as case-managers, ensuring the pain management plan for the Young Person was enacted, and demonstrated advanced nurse practice skills including prescribing, patient assessment and onward referral. Clinical Nurse Specialists were committed to pain education for patients, families and other professionals. Most Clinical Nurse Specialists felt autonomous.
Conclusion
The CNS role in this setting had evolved to meet the needs of the service users. The ‘named nurse’ system deployed, improved communication, enhanced continuity of care and was valued by families, other staff and Clinical Nurse Specialists themselves. Based on these findings a model of the CNS role in this specialist service has been hypothesised. Further study is required to explore how CNSs might better support YP and other family members.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic pain affects up to 28 million adults in the UK. Axial spine pain, arthritis and other musculoskeletal conditions account for 3 of the top 12 disabling conditions globally. Treatment of persistent pain involves a biopsychosocial approach where the goal is to improve functioning and quality of life. Limited service provision is a common obstacle to the optimal management of these conditions. Waiting times are often high and services are disjointed with inadequate communication between specialities and between primary, intermediate and secondary care. Patients with persistent pain have a very poor quality of life and other co-morbidities make clinical management more complex. A local review of chronic pain patients highlighted that a significant number make multiple attendances within secondary care over a period of years. An analysis of the top 20 highest attenders revealed 1035 attendances at a cost of £540,000 in a 5 year period.
Aims
To set up an integrated seamless service between primary, community and secondary care that achieved reduction of waiting times, early access to specialist assessments, diagnostics and high quality evidence based pain management therapies and thereby reduction in chronicity and the need for frequent referrals into secondary care.
Methods
In 2014 clinicians from the Community Trust (Berkshire Healthcare Foundation Trust), Acute Trust (Royal Berkshire Hospital), primary care physicians, commissioners and patients came together to address the problems of increasing out-patient activity for pain related conditions and the associated management. The recommendations from this group led to the development of the Integrated Pain and Spinal Service (IPASS).
The purpose of the IPASS was to:
Provide appropriate assessment/treatment earlier and to avoid delay
Offer a range of therapeutic strategies and promote self-management
Reduce secondary care attendance
The service is run by a team of specialised physiotherapists and psychologists, supported on a weekly basis by a pain consultant from the acute hospital pain service. GPs have been provided a simplified referral procedure for patients with general pain or spinal pain . IPASS will provide quicker access to early assessment and offers a much greater range of locally available biopsychosocial interventions.
Results
The service went live in September 2015. Prior to IPASS, waiting times with the pain service were more than 7–9 months for 1-to-1 physiotherapy and psychology assessments, and 6 months for a group programme. The average waiting time across multiple sites is now 3.4 weeks and 92% of patients are seen within 6 weeks.
In the first year 1200 patients have been referred to the service and more than 70% were managed within the community setting through a range of interventions such as individual psychology or physiotherapy treatment, pain education session, back programme, fibromyalgia programme, and a group pain programmes.
Pain linked multiple attendances are expected to cut by 50% each year. Feedback on the service has been very positive with patients remarking that the group sessions were very helpful in learning skills to manage pain and greatly improving confidence.
Conclusion
Since September 2015, IPASS has provided timely access to a multi-disciplinary team of specialists, delivered personalised treatment plans, and demonstrated the potential to be cost-saving when compared to current standard-of-care. The IPASS was recently awarded the Emerging Best Practice Award by the British Society for Rheumatology and a toolkit is being produced for national dissemination. It is locally been used as a model for developing MSK care.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Pain teams are often challenged when supporting patients on long term high doses of opioid medication. Patients and clinicians can both aim to reduce these harmful drugs but are both often met with barriers and providing follow up treatment in the form of medical, nursing and or psychology reviews can be difficult to plan and implement. The aim of our team’s pilot joint nursing-psychology medication reduction clinic is to explore whether this interdisciplinary approach provides patients with the skills to reduce opioid medication.
Aims
The aim of this study is to evaluate 8 case studies of patients who have started attending the joint nursing-psychology opioid reduction clinic. These patient are motivated to reduce their opioids, have possibly tried to reduce themselves in the past and are requesting support with this goal.
Methods
The joint clinic has been in operation for approximately 18 months during which time a total of 14 patients have been assessed with the aim to reduce their opioid medication. The case studies analysed included joint assessment letters and MDT discussion notes of 8 patients seen more than once in this clinic including phone follow up consultations.
Results
A total of 8 patients seen more than once in the joint clinic were selected, nursing and psychology notes and letters on medical records were collected and analysed for themes. These themes were categorised in terms of patient self-care and routine, self-management strategies, flare up plans, moods and thoughts, engagement of pleasurable activities and goals. The themes were collected and using inter-rater coding, placed into these categories to develop a codebook of clinician’s observations using the method of contents analysis. A qualitative description of clinician’s personal experiences was also recorded e.g. insights, concerns, and hopes for the patient.
Conclusion
The data collected is qualitative and we are continuing to develop further insights to generate theories towards this pain management approach. There is much discussion about how best these patients can be supported within a pain management centre as drug dependency centres may not always be appropriate for chronic pain patients. The reflective themes explored aims to further develop an opioid reduction service within a pain management centre.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Progress has been made in our understanding of the biological and psychological mechanisms involved in reporting pain, but there is limited research on the social influences on pain. Research suggests that the relationship between individuals experiencing pain and observers can impact on how pain is communicated; for example, pain is reported differently between friends, strangers and romantic partners. Additionally, there are differences in the way men and women communicate their pain in front of an observer; women report more pain than men. The next step in the research is to try and understand why and how pain is reported differently, depending on who is present. In the context of social support and friendship, competitiveness and cooperativeness are two main components of social interaction which could impact on pain reporting.
Aims
We investigated the role competitiveness and cooperatives in strangers and friends with regards to the reporting of pain. This was conducted over two independent studies; study 1 compared same-sex friends and opposite-sex friends, and study 2 same-sex and opposite-sex strangers.
Methods
An experimental design was adopted, with a tennis-based game on the PlayStation 3 used to manipulate cooperativeness (a doubles match) and competitiveness (participants played against each other), and with a Cold Pressor Task (CPT) used for the experimental pain induction. Both studies adopted the same methodology. Participants were recruited in dyads; both played on the PlayStation, and afterwards one completed a CPT and one observed. After each of the cooperative and competitive manipulation tasks, participants were asked to rate how competitive/cooperative they felt, before going on to complete the CPT. The order of manipulation task which was counterbalanced throughout the studies. On the CPT, participants indicated when they first felt it was painful and withdrew their hand when they could no longer tolerate it, and these two time points were recorded. Participants also completed relationship closeness questionnaires; the friend’s conditions reported closer relationships than the stranger’s conditions.
Results
In both studies, participants felt more cooperative in the cooperative condition, and more competitive in the competitive condition, which suggests that cooperativeness and competitiveness were successfully manipulated. In study 1, the manipulation task only had an impact on pain tolerance; pain tolerance increased after the competitive manipulation, but the sex of the friend did not matter. In study 2, pain tolerance was also higher in the competitive condition, as opposed to the cooperative condition. Interestingly, pain tolerance was highest when the participants experiencing the pain was female and the stranger-observer was male.
Conclusion
These results suggest that individuals may tolerate more pain when in a competitive environment. In addition to the contextual factors, the sex of the participant and observer should still be considered, as both the context (cooperation vs. competition) and the sex of the participants both had an impact on pain reporting. These studies collectively add a new dimension to previous work, and suggests the social contextual influences on pain should be considered in more depth. The next step is to investigate why males and females report their pain differently, and why competitiveness and cooperativeness can impact on pain.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
There has been an accumulation of research supporting the effectiveness of mindfulness based approaches for pain management over the last decade. Studies have found that mindfulness practice improves quality of life and results in improvements in physical and mental health. In response to the growing evidence base, the Newcastle Upon Tyne Hospitals Foundation Trust’s Pain Management Programme (PMP) team set up a two hour, group based, introductory mindfulness and meditation session in April 2014. Fifteen sessions have taken place from April 2014 to June 2016. The session provides a brief framework of meditation and mindfulness, which is accompanied by experiential practices followed by reflections. The group concludes with detailed information on apps and internet resources and with signposting to community resources. Although studies have examined the effectiveness of brief meditation interventions, as far as the authors are aware none have implemented an intervention as brief as the one described here.
Aims
The aims of this study were to explore: 1) whether a brief introductory mindfulness and meditation session was sufficient for people living with persistent pain to start their own practice, 2) their views and experiences of the session, and 3) the outcomes of their practice.
Methods
People who attended the session were randomly selected to be invited to take part in an interview. The interviewer contacted potential participants via telephone and read a participant information sheet, detailing what the interview would involve. If they wished to take part, consent was provided and a mutually suitable time was arranged. Of the 20 people who wished to take part in an interview, two could not recall much information about the session; therefore 18 individual, semi-structured telephone interviews were conducted. Several topics were covered in the interviews: 1) any existing practice of meditation before attending the session, 2) views of the sessions format and content, 3) development of own practice, 4) experiences of practicing mindfulness including adverse experiences. Interviews were transcribed by the interviewer and were anonymised. The length of the interview depended on the participant and ranged from 8 to 34 minutes (Mean: 16 minutes).
Results
All 18 interviewees reported that they would recommend the session to someone else with persistent pain. 88% thought the session was in the right format and the right length. All participants described the mindfulness practices and group discussions as the most important parts of the session. Having a follow up session with a clinician was helpful to discuss their experiences of the group and any subsequent practice. People reported that the session could be improved by having more time for questions and more resources.
88% of people had developed their own practice after attending this session, with 87% of those still practicing mindfulness regularly now. Of those people still practicing, 92% described now being better able to manage their pain. Other outcomes people described were improvements in fatigue, memory and attention, and coping with emotions, such as anxiety. People also discussed the difficulties they experienced during practice.
Conclusion
This evaluation demonstrates that a brief, group-based, introductory meditation and mindfulness session can be sufficient for people with persistent pain to start their own mindfulness practice. People experienced subjective improvements in their pain management and other symptoms as a result of this brief session. This offers support to the growing evidence base for mindfulness interventions for persistent pain. Further research should determine whether this brief intervention results in behavioural change and significant improvements in health compared with controls. This evaluation highlights that an introductory session can be effective, as well as feasible, in a service with increasing numbers of referrals.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Sex and gender are known to play a role in the perception and experience of pain. We know that women experience more pain compared to men, and that gender-based expectations might partially explains some of this variation. Recently with the emergence of men’s health as a specific focus of research, there has been a general interest in the role that gender-based constructs, such as masculinity, might have on health-related behaviours. Here it seems as if masculine-related beliefs around being stoic and less emotional may be related to a reduced likelihood to seeking help and support, as well as poorer health behaviours. However, few studies have considered these issues within the specific context of pain. This study therefore sought to examine whether these masculinity-related concepts are of relevance to pain and pain-related behaviours.
Aims
The aim of this study was to conduct an exploratory investigation to see whether there are associations between masculine gender beliefs, perception of stigma associated with help-seeking behaviours specifically related to pain, and health-related behaviours in men and women with and without persistent pain.
Methods
Adults were invited to complete an online survey on gender and pain using web-based advertisements and social media. Of the 641 participants who started the survey, 453 completed all measures and were included. The final sample was aged between 18 and 80 years (mean = 35.28, SD = 14.23), of which 283 report no regular pain (m = 40; f = 131), and 171 reported pain that had persisted for longer than 3 months (m = 72; f = 211). They all completed various measures including: Male Role Norms Scale (Thompson & Pleck, 1986), Health Behaviour Inventory-20 (Levant et al., 2011), and the Self-Stigma Of Seeking Psychology Help (SSOSH; Vogel, Wade, & Haake, 2006) modified to relate to pain help seeking. Total scores of each scale were used, with higher scores indicating greater agreement with male roles norms, greater health promotion behaviours and stigma associated with seeking help for pain.
Results
ANOVA revealed that those with persistent pain, and females, reported lower overall agreement with traditional male role norms. No interactions between pain status and sex were found. Hierarchical multiple regression analysis, controlling for age, found that higher agreement with traditional male role norms (beta = .22, p<.001), but not sex (beta = .06, NS) or pain status (beta = .06, NS), predicted greater stigma associated with seeking help for pain (R2 =.05; F(2, 448) = 6.35, p<.001). Interestingly, agreement with male role norms (beta = .18, p<.001) and being male (−.12, p<.05) were associated with a greater degree of health promotion (R2 =.15; F(2, 448) = 20.09, p<.001), whereas pain status (beta = .04, NS) did not seem to contribute to the explained variance.
Conclusion
This exploratory investigation found that beliefs around masculinity and male norms were related to both stigma associated with seeking help for pain, as well as general health promotion behaviours. Caution is of course required when drawing conclusions from cross sectional studies, especially given the relatively low proportion of explained variance. However, these results do suggest that the themes that are emerging from the men’s health literature are of potential relevance to pain in both men and women, and certainly worth noting and considering in future research.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Pain is a major health, social, and economic problem worldwide. Evidence has suggested that about 20% of adults suffer from pain globally and 10% are diagnosed with chronic pain each year(Goldberg&McGee, 2011). This problem has interfered with different aspects of individuals’ life i.e. mood, physical movements, social life and work(Gunnarsdottir,et.al., 2010; Chung et.al., 2007), which consequently affected their quality of life. It is also a huge burden to any healthcare economic system(Phillips. 2009).
The prevalence of pain has been studied in various settings and despite the variation in pain estimation attributed to different methodology, pain occurred regardless of individuals’ age, gender, or ethnicity(Beasley, et.al. 2014).
Pain management research has reported the positive contribution of psychological interventions as pain relief method in both medical and experimental settings. However, there are some factors could influence peoples’ adherence and acceptance to these techniques as pain relief e.g. beliefs, preferences or any other attitudes.
Aims
The research aims are: 1)to investigate the various pain experiences of individuals and explore their views which might influence their choices of pain relief methods, particularly psychological techniques. 2) assessing individual’s willing to accept psychological techniques as efficient pain relief options. 3) to discover potential barriers to practising these techniques.
Methods
Qualitative semi-structured interviews were conducted in order to explore people’s beliefs and attitudes regarding pain relief methods. A convenience sample of 19 individuals (8 males and 11 females), aged 20 – 72, who had various experiences of pain, either currently or in the past, were recruited from both the students and staff of Plymouth University.
The interview guide was structured in parts, which allowed participants to describe their pain experiences emotionally and physically and their methods of dealing with this experience. Then they were asked to give their opinion about psychological techniques as a method of pain relief.
Data were analysed using a thematic approach to identify and analyse patterns and themes from the transcripts.
A preliminary list of noteworthy quotations was created and discussed, potential themes appeared from these data which were reviewed by the research team, and agreement of themes to be included in the final report was reached.
Results
We identified four main themes:
Living the pain experience including two main parts: the impact of pain emotionally (mood), physically (routine activities) and socially (relationships and workplace); and the revelation of various approaches to dealing with the pain experience (fatalism vs. stoicism).
Views on pain medications including concerns about the risks of side effects, and developing a tolerance to and dependence on medications.
Views on non-medication interventions including psychological and non-psychological techniques.
The possible barriers to practising psychological techniques include several factors, some of which can be resolved, i.e. time and place to practise, while other factors are more complicated and need more attention/work from professionals who are interested in pain management.
Conclusion
People are practising psychological techniques spontaneously when they experience any level of pain such as distraction techniques and breathing exercises, they are also willing to practise them as complementary treatments for pain relief. However, they tend to be more conservative when asked directly about their opinion on using these techniques, such as self-hypnosis. Therefore, the delivery of psychological interventions should consider the labelling and packaging, and the stigma surrounding psychological experiments which might affect people’s beliefs in the effectiveness of psychological techniques.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Low physical activity level is a common consequence of chronic pain that significantly affects patients’ quality of life. Poor sleep has been associated with overall reduction in physical activity level, but the way how sleep impacts on chronic pain patients’ day-to-day physical activity is less understood.
Aims
We examined the temporal association between sleep and subsequent daytime physical activity on a day-to-day basis, and applied time-structured multilevel modelling to explore the effect of a good night’s sleep on the subsequent quantity of different types of physical activity.
Methods
51 patients with chronic pain were trained to monitor their sleep and physical activity, for 14 days in their natural living and sleeping environment, using subjective and objective methods. Subjectively, a daily diary was used to record participants’ subjective estimate of sleep, pain, mood, fear-avoidance response, endurance-related response, and tiredness at different times of the day. Objectively, actigrapahy was used to measure sleep and overall level of physical activity during the night, together with a Physical Activity Monitoring Sensor (PAMSys) that assessed time spent on different types of physical activity (lying down, sitting, standing, walking, running) during the day. Multilevel modelling was used to fit the data to examine the within-person temporal association between sleep and physical activity the following day.
Results
Findings indicated that subjective sleep quality was a significant within-person predictor of the overall level of physical activity the next day. The better the sleep quality on the previous night, the less time people spent engaging in stationary activity the following day (i.e., lying down).
Conclusion
Sleep appeared to be a significant day-to-day determinant of daytime physical activity. Interventions seeking to improve sleep quality may also help regulate daytime physical activity in people with chronic pain.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Studies have suggested that self-compassion may be a key factor in determining the degree of psychological distress experienced by people in chronic pain and their ability to adjust to the pain (Costa & Pinto-Gouveia, 2013; Wren et al, 2012; Purdie & Morley, 2015). Chronic pain can be associated with feelings of shame and self-criticism. These feelings may present barriers to benefiting from traditional CBT-based pain management, such as pacing and acceptance, because shame can drive people to over-activity.
Compassionate Mind Training (CMT) for people with chronic pain provides education about neurobiology and evolutionary psychology: how these contribute to the chronic pain experience by engaging the threat system and winding up the central nervous system. CMT for pain emphasises common humanity, encouraging participants to experience understanding and compassion from other group members, as well as helping them to develop skills and strategies such as mindfulness, self-soothing and self-compassion.
Aims
This study aims to use qualitative methodology to investigate the experiences of patients attending CMT for pain groups. Using the participants’ own words to illustrate key themes allows us to learn more about the aspects of these groups that are unique and how these might contribute to change.
Methods
Data was collected from CMT groups across multiple sites in Manchester and Durham. Groups consisted of 8 sessions of 2 hours, and included the following key content:
Bio-psychosocial understanding of pain and the evolution of compassion for soothing
Relationship between stress and pain; introduction of soothing techniques
Mindfulness, breathing awareness, compassionate body scan
Understanding the drive system and mindfully listening to the body to prevent over-doing and burnout
Compassionate imagery: safe place & compassionate colour breathing
Working with the inner critic Compassionate companion and compassionate self-imagery
Multiple selves work - understanding our anxious, angry and critical selves
Maintaining change: the long term benefits of self-compassion and the pain journey
Qualitative data was collected about participants’ experiences of attending a group using open-ended discussion and written evaluation questionnaires. Verbal and written comments from all participants (n=32) across the groups were combined and transcribed. These comments were analysed using inductive thematic analysis (Braun & Clarke, 2006).
Results
Three major themes were identified, illustrating the impact of the group on participants’ experiences of: self, others and pain. The table below illustrates the main themes and twelve sub-themes. Quotes have been included for each main theme.
SELF: “I feel a lot better in myself”
Self-care
Self-efficacy
Behavioural change
Emotional change
Mindfulness/ imagery exercises
OTHERS: “We’ve all been on a journey together”
Common humanity and group processes
Impact on family/ relationships
Developing compassion for others
PAIN: “I feel much more at ease with the pain I have”
Pain relief
Acceptance of pain
Fighting/ beating the pain
Learning about the brain, pain and the role of stress/ threat
In summary, participants reported that as a result of the CMT for pain groups, they learned about themselves, pain and stress; developed a greater sense of self-efficacy and acceptance of pain; noticed positive changes in emotions and behaviours; became more compassionate with themselves and others.
Conclusion
This research contributes to a growing body of evidence suggesting that CMT is effective in managing pain. Furthermore, results suggest that CMT groups may emphasise an additional factor in comparison with CBT methods of Pain Management: a greater sense of common humanity, which has the potential to change not only aspects of the self and its relationship with pain, but also to reduce feelings of shame, judgement and isolation, thereby enhancing relationships with others and the self. Further studies are required to clarify which aspects of CMT are most effective in managing pain and how this compares to other psychologically based PMPs.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Sleeplessness is often overlooked in chronic pain patients (e.g. Champaneria et al., 2012; Macfarlane et al., 2016; Tang and Crane, 2006). Moreover, among those who have treatment, pharmacological treatments are often offered, although sleep medications are linked with a host of side effects and dependency syndrome (Black et al., 2014). It has been suggested that mindfulness-based interventions (MBIs) such as Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams and Teasdale, 2012) can contribute to reduce pre-sleep rumination as it teaches people to make intentional, skillful choices (e.g. recognising and responding to aversive cognitions, sounds, bodily sensations that can keep a person awake all night) with appropriate actions as opposed to acting on ‘automatic pilot’ with conditioned responses that can be emotionally and somatically arousing (Hubbling et al., 2014).
Aims
This exploratory clinical study aims to add to previous quantitative research in the area by qualitatively exploring individual experiences of attending an MBCT pain management programme and identifying the key constituents of the programme that participants felt facilitated change.
Methods
Eight outpatients who completed the 8 weeks programme contributed to a post-intervention focus group. Participants’ perceptions of the intervention were elicited, recorded, transcribed verbatim and then qualitatively explored using semantic theoretical thematic analysis.
Results
Five themes emerged from the analysis of participant experiences:
Feeling empowered by learning to ‘respond’ instead of habitually react to sleeplessness and pain
Appreciating more in daily life
Cultivating equanimity (balance and mental calmness in the midst of difficulties)
‘Thriving’ in the moment instead of ‘striving’ (to sleep or be pain free)
Befriending the body: Practising moving meditation makes gentle stretching more safe and enjoyable
The elements of the MBCT that appeared to facilitate positive outcomes included contemplative home practices, experiential, psychoeducational, and reflective elements in a supportive small group environment.
Conclusion
The outpatients’ reported experience of the MBCT pain management programme is strongly indicative of positive change not only in their relationship with their chronic pain and insomnia, but also in their beliefs about personal self-efficacy regarding pain management. This programme works well alongside other chronic pain interventions and could be an effective and empowering treatment for secondary insomnia that alleviates patients’ dependence on pharmaceuticals as well as the debilitating effects of their chronic pain and lack of sleep.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
The biopsychosocial model of chronic pain recognises the condition as a combination of physical dysfunction, beliefs, coping mechanisms, distress, illness behaviour and social interactions. Due to the variety of different contributing factors, the condition fails to respond well to a single treatment approach. As a result, chronic pain is managed within a multi-disciplinary team. One intervention commonly used is the Pain Management Programme; PMP. PMP’s based on cognitive-behavioural principles are positively associated with clinical effectiveness for individuals suffering with chronic pain. (Smith et al., 2015) However, an Intensive Pain Management Programme, iPMP has a significant improvement in short-term results; pain intensity and functionality. (Artner et al., 2012) Currently in the West Midlands there are no active Intensive Pain Management Programmes, and so by conducting this pilot, we are working towards filling a niche in the market; and those patients who need the service are able to access it relatively easily.
Aims
The programme aimed to introduce vocational rehabilitation to the patients, in order to allow them to return to work. We also aimed to achieve a higher intensity by increasing contact hours. Finally we aimed to decrease the patient’s reliance on the medical model and introduce them to the bio-psycho-social model.
Methods
The iPMP consisted of 60 contact hours, split equally into 5 hour days, 3 days per week; spreading across one month. The programme content aimed to educate and supply the patients with the relevant knowledge; in relation to their individual chronic pain, and how to effectively manage their pain. Sessions included: a medical explanation of what causes chronic pain, the psychological components of pain; effects of mood and pain, the rationale behind physical activity, and the benefits of reducing analgesia. Patients were able to use the facilities at Portway, a centre of excellence for people with disabilities. Introductory gym, hydrotherapy and Tai Chi sessions were delivered here. A strong vocational focus was present in this group, with 2 full days set aside to enable patients to make steps to resume work. A friends and family day was also included, where focus was placed on being a carer for pain patients.
Results
Questionnaires included; Chronic Pain Acceptance Questionnaire, CPAQ, Generalised Anxiety Disorder Scale, GAD-7, Patient Health Questionnaire, PHQ-9, and Pain Self-Efficacy Questionnaire, PSEQ. With a sample size of 13, 69.2% obtained an increase in scores on the CPAQ. There was a 53.3% decrease in anxiety levels, and a 69.2% decrease in depression levels. Self-efficacy increased by 84.6%. Four exercises were used to investigate the patient’s ability to move; sit-to-stand, arm elevations, step-ups and a timed 10 metre walk. There was improvement in all exercises at the end of the programme; 69.2% increase in sit-to-stand, 76.9% increase in arm elevations, 84.6% increase in step-ups, and 61.5% decrease in the time for a 10 metre walk. Telephone and face-to-face consultations were held on a monthly basis and a review session will take place in January 2017. Here we will see if these results have been maintained without any guidance from professionals.
Conclusion
The iPMP proves useful to increase the mobility and functionality of chronic pain patients. With further research, it will become clearer whether an iPMP has any long term benefits which are otherwise not achieved when delivering a normal PMP. Results now need to be disseminated to Commissioners in order to secure permanent funding, rather than using charitable funds. Until funding has been decided, members of the Pain Management team will reflect upon way to incorporate elements from the iPMP into the standard PMP.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
There is good quality evidence for internet based / online pain management programmes (PMP) for improving anxiety, depression and kienesophobia.
The advantages of online PMP include -
Facilitating users to manage their pain in their own time, place and pace. No need to come to hospital, clinic or surgery.
Standardise and control service quality, to enable measuring value (outcomes / costs) and use this measure to drive quality improvement.
Test a model for delivering care over a longer period of time (4 - 6 months), by a flexible workforce (time and place).
RCT using n=1 methodology can be carried out, rather than using a waitlist control group. This is the recommended method for clinical research in pain psychology (instead of a waitlist control).
Aims
The aim of our project is to research, design, develop and test an online PMP and clinical outcomes measuring software and test it using n = 1 research methodology.
Methods
A multidisciplinary team contributed to the project over a 3 year period.
Seed funding was raised from private investors.
The content of MyPain Compass was scripted, comprising of 12 modules - Definition of pain, Injury and healing, Values and goal setting, Activity pacing, Cognitive behavioural therapy, Movement and exercises, Sleep, Relaxation, Mindfulness, Communication, Flare ups and The future. This was converted into 50 animations, 3-5 animations per module, designed into software (UI / UX), prototype tested and feedback from users incorporated in updated designs. Coding and testing (beta version – ongoing).
In parallel, research was undertaken using similar methodology to develop software for gathering clinical outcomes, using questionnaires validated in chronic pain populations (MyPain Impact).
The research team prepared the protocol, sort ethics and HRA approval, and established 1 NHS trust as sponsor (Chelsea & Westminster Hospital NHS Foundation Trust) and 2 NHS trusts as PIC sites (UCL Hospitals)
Results
The draft text for all the animations was originally 60000 words. It was amended 6 times, before a 30,000 word manuscript was finally approved and animated.
It was challenging to get funding for the project, hence it was conceived as a private company (My Pain Ltd) to fund the research and development.
We underestimated the complexity of software design.. It was revised 5 times, based on user feedback for the minimum viable product and continues to be work in progress.
The protocol has been approved by the national ethics committee (no - 16/LO/0272)
The beta version of software is ready for release and patient enrolment into the feasibility study is expected to commence in Q1 2017.
Conclusion
We believe My Pain Compass and Impact will improve access and enable PMP to be delivered in a more efficient and cost effective way.
The interaction between users and the software is dynamic, real time, and the analytics can help work on theoretical models for scientific advancement which has been limited to date.
The service model allows for a future ready flexible work force, enabling secure consultations at a mutually agreeable time, without additional expense of hospital based infrastructure and associated overheads. It is an example of clinician-led small scale entrepreneurial enterprise, partnering with NHS organisations.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic pelvic pain (CPP) is a debilitating condition often associated with significant psychological difficulties such as anxiety and depression. There is increasing experimental and clinical evidence for the effectiveness of hypnosis in treating a variety of chronic pain problems, although the usefulness of hypnosis for treating CPP has not been reported.
Aims
Given the paucity of psychological interventions for CPP and the increasing evidence of effectiveness of hypnosis in other pain disorders, the aim of the current research was to assess the use of hypnosis for reducing pain and psychological distress and improving function in people suffering with CPP.
Methods
A prospective, multiple single case approach was used. 5 patients diagnosed with chronic pelvic or abdominal pain participated, attending 2 baseline visits, 5 treatment sessions and one post-treatment visit. A mixed methods approach to data collection was taken, combining self-report outcome measures and semi-structured interview to assess how participants used self-hypnosis. Visual, graphical analysis, was used to explore the relationship between psychological variables and change in pain experience over treatment. Post treatment interviews assessing experience of hypnosis were analysed using Thematic Analysis.
Results
All participants completed the study. Overall, the results of the post interview thematic analysis showed benefits from hypnosis but those benefits varied across individuals and across outcomes such as pain relief, acceptance of pain and engaging in more valued activity. Several participants reported clinically significant and reliable changes, notably in terms of pain reduction (intensity and unpleasantness, range 41%-100% reduction from baseline) and less catastrophizing (range 40%-65% reduction from baseline).
Conclusion
Hypnosis can be a useful adjunct in the multidisciplinary management of pain with possibilities of improving outcomes in sensory, psychological and behavioural domains. The findings also propose some factors that may mediate the effects of hypnosis on pain relief, in particular, acceptance of pain and worry/relaxation. Replication with larger sample sizes and more complex analyses (such as regression) are required to assess these hypotheses further.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Chronic headache (CH) is defined as headache which is present for 15 or more days a month for more than 3 months and is distinct from episodic headache. Tension type headache and migraine are the main types of CH which are disabling, affecting people’s work, social relationships and quality of life. A high proportion of people with CH will also have medication overuse which itself can increase headaches. We report a systematic review and synthesis of qualitative studies giving the patients’ perspectives of CH.
Aims
This review informs the Chronic Headache Education and Self-management Study (CHESS) feasibility study which is piloting a classification tool and a psychoeducational group intervention for people with CH.
Methods
We used electronic and hand searches of key databases and journals and appraised the included studies for risk of bias using a modified CASP tool. We used a thematic analysis followed by a synthesis of the data using a meta-ethnographic approach.
Results
We screened 6,421 titles and abstracts identifying 86 studies of interest. Four studies met our criteria. All differed in their focus on CH exploring; patient-centred outcomes, CH as a socially invisible disease, psychological processes mediating quality of life impairments and the process of medication overuse.
Themes were explored across the studies, further analysis of the results and subsequent synthesis produced three overarching themes; headache as a driver of behaviour, the spectre of headache and strained relationships. These themes show that CHs have wide ranging effects similar to episodic migraine. Although chronic tension type headaches were represented in the data they may have been overshadowed by chronic migraine features.
Conclusion
There are very few qualitative studies specifically about CH. Future research is need to explore patients’ perspectives of; the evolution of CH, addressing medication overuse, chronic tension type headache compared to chronic migraine and whether non-pharmacological treatment approaches may be of benefit.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Emerging longitudinal research has highlighted poor sleep as a risk factor for a range of adverse health outcomes, including disabling pain conditions such as arthritis, chronic back pain, and fibromyalgia. In establishing the causal role of sleep on pain, it remains to be clarified whether sleep deterioration over time is a driver of pain onset and, importantly, whether sleep improvement over time can prevent or mitigate pain related outcomes.
Aims
A systematic literature search was performed using PubMed MEDLINE, Ovid EMBASE, and Proquest PsycINFO to identify longitudinal studies that evaluated the effect of sleep changes on subsequent pain related outcomes in the general population.
Methods
Search results were screened for eligibility and 14 articles met the full inclusion criteria. Findings of all included studies were synthesised in a narrative form to illuminate the associations between (i) changes in sleep and subsequent risk of developing pain conditions, (ii) changes in sleep and subsequent inflammatory or immune function biomarkers, and (iii) changes in sleep and subsequent subjective reports of pain related health status. An exploratory meta-analysis was also carried out with a subset of studies that had comparable outcome measures, to quantitatively estimate the magnitude of the effect of sleep changes on subjective pain related health status.
Results
There was narrative and quantitative evidence to suggest that an increase in insomnia symptoms over time (follow-up duration: 1 month – 23 years) was associated with a two- to three-fold increase in risk of subsequently developing a pain related medical condition, including chronic back pain and arthritis. Further, a reduction in sleep quantity was associated with an aggravation of pain related inflammatory and immunological processes, as indicated by natural killer cell activity (NKCA), C-reactive protein (CRP), Interleukin-6 (IL-6), and cortisol levels; and with a decline in subjective health status, as measured with SF-36.
Conclusion
Together, these findings converge to suggest a negative effect of sleep deterioration on both objective and subjective pain related health outcomes. There is, however, insufficient evidence to suggest a clear positive effect of sleep improvement. Conclusions that can be drawn from the current review are limited by the overall size of the literature and the heterogeneity of the included studies. Future research is needed to verify both directions of the causal links between sleep and pain and to investigate whether public health interventions aiming to promote sleep can lead to better pain outcomes and quality of life.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
Visual feedback of body parts is used to alleviate pain in conditions where body parts feel large, heavy and swollen (e.g. complex regional pain syndrome) or small and withered (e.g. osteoarthritic hands). Generally, visual feedback is of a normal-sized body part, although lenses, virtual reality and mirrors have been used to minify the appearance of painfully swollen hands and magnify painfully withered hands. Originally, Moseley et al. (2008) studied individuals with chronic painful arms and found that magnifying the affected arm increased pain and minifying the arm reduced pain, although conflicting evidence has emerged (Preston and Newport, 2011, Diers et al., 2012). Experiments using pain-free individuals exposed to painful stimuli have been used to evaluate the effect of visually distorting the size of a body part and have shown inconsistent results.
Aims
The aim of this systematic review was to evaluate the effect of visual feedback techniques on pain perception by analysing the effect of normal-sized, magnified or minified visual feedback of body parts on clinical and experimentally-induced pain.
Methods
The following databases were searched between 11 and 13 October 2016: Medline, Embase, PsychInfo, PEDro, CINAHL, CENTRAL, and OpenSIGLE. A combination of controlled vocabulary (i.e. medical subject headings) and free-text terms were used to identify published articles including ‘visual feedback’, OR ‘mirror visual feedback’ OR ‘visual distortion’ AND ‘pain’. A manual search of the reference lists of included studies and systematic reviews was also undertaken. Studies evaluating any type of visual feedback of any body part were included providing they had a control condition. Study outcome was recorded as positive if there was at least one statistically significant reduction in pain in favour of the experimental intervention at any time point during the study measurement period. Analysis involved frequency counts of study outcome of all studies and according to visual feedback technique.
Results
Seventeen clinical studies and ten experimental studies were included in the review. When compared with control interventions, mirror visual feedback using a normal-sized reflection alleviated clinical pain in 7 out of 14 comparisons and decreased experimental pain in 7 out of 14 comparisons. Normal-sized visual feedback using other techniques alleviated clinical pain in 6 out of 11 comparisons and decreased experimental pain in 2 out of 7 comparisons. Two out of 3 clinical studies found that magnifying a painful body part reduced pain and 1 out of 3 studies found that minifying a painful body part reduced pain. Two out of 3 experimental studies using mirror visual feedback found that magnifying a body part reduced experimental pain to a greater extent than a normal-sized control. There were no differences between normal-sized visual feedback of a body part compared with magnified nor minified body parts when using other visual feedback techniques.
Conclusion
It was not possible to determine whether normal-sized, magnified or minified visual feedback of body parts affects pain perception in patients or pain-free participants because of contradictory findings in primary studies. The most likely explanation for the contradictory nature of the findings is shortcomings in study methodologies, including inadequate sample sizes and the variability in type of visual feedback technique and controls. This review should serve to emphasise the need for further research.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
It is suspected that the prevalence of Neuropathic pain (NeP) is higher in the countries normally categorized as belonging to the global South, i.e. developing countries, because of the high prevalence of NeP generating diseases including HIV, diabetes mellitus and cancer. However, few articles have estimated the prevalence of NeP in these limited resource countries. By contrast, the prevalence of NeP worldwide has been evaluated in two systematic reviews to range between 3.3% in Austria to 8.2% in the UK (Smith and Torrance, 2012, Hecke et al., 2014) with an outlier of prevalence at 17% in Canada.
Aims
The aim of this systematic review was to screen the literature for the prevalence of NeP in the general population of the global South and to compare this prevalence with the prevalence in the global North using a meta-analytic approach.
Methods
Pubmed; Siencedirect; EMBASE; AMED and PsycINFO databases were searched on July 2016 to capture peer reviewed articles that contain data on NeP prevalence either in adult general populations or among chronic pain patients.
Two reviewers applied the inclusion criteria and extracted information from all eligible studies including study period, country, study design, sample size, tools to diagnose NeP, outcome and overall prevalence and judged the outcome for each study by scrutinising the methods and result section. Guidelines for reporting Meta-Analysis of Observational Studies in Epidemiology (MOOSE) (Stroup, 2000) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher, 2009) were followed.
Random effects modelling was applied on extracted data to produce the overall prevalence in the two study areas. Effect size and confidence intervals of overall prevalences was calculated by producing Forest plots in the Comprehensive Meta-analysis software. Risk of publication bias and heterogeneity between studies were also estimated.
Results
Out of the 624 studies identified in the search 14 studies were finally selected (total sample size of 78421 patients, 8137 from developing countries (global south) and 70284 from developed countries (global north). The average quality score of all studies was 6.7 out of a maximum of 8.
There was a high level of heterogeneity between the studies (I2>90) possibly because of differences in the target populations, sample sizes, study design and data collection methods. However, there was no publication bias as the Egger’s test value was not significant (p=0.053). The prevalence of NeP worldwide was 4.8 % (95%CI, 4.7%-5.0%). Only four studies were conducted in the global South; 2 in Libya, 1 in Morocco and 1 in Brazil. The prevalence of NeP in the global South was 8.3% (7.7%-9.0%). The overall prevalence in the global North was 4.9% (4.7%-6.0%).
Conclusion
There were few studies on the prevalence of NeP in the global South suggesting that there is less awareness of the significance of NeP in the developing countries. Differences exist between the studies in each region in the estimate of the prevalence of NeP and this is mainly because of differences in data collection methods. Clinical examination tends to produce more variable estimates than telephone, postal and internet based questionnaires using NeP screening tools such as DN4 and S-LANSS. This meta-analysis tentatively suggests that the prevalence of NeP is significantly higher in the global South compared to global
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
A wide range of demographic, clinical, psychological and social factors may affect prognosis and treatment outcome for people with chronic headache.
Aims
Our aims were to identify factors that predict poor prognosis in patients with chronic headache and identify factors associated with differential treatment outcomes.
Methods
A systematic review of published literature in peer-reviewed journals. We included a) randomised controlled trials (RCTs) of interventions for chronic headache that reported subgroup analyses and b) prospective cohort studies, published in English, since 1980. Participants included adults with chronic headache (including; chronic headache, chronic migraine, chronic tension-type headache with or without medication overuse headache respectively).
We searched key databases using free text and MeSH terms. Two reviewers independently extracted data and assessed the methodological quality of studies and overall quality of evidence identified using appropriate published checklists.
Results
We identified 16556 titles, removed 663 duplicates, and reviewed 233 papers, of which 27 were included in the review - 17 prospective cohorts and 10 RCTs with subgroup analyses reported.
There was moderate quality evidence indicating that depression, anxiety, poor sleep and stress, medication overuse and self-efficacy for managing headaches are potential prognostic factors in chronic headache. There was inconclusive evidence about treatment expectations, age, age at onset, body mass index (BMI), employment and several headache features.
Conclusion
This reviews has identified several potential predictors of poor prognosis and worse outcome post interventions in people with chronic headache. The majority of these are modifiable. The findings also highlight the need for more longitudinal high quality research of prognostic factors in chronic headache.
Br J Pain. 11(2 Suppl):5–96.
Abstract
Background
There are effective behavioural self-management interventions for headache available, but it is not clear which approaches should be included in a self-management program. We present a systematic review of the effectiveness of several components and characteristics of behavioural self-management interventions, for people with headaches.
Aims
Our aims in this review were to provide an overall effect size for self-management interventions against waiting list controls or usual care, and to quantify the effectiveness of different components within behavioural self-management interventions for headache.
Methods
We searched five relevant electronic databases for full reports of randomized, controlled trials (RCTs), published in English from 1980 to June 2016. Two reviewers screened records for inclusion, extracted data and assessed the risk of bias. Participants were adults with migraine and /or tension-type headache.
We classified interventions according to course delivery (group or individual, and face-to-face or remote); who delivered intervention (psychologist/therapist, versus nurse/allied health professional); the inclusion of additional support components (homework or email/telephone follow up); and content of specific intervention components (relaxation, psychological, educational-, mindfulness component). We grouped outcome measures together in outcome categories and produced a pooled effect size where outcome data was available from at least ten studies (pain intensity, mood and headache related disability) by combining the final value data in the intervention and control arm for each study and calculating standardised mean differences (SMD).
Results
We found a small overall effect for behavioural self-management interventions versus usual care/waiting list control, with an SMD of-0.36 (−0.45, −0.26) on pain intensity and −0.32 (−0.42, −0.22) on headache related disability.
Studies including a psychological component found a larger effect size of −0.72 (−0.93, −0.51) compared to those without of −0.41 (−0.58, −0.24) on mood, but made no difference on intensity or headache related disability.
Studies including educational component found a larger effect size on pain intensity of −0.51 (−0.68, −0.34) compared to −0.28 (−0.40, −0.16) for those without.
Studies including a mindfulness component found a larger effect size on pain intensity of −0.50 (−0.82, −0.18) compared to those without 0.34 (−0.44, −0.24).
Studies of group-delivered interventions found a larger effect on pain intensity; effect size of 0.56 (−0.72, −0.40) compared to −0.39 (−0.52, −0.27) for individually delivered interventions.
Conclusion
Self-management interventions for people living with headaches should include should be group-delivered and include a psychological, mindfulness and educational component.