Abstracts selected for oral presentation
The following are the best five abstracts and instead of presenting a poster they will be presented during Plenary Session 7 on Wednesday 2nd May.
. 2018 May 3;12(2 Suppl):5–54. doi: 10.1177/2049463718762348
Br J Pain. 12(2 Suppl):5–54.
Oral 1
Assessment of Pain in Adults Who Have a Learning Disability a Snapshot Survey of Practice in Secondary Care NHS Trusts Across The United Kingdom
Category: Service Management
Dr Lorraine de Gray - Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn Faculty of Pain medicine, Royal College of Anaesthetists, Dr Bharti Seth - Department of anaesthesia and Pain medicine Queen Elizabeth Hospital NHS Foundation Trust, Dr Sheila Black - Department of Anaesthesia and Pain Medicine Leeds Teaching Hospitals NHS Trust
Background
In the UK there are currently various guidelines which specifically promote the assessment and management of pain in adults who have a learning disability. The NICE guideline, NG11, published in May 2015 on “Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges” specifically states that “there should be an agreed and shared care plan for managing any physical health problems (including pain).” The Royal College of Anaesthetists guidelines on acute pain management state that “Tools such as the Abbey pain scale may be appropriate for non-verbal adults. However as with all guidelines and recommendations, what happens in practice may be very much dictated by resources both in terms of man power as well as staff training. A survey of published literature reveals various publications which have pointed towards significant lack of adequate care for patients who have a learning disability.
Aims
With this view in mind, a survey has been conducted on behalf of the Faculty of Pain medicine to analyse assessment of pain in adults with learning disability across secondary care NHS Trusts in the United Kingdom.
Methods
One hundred and three NHS Trusts across the United Kingdom were randomly picked. A further random analysis of around twenty websites, revealed that most did not name a specific person who was designated Safeguarding Lead for Adult patients with Learning Disabilities. A postal survey was therefore sent out and simply addressed to the “Safe guarding Lead for Adult patients with Learning Disabilities”. The survey specifically asked for details of the responsible Lead, mandatory training of staff, assessment tools used, audit performed to assess the management of such patients and whether these patients were being appropriately assessed and managed. Eight weeks were allowed to pass before all data received was collated and analysed.
Results
Although the return of surveys was low at 23%, we believe our data is a reasonably accurate representation of current practice in the United Kingdom. The survey confirms that there is appreciation of the fact that there is a population of adults with learning disabilities that maybe admitted to acute hospital Trusts. However training of medical and nursing staff to deal with these patients is surprisingly low with only 39% of Trusts providing mandatory training. Only 87% of Trusts have a named Lead for Safeguarding adults with Learning disabilities. There appears to be a reasonable understanding and use of communication tools suitable for pain assessment in this population of patients with only thirteen percent of Trusts apparently not using any specific recognised or bespoke tools. The response to our question as to whether this population of patients is being appropriately assessed and managed well suggests that their assessment and management remains a challenge. Only 39% of Trusts were actively involved in auditing measures and outcomes being used in this group of patients.
Conclusion
All health professionals need to have a greater awareness of learning disability, how to increase opportunities for effective communication and be very familiar with the issue and guidelines relating to this group of patients. It appears likely that pain continues to be under-recognised and under-treated, particularly in those with severe and profound intellectual disabilities and impaired capacity to communicate. These patients depend on their care givers to interpret behavioural responses to pain, to recognize their pain and at the end of the day, to relieve their pain.
Despite increasing awareness of the need for safeguarding this vulnerable group of patients, there appears to remain a significant need for improvement in both assessment and delivery of pain management in particular in the acute care setting.
Br J Pain. 12(2 Suppl):5–54.
Oral 2
Impact of Brief Psychological Interventions for Patients with Complex Needs: The Role of the Clinical Psychologist within the Inpatient Pain Team
Category: Acute Pain
Chandran Jepegnanam - Anaesthesia Manchester University NHS Foundation Trust, Dr Sujesh Bansal - Anaesthesia Manchester University NHS Foundation Trust, Sr Maureen Booth - Pain Medicine Manchester University NHS Foundation Trust, Sr Elizabeth Purser - Pain Medicine Manchester University NHS Foundation Trust, Sr Tecla Makaka - Pain Medicine Manchester University NHS Foundation Trust, Sr Gemma Shapley - Pain Medicine Manchester University NHS Foundation Trust, Dr David McCarthy - Anaesthesia & Pain Medicine Manchester University NHS Foundation Trust, Dr Zoey Malpus - Pain Medicine Manchester University NHS Foundation Trust
Background
An internal audit of referrals to the inpatient pain service found that 38% of patients had a history of chronic pain or substance abuse. This is a group with complex needs, presenting specific challenges such as multiple admissions with prolonged length of stay. Psychometric screening demonstrated high prevalence of severe pain related disability, anxiety and depression.
There is strong evidence for psychological intervention for pain management in outpatient settings (Williams, Eccleston and Morley 2013). The strongest evidence being for Cognitive Behavioural Therapy (CBT) which focuses on correcting any misunderstandings about causes of pain, psycho-education regarding the stress pain cycle and training in stress reduction strategies, cognitive techniques for challenging negative thoughts, problem formulations, problem solving and goal setting. However, there is little published data on the impact of psychological intervention for pain within an inpatient setting, or the role of a Clinical Psychologist delivering inpatient pain rehabilitation for complex patients.
Aims
The aim of this service evaluation was to assess the impact of the addition of a Clinical Psychologist into a multidisciplinary inpatient pain service, on the management of this group of patients in terms of number of admissions and duration of each admission.
Methods
All patients were initially seen by the inpatient pain team and assessed as having complex needs. Psychometric screening questionnaires were administered as opt-in to seeing the clinical psychologist. Screens included McGill Pain Questionnaire, Roland Morris Disability Questionnaire, Pain Anxiety Symptom Scale, Centre for Epidemiological Studies of Depression and Chronic Pain Acceptance Questionnaire.
49 patients completed inpatient psychometric screening questionnaires during the three-year pilot. The intervention group consisted of 34 patients who had completed the 12-month post-treatment phase.
The control group comprised 30 patients who completed identical psychometric screens but had been discharged home before they could be seen by the clinical psychologist.
Health economic data was collected including number of hospital admissions and total length of stay. Pre-treatment data included all admissions in the 12 months preceding intervention. Post-treatment data related to the following 12 months. Control data related to 12 months prior to and following completion of psychometric screens.
Results
Pre-treatment admission rates were similar for both groups: intervention (n=34, mean = 2.71, range 1-10), and controls (n=30, mean = 2.78 range 1-10). Pre-treatment bed days appeared to differ across groups: intervention = 44.6 (4-199) and controls = 29.7 (1-113) but this difference did not achieve statistical significance (t=0.102, df=62, ns).
There was a significant post-treatment difference between groups for both admissions: intervention = 1.1 (0-6) and controls = 3.0 (0-22), df=62 p<0.05 and bed days: intervention = 7.1 (0-58) and control 17.5 (0-171) df=62 p<0.05
Both groups demonstrated significant difference between pre/post admissions but there was a significant interaction effect: Intervention group showed 60% reduction in subsequent admissions (df=33 p<0.000) and controls showed small increase of 7% (df=29 p<0.001).
Both groups demonstrated significant improvement in post-treatment bed days: intervention showed 84% reduction (mean reduction 37.5 days, df=33 p<0.000) and controls 41% reduction (mean 12.2 days, df=29 p<0.000).
Conclusion
The introduction of a clinical psychologist to the inpatient pain team led to a significant reduction in re-admissions and length of stay (LOS) for complex patients. On average this meant 84% reduction in LOS or 34.5 fewer bed days in the twelve months following brief psychological intervention. This represents a total cost saving of £7,038 per patient per year (using LOS of £204 per day 2015/6).
This intervention is available one day per week due to limited access to the Clinical Psychologist. Widening access could lead to greater cost savings and improved quality of life for patients with complex needs.
Br J Pain. 12(2 Suppl):5–54.
Oral 3
Prescribing Opioids for Chronic Pain in Primary Care: A Qualitative Metasynthesis
Category: Other (research)
Mary-Claire Kennedy - School of Healthcare University of Leeds, Phoebe Pallotti - Faculty of Medicine and Health University of Nottingham, Clare Harley - School of Healthcare University of Leeds, Rebecca Dickinson - School of Healthcare University of Leeds
Background
Worldwide use of prescription opioids has increased markedly in the past three decades; the greatest increase recorded in the US although many other countries have also reported an upward trend (1-3). Studies have found that the decision by a primary care provider (PCP) to prescribe an opioid is influenced by many factors such as concerns about side-effects, addiction or misuse and fears of professional scrutiny, with the process being further complicated by insufficient clinical guidance and a reported lack of knowledge among physicians (4-6). Recent qualitative studies have examined the issue of opioid prescribing for chronic non-malignant pain from a PCP’s viewpoint. However, there has been no attempt to synthesize the findings from these studies to develop an overarching set of themes to capture the phenomenon. We require a better understanding of problems PCP’s face when prescribing opioids and interventions to provide clearer guidance.
Aims
The aim of this review is to develop a clear understanding of the factors influencing the nature and extent of opioid prescribing for patients with chronic non-malignant pain and to model the decision making processes associated with opioid prescriptions in primary care to elicit PCP’s support needs in this process.
Methods
MEDLINE, Embase, PsychINFO, Cochrane Database, International Pharmaceutical Abstracts, Database of Abstracts of Reviews of Effects, CINAHL and Web of Science were systematically searched from January 1986- 2017. Two reviewers independently screened titles and abstracts of all references. Inconsistencies in selection were examined following review of titles and abstracts. The reviewers then independently assessed the full text of the articles. The quality of selected studies was assessed using the Critical Appraisal Skills Programme (CASP) tool for qualitative research (7). Thematic Network Analysis was used to organise and analyse the results of the studies and to develop a new model to further explain the findings of the studies (8). Data were independently coded by two researchers who discussed and compared codes. Organising themes were then developed followed by global themes which summarised the key theories emerging from the texts.
Results
From 7017 records, 15 full text papers were assessed and 11 studies included in the synthesis. Seven organising themes were identified including trust and mistrust, the importance of aetiology, monitoring of prescription use, physical, psychological and societal harm, consultation variables, inadequate pain management, stigma and stereotypes and system barriers to effective and safe prescribing such as limited access to specialist care or support from allied healthcare professionals in primary care. Four global themes emerged and included suspicion, risk, agreement and encompassing systems level factors. These global themes are inter-related and capture the complex decision making processes underlying opioid prescribing, whereby the physician both consciously and unconsciously quantifies the risk-benefit relationship associated with initiating or continuing an opioid prescription.
Conclusion
The patient and physician work collaboratively during the consultation; the prescription is decided upon following consideration of the potential for physical harm, the perceived validity of the pain condition balanced with the risk of addiction or misuse and the extent to which the patient agrees with the decision-making of the physician. Patients who present with an unclear aetiology, a likelihood of developing side-effects and who appear at high risk of developing opioid addiction or misuse behaviours are unlikely to receive a prescription, and thus adequate pain management, in comparison to patients without these risk factors and a confirmed aetiology.
Br J Pain. 12(2 Suppl):5–54.
Oral 4
What Do People with Persistent Pain Think About When they Complete the Tampa Scale of Kinesiophobia (TSK)? A Qualitative Study
Category: Assessment & Measurement
Lorna Semple - Glasgow Pain Management Programme NHS Greater Glasgow and Clyde
Background
Fear of movement has been identified as a driver of disability in chronic pain, and as such, it can have a more devastating effect than the pain itself. It is therefore important clinically that fear of movement is identified as early as possible in order to facilitate optimal treatment planning and delivery. The TSK 13 is intended to measure fear of movement, and is frequently used in chronic pain services. We are not aware of any qualitative studies that explore the clinical and content validity of this questionnaire, and anecdotally, our patients frequently struggle to answer questions in the TSK 13.
Aims
The aim was to explore how people with persistent pain interpret and select their responses to the TSK 13 using a cognitive interviewing approach
Methods
17 chronic pain patients sampled from groups at the Glasgow Pain Management Programme completed the study. Using a cognitive interviewing approach, the interviewer asked each patient to complete the TSK 13, and think aloud how they reached their answer. Analyses of interview transcripts were carried out by the two researchers, first independently, and then in unison. These analyses were twofold:
any problems identified within the answers attributed to specific items and questionnaire design.
an exploration of themes and subthemes arising from the data in line with a thematic analysis framework.
Results
Several issues such as misunderstanding, questioning content, and inability to reach an answer arose from the analyses related to the questionnaire design.
- Five overarching themes emerged from the data:
- Threat. Patients discussed the various ways in which they perceived risk and danger.
- Fear. Patients identified ways in which pain informed their day-to-day activity ranging from caution to fear, and viewing pain as a helpful guide.
- Control. Patients had differing perceptions of control when dealing with pain, ranging from hopelessness to having personal choice in how to manage pain.
- People. Patients discussed the influence of experts, friends and family when it comes to managing pain and activity.
- Hurt & Harm. Patients revealed varying perceptions of whether or not hurt equals harm.
- Activity versus exercise. Patients tended to view ‘exercise’ as strenuous and something to be cautious about, and ‘activity’ as something more manageable.
Conclusion
Patients with chronic pain struggled to interpret or answer specific items of the TSK 13, and felt that some of the terminology used was irrelevant to their condition. This influenced their answers to the items.
Several factors influenced patients’ answers on the TSK 13.
It is important to understand the thinking behind patients’ answers on outcome measures, especially where the questionnaire design directly influences patients’ responses through misinterpretation or disagreement with terminology. This helps inform services of the clinical and content validity, and limitations of the TSK 13 for patients with chronic pain.
Br J Pain. 12(2 Suppl):5–54.
Oral 5
Exploring Perceptions of Pain Relief Strategies as Masculine and Feminine Gender Norms and Stereotypes Using Q-Methodology
Category: Psychology
Samantha Wratten - Department of Psychology University of Bath, Christopher Eccleston - Centre for Pain Research University of Bath, Edmund Keogh - Department of Psychology University of Bath
Background
All individuals deserve to live pain-free lives, but research shows that not only do women experience more pain than men (Pieretti et al.,2016), but there are also sex differences in use of pain coping strategies. For example females utilise social support and use positive self-statements more than males (Unruh, Ritchie, & Merskey,1999; Keogh & Eccleston, 2006). There is also evidence of sex differences in use of pain relief strategies specifically, which warrant consideration given their potential to transform the individual’s experience of pain and its impact on their life. Notably, women tend to use analgesics more than men (Vowles et al.,2014), whereas men are more likely to drink alcohol to self-manage their pain than women (Riley & King,2009). However, many studies fail to consider the broader social context in which pain relief is used, including the gendered reputation of these strategies and their associations with masculine and feminine stereotypes.
Aims
There are a variety of ways in which gender stereotypes can be constructed, making it entirely possible for competing stereotypes to emerge and change over time. The aim of this study was to explore any pain relief gender stereotypes held in 21st century Britain.
Methods
Sixty participants completed a Q-sort task which involved ranking 62 analgesic behaviours in terms of their stereotypical social acceptability for either women (Study 1; 30 participants, 50% female) or men (Study 2; 30 participants, 50% female) depending on the instruction given. All participants were over the age of 18 (range = 18-78) with a good understanding of English. Twenty of these participants were also interviewed to aid interpretation of the Q-sort results. Ethical committee approval was granted by Department of Psychology Ethics Committee.
Results
Centroid factor analyses with Varimax rotation identified groups of participants who constructed similar Q-sorts, with each group holding a distinct viewpoint. Four stereotypes emerged; two for men and two for women. There was some overlap; each study captured the view that it is acceptable to use strategies perceived as effective in relieving pain regardless of whether an individual is male or female. However, opposing, more gendered viewpoints also emerged. For women there was a view that it is acceptable to use normative ‘feminine’ behaviours such as asking a female friend or relative for advice, and strategies which pose no burden to others, such as drinking water. For men, a stereotype reflecting hegemonic masculinity was captured, suggesting it is acceptable for men adhere to masculine norms such as ignoring the pain and hoping it goes away, but less acceptable to seek help or use typically ‘feminine’ strategies.
Conclusion
There are gendered and ungendered lenses through which pain relief can be viewed. These different stereotypes coexist in the same society at the same time, with individuals differing in the degree to which they perceive their presence. These stereotypes may influence the way men and women use pain relief, potentially presenting gender-related barriers to achieving optimal analgesia. These findings warrant consideration by practitioners implementing pain management programmes, as well as in guiding individual pain self-management, in order to facilitate better pain management.
Br J Pain. 12(2 Suppl):5–54.
Acute Pain
1
Chronic and Complex Pain Workload of Inpatient Pain Services (Chips) – a National Audit
Category: Acute Pain
Mark Rockett - Anaesthesia, critical care and pain medicine Plymouth Hospitals NHS Trust
Background
Despite evidence that inpatient pain services can be cost effective, they have been generally under resourced in the UK and are at risk from decommissioning in many areas. It is imperative that these services demonstrate added value in a cash limited NHS. Two areas where benefit to patients and savings may be achieved are in the management of inpatients with exacerbations of chronic pain and those with complex pain problems who have undergone surgery or trauma. Both these groups often have prolonged and costly inpatient stays. These patients do not fit within enhanced recovery programmes without support from effective inpatient pain services and account for approximately 15% of the surgical workload. Published single centre audit has revealed the significant extent of this workload and this poster presents findings from the pilot to a national audit.
Aims
The aim of this national audit is to reveal the workload of managing inpatients with chronic and complex pain. We aim to collect data on diagnoses and referral patterns, length of hospital stay, organisational data and impact of intervention. National level data will inform NHS resource use.
Methods
The dataset was selected following local audit and review by members of the acute pain specialist interest group of the British Pain Society. A pilot audit was carried out in two centres and the dataset modified based on these findings. Sites for the national audit were identified from previously published acute pain service census data and via advertising on the National Acute Pain Symposium website. To date 63 hospitals have agreed to carry out the audit throughout the UK. Data collection spreadsheets will be sent to all participating hospitals in January 2018 and each will begin a staggered eight-week data collection period up to mid-May 2018. Data collection will be complete by late summer 2018. Following analysis, the findings on the two key patient groups will be published in peer-reviewed journals. Each hospital will also be able to benchmark its own data against national data to facilitate local commissioning discussions.
Results
Pilot data were available for one month. These data included time spent managing patients with exacerbations of chronic pain only. National data on acute pain management in patients with chronic pain will be presented in the poster. 25 patients were identified. 68% of the patients were female with a mean age of 62.6yrs (SD 18.9). Male patients mean age was 47.5 (16.7), not significantly different from the female patients (p=0.06). The median length of stay was 7 days, with a range of 1-44 days. Patients were seen a median of 2 days after admission and discharged a median of 3 days later. The data were skewed by outliers. 72% of referrals were from acute medicine, the remainder from surgical specialties. 56% of the patients had chronic back or neck pain and 20% had exacerbations of chronic abdominal pain. Other diagnoses included medical pain, chronic widespread pain and chronic infection.
Conclusion
Given these figures, we conservatively expect 1550 datasets nationally from 63 sites for exacerbations of chronic pain and a similar number for complex pain management. The pilot audit has demonstrated that we can collect data reliably from multiple sites. The data reveal high levels of inpatient service use by patients with exacerbations of chronic pain. National data may reveal which models of care result in reduced length of stay in these patients and help to inform future investment in inpatient pain services.
Br J Pain. 12(2 Suppl):5–54.
2
The Prevalence of Vitamin D Deficiency in Patients Referred to the Inpatient Pain Service
Category: Acute Pain
Amal Thomas - Medical Student attached to Acute Pain St George’s Hospital, London, Lenny Ng - Inpatient Pain Team, Anaesthesia St George’s Hospital, London, Rozanna Kinmans - Inpatient Pain Team, Anaesthesia St George’s Hospital, London, Alison Moss - Inpatient Pain Team, Anaesthesia St George’s Hospital, London
Background
Vitamin D deficiency causes musculoskeletal pain and weakness, and is associated with negative health effects, including osteoporosis, cardiovascular disease, type2 diabetes and autoimmune conditions. Vitamin D deficiency is common in the general UK population, especially the elderly, the institutionalised, obesity, malnutrition, renal and liver disease, anticonvulsant use and skin pigmentation. We have found a high prevalence of Vitamin D deficiency among the patients with the above risk factors in patients referred to the Inpatient Pain Service at St George’s Hospital, London. Addressing low Vitamin D levels can help to lower self-reported pain, improve bone health and lead to better patient outcomes in terms of quality of life and the prevention of associated morbidity.
Aims
Our aim was to look at the prevalence of Vitamin D deficiency in patients referred to our service with the following risk factors: the elderly, prolonged stay in hospital, obesity, malnutrition, renal and liver disease, anticonvulsant use, skin pigmentation or who presented with a fragility fracture.
Methods
We retrospectively examined the results of patients who had their Vitamin D levels checked between 1 April 2016 and 1 March 2017. A total of 21 patients were identified. The recorded Vitamin D levels for these patients were compared to the NICE recommendations of deficient (less than 30nmol/L), insufficient (30-50nmol/L) and sufficient (above 50nmol/L).
Results
We found that the vast majority of our patients (81%) were either insufficient of deficient in Vitamin D.
Out of the 21 patients, it was found that 11 (52%) were Vitamin D deficient, 6 (29%) insufficient and only 4 (19%) were Vitamin D sufficient.
We recommended treatment in those deficient and insufficient according to the NICE guidelines 2016.
Conclusion
We found a high prevalence of Vitamin D insufficiency and deficiency in our inpatient population with risk factors. This has significant health and quality of life implications, as well as the prevention of morbidity for this group of patients. We would advocate for wider screening in the inpatient population to enable adequate supplementation to improve health outcomes.
Br J Pain. 12(2 Suppl):5–54.
3
Audit of Adequacy of Perioperative Pain Management in Cancer Patients Undergoing Video-Assisted Thoracoscopic Surgery at st. George’s Hospital
Category: Acute Pain
Dr Ying Ran Tow - General Surgery Royal Cornwall Hospitals NHS Trust, Dr Michael Robson - Anaesthetics St. George’s University Hospitals NHS Foundation Trust, Dr Lenny Ng - Anaesthetics St. George’s University Hospitals NHS Foundation Trust, Dr Hannah Dawe - Anaesthetics Ashford and St Peter’s Hospitals NHS Foundation Trust
Background
St. George’s Hospital is a cancer centre, performing video-assisted thorascopic surgery (VATS) procedures.
It is well recognised that VATS is associated with a high risk of developing persistent post-surgical pain (PPSP) with reported rates of 22 to 63%. PPSP can have a negative impact on the patient’s quality of life, but the risk may be reduced if acute pain is well managed.
Aims
The primary aims of this audit were to:
assess the adequacy of perioperative pain management in cancer patients undergoing VATS
assess the referral rates of this patient cohort to the inpatient pain service (IPS).
Methods
All patients with suspected or confirmed cancer undergoing VATS during May to June 2017 were identified prospectively.
Patients admitted to intensive care post-operatively were excluded.
Information regarding perioperative care was collected including:
Pre-operative
Pre admission analgesia
Intra-operative
Surgery performed and duration
Anaesthetic technique and analgesia
Post-operative
Pain score on movement (0=no pain, 1=mild, 2=moderate, 3=severe)
Analgesia administration in response to pain on movement rating >1
Patient satisfaction with anaesthetic care and post-operative pain management
Referrals to the IPS
Hospital length of stay
Results
25 patients identified
11 (44%) male, 14 (56%) female
Mean age 68 years.
Mean length of hospital stay 4.5 days
Pre-operatively:
All patients reported pain score of 0
7 patients were taking regular analgesia prior to admission.
Intra-operatively
All patients had a general anaesthetic.
All received fentanyl and paracetamol.
7 (28%) received ketamine
12 (48%) had paravertebral catheter (PVC) inserted; 22 (88%) had local anaesthetic infiltrated at the surgical site
Recovery
4 (17%) reported pain score >1, all subsequently received morphine
Post operatively
All patients with PVC received local anaesthetic (LA) infusion.
21 (84%) were given patient controlled analgesia (PCA) morphine, 9 of whom also had a PVC.
13 patients (54%) reported pain scores 2 or 3; 4 (31%) received analgesia within an hour.
There were no referrals to the IPS.
Patient satisfaction:
All patients were satisfied with anaesthetic care
96% of patients were satisfied with pain management
Conclusion
These patients received adequate perioperative pain management.
Multimodal analgesia was used incorporating ketamine, continuous local anaesthetic infusions via PVCs and/ or morphine PCA.
24 patients stated they were satisfied with their pain management when questioned directly.
However, more than half of patients reported moderate or severe pain post-operatively and only a third of these received analgesia within an hour, suggesting potential for improvement.
There were no referrals to the IPS during the audit period. This could be due to lack of understanding of which patients may benefit from IPS input, or that the team were confident in escalating analgesia independently.
Br J Pain. 12(2 Suppl):5–54.
4
Intravenous Lidocaine Infusions for Complex Inpatient Pain Management at Torbay Hospital
Category: Acute Pain
David Hutchins - Anaesthesia & Pain Torbay & South Devon NHS Foundation Trust
Background
Severe acute pain is debilitating and distressing, and conveys profound multi-system, acute and chronic effects. It also carries implications for healthcare providers, as patients often require many resources within the multi-disciplinary team. This can be costly in terms of both staff time and Trust finances.
Many current systemic analgesics are associated with adverse effects, which increase patient suffering and prolong inpatient length of stay. There is an associated greater use of resources and ultimately greater healthcare costs. There are also certain patient groups in which pain can be very challenging to manage.
Recent research into the analgesic benefits of intravenous Lidocaine has proved promising, particularly in patients with acute hyperalgesia in complex pain, and where opioids are not effective. Lidocaine provides good analgesia with reduced opioid consumption and avoidance of adverse effects, with faster return of normal physiology. These combine to potentially reduce length of stay, resource usage, and expenditures.
Aims
The Torbay In-Patient Pain Service (TIPPS) aimed to introduce and trial an intravenous Lidocaine analgesic pathway for a specific in-patient patient group suffering acute pain. We aimed to improve patients’ pain, reduce TIPPS patient review frequency, reduce length of stay and provide fiscal savings to the Trust.
Methods
Following a literature search, a guideline was constructed accounting for local staffing and infrastructural factors. A four-month trial was undertaken by the TIPPS.
TIPPS identified a number of inpatients whose symptoms did not respond to ‘conventional analgesics’, including anti-neuropathics. Indications for pathway inclusion are:
Severe neuropathic/post-operative pain.
Pain unresponsive to maximal in-patient, ward-based, conservative and medical pharmacological management following review by TIPPS.
Acute, or an acute exacerbation of chronic pain.
If all indications are met, following written consent patients are transferred to the emergency theatre anaesthetic room. With full AAGBI monitoring in-situ, the infusion of 3mg/Kg at a rate of either 60 or 90 minutes (based on Trust frailty score) begins. Following 15 minutes without adverse effects, the patient is moved to the post anaesthesia care unit for a reduced monitoring intensity and infusion completion.
If successful, patients are offered inclusion on a Nurse-led day-case IV Lidocaine outpatient pathway.
Results
To date, five inpatients have converted to the pathway with an average age of 43 years.
The average length of inpatient admission prior to the IV Lidocaine pathway trial was 20.6 days. The average length of admission is now 12 days; an average reduction in length of stay of 7.4 days. Inpatients received a TIPPS review on average 7.2 times prior to receiving IV Lidocaine. Following IV Lidocaine, patients average review frequency was 3.5 times. TIPPS review frequency therefore fell by 51.7% following successful completion of an IV Lidocaine infusion. No safety issues/clinical incidents have been reported in relation to the use of the pathway.
Four of the five patients have had no inpatient admissions since converting to regular treatment via outpatient-based infusions. This has resulted in cost reductions for the Trust equating to approximately £60,000 within a year of commencing the service.
Conclusion
We have developed and are safely and successfully running an intravenous Lidocaine pathway for complex pain patients resistant to NICE-endorsed optimal ward-based conservative and medical therapy.
From a patient perspective, this pathway has reduced pain and in-patient length of stay. From a service perspective, initiation of this pathway has reduced pressure on a pressured TIPPS, and reduced readmission rates. This has reduced overall Trust healthcare costs by approximately £60,000 per annum.
Key to the success of this pathway has been appropriate involvement from key stakeholders within the Trust, a highly motivated pain service, and appropriate patient selection.
Br J Pain. 12(2 Suppl):5–54.
5
Pain in Recovery - A Local Quality Improvement (QI) Project
Category: Acute Pain
Kerry Elliott - Anaesthetics Royal Free NHS Trust, Oliver Pietroni - Anaesthetics Royal Free NHS Trust
Background
Severe postoperative pain has been shown to negatively impact on patient satisfaction and can influence postoperative morbidity. It has also been implicated as a risk factor for the development of persistent post-surgical pain (PPSP).
In our hospital we use a numerical rating scale of 0-3 with scores of 2 and 3 being moderate and severe pain respectively.
Aims
To identify those patients with significant (moderate to severe) pain in recovery and to try and identify recurrent themes within this cohort.
Methods
As part of a QI project we collect data on outcomes after anaesthesia, including pain scores (PS) in recovery. Data is collected for a 2 week period every quarter and captures all patients passing through theatre recovery.
Our aim is to have < 10% of patients with a PS 2+ in recovery. Over three cycles we captured 876 patients of which 18.4% (161 patients) had PS 2+ in recovery. We reviewed all of the available notes in further detail (145/161).
Results
42% of PS 2+ patients had a history of regular analgesic use or were being treated for anxiety, depression or chronic pain.
Most patients received a fentanyl and paracetamol based analgesic plan with only 25% of cases receiving a long acting opiate intra-operatively. Just 23% received non-steroidal anti-inflammatory drugs and 5% received other analgesics.
Although 58.6% of cases were amenable to some form of regional anaesthetic, only 17.9% received this. 43.3% of cases had no documented local anaesthetic given.
Overall 18% of patients experienced significant pain postoperatively. However this was considerably higher for some procedures: Laparoscopic cholecystectomy 47.4%; total knee replacement 44.4%; laparoscopic surgery 37.7%; mastectomy 37.5% and nephrectomy 34.8%.
For one cycle (238 patients) we examined length of stay in recovery (LOS). The median LOS for PS 2+ was 1h 40min (range 47min - 18h35min) compared with 1 hour (range 15min - 22h) for PS < 2.
Conclusion
We have highlighted risk factors known to be associated with increased post-operative pain. We have also seen patients in pain spend longer in recovery. Improving peri-operative analgesia may help improve patient satisfaction, reduce PPSP and increase recovery utilisation.
Through presenting these findings and education within the multidisciplinary team the subsequent cycle had 15.3% of patients with PS 2+.
As a result of this we are carrying out prospective audits on specific surgical cohorts. We also aim to identify high risk patients preoperatively and provide extra resources for them.
Br J Pain. 12(2 Suppl):5–54.
6
The Creation of a Peri-Operative Analgesia Protocol for Major Hepatobiliary Surgery in a Tertiary Referral Hospital
Category: Acute Pain
James Parry - Anaesthetics Royal Free NHS Trust, Clare Melikian - Anaesthetics Royal Free NHS Trust, Pippa Pemberton - Pain management Royal Free NHS Trust
Background
Standardisation of practice is a proven way to streamline systems, improve efficiency and potentially patient care. There is a multitude of analgesic regimes that can be utilised intra and post-operatively for hepatobiliary (HPB) surgery including the use of lignocaine intravenous infusion (IVI), intrathecal opioids, epidural anaesthesia and patient controlled analgesia (PCA). Adequate analgesia has a major impact on patient satisfaction, can potentially aid earlier mobilisation, reduce short term complications and reduce chronic post-surgical pain. Anecdotal reports from the hospital’s acute pain team has found difficulty in managing pain in major HPB surgery patients on the wards.
Aims
We initiated a quality improvement project. Our aim was to standardise analgesic regimes for major hepatobiliary surgery to reduce post-operative pain scores in 12 months at the Royal Free Hospital NHS Trust.
Methods
We performed an analysis to identify key stakeholders (anaesthetists, surgeons, intensive care team, acute pain team, patients, management). Baseline data was collected prospectively via a paper proforma reviewing adult major HPB patients over a two month period between September and November 2017. The outcome measure was pain scores, the process measures were analgesia used and duration, complications and patient satisfaction. To guide protocol creation, we established current practice nationwide amongst other HPB units via an online survey sent to 32 departmental secretaries and distributed accordingly to HPB anaesthetic consultants. Data was input into Microsoft Excel ©. Data was analysed as medians for daily pain scores and percentages for proportions of analgesics used across the patient cohort. Following data analysis, we developed an analgesic protocol including a flowchart for major HPB surgery.
Results
22 cases were analysed, 59% male, 45% 61-80 years old. Intra-operative analgesia use was: Paracetamol (90%), Fentanyl (77%), spinal diamorphine (50%), ketamine (50%), lignocaine IVI (27%), magnesium (18%), epidural (14%). Post-operative analgesia use was: Paracetamol (72%), Fentanyl PCA (68%), epidural (9%). Median daily pain scores (0-3) were day 0: 1, day 1: 2.5, day 2: 2, day 3: 1, day 4: 1, day 5: 1, day 6: 1. Two patients had chronic pain and there were three analgesia-related complications. Fentanyl PCA use ranged from 100mcg/24 hours to 5mg/24 hours, median duration was 1.5 days. Regarding the national survey, 91 anaesthetists from 22 units responded. 60% use an enhanced recovery program, 50% an analgesic protocol. Intra-operative analgesia use was: Paracetamol (71%), epidural (55%), Fentanyl (55%), morphine (20%), spinal diamorphine (15%), ketamine (12%), lignocaine (10%). Post-operative analgesia use was: Paracetamol (80%), epidural (59%), wound catheter (34%), Fentanyl PCA (21%), Morphine PCA (21%).
Conclusion
There was varied practice nationally and locally indicating the need for standardisation, especially as simple analgesia was not always given. The first cycle demonstrated areas for improvement. PCA use was varied and short, with apparent trends demonstrating a peak of pain scores at 24 hours post-operatively, falling at day three, potentially indicating a need for longer PCA use. A protocol has been introduced with multi-disciplinary input. Cycles are ongoing to review and adapt the protocol to enable improved pain scores. A pre-operative information video to help reduce patient anxiety and manage pain expectations is also in production.
Br J Pain. 12(2 Suppl):5–54.
7
Opioid Prescribing in an Acute Trust
Category: Acute Pain
Michael Husband - Anaesthesia Western Sussex Hospitals NHS Trust, Jade Baker - Pharmacy Western Sussex Hospitals NHS Trust
Background
Opioid medications are used to control acute, severe pain and cancer-related pain (particularly in the palliative setting) but the benefits of using opioid therapy for chronic, non-cancer related pain are being increasingly questioned. This is due to a lack of high quality evidence demonstrating benefit and the potential to cause harm. In both inpatient and outpatient settings our Trust encounters or commences many patients on oral immediate release (IR) strong opioid preparations. The IR preparations may be used for approximately 1-2 weeks for acute pain or for chronic pain as a trial to assess suitability of opioid therapy. After this time period they should be stopped or changed to slow release preparations if clinically effective, especially in patients with chronic pain. IR preparations should not be used for chronic pain management due to concerns of tolerance/dependence and addiction as well other adverse health problems if used long term.
Aims
To determine whether patients commenced on IR, strong opioids by our hospital Trust are discharged with a documented plan for duration/review of treatment by their GP.
Secondly, of these patients discharged without an opioid discharge plan, we recorded at 12 months if they had been re-issued opioids by their GP.
Methods
A report was generated from the electronic prescribing system to look for all IR opioid prescriptions written on discharge during September 2016. Medication histories during their admission were scrutinised and all patients taking opioids before admission were excluded. Analysing the discharge document, all patients with a documented malignancy or described as palliative were also excluded. The discharge letters for the remaining patients i.e. those newly started on IR opioids without malignancy or receiving palliative care were assessed. We evaluated whether or not their primary care physician were informed of the reason for initiating the opioid and its intended length of course. In September 2017 the primary care prescribing histories for patients discharged without the appropriate information were reviewed to determine the number of patients who had received IR opioids from their GP.
Results
266 patients were discharged with IR strong opioid preparations during the month of September 2016. 214 (80%) of these patients had a documented, medicines reconciliation (drug history) on their electronic prescribing record. Of these 214 patients 113 (53%) were newly prescribed these medications. 26 of these 113 patients were excluded as they were palliative or suffered from a malignancy leaving 87 records to be evaluated. 72 (83%) of the evaluated patients had no reference in the text of the letter to the newly prescribed opioids in their discharge summary. 12 months following discharge the patients who were prescribed opioids without reference to them in the discharge summary were reviewed. 23/72 (32%) of these patients had been prescribed an acute opioid by their GP on at least one occasion after their discharge from hospital and 7/72(10%) had IR opioids issued by their primary care physician on a monthly repeat.
Conclusion
Initiating IR opioids for acute, severe pain requires the prescriber to ensure that these medicines are reviewed and ceased as soon as possible. The patient’s primary care physician must be made aware of the reasons for the initiation of the medication and intended treatment time. 83% of the discharge letters we assessed did not contain sufficient information with regards to the IR opioid prescription. Potential exists to create adverse health problems related to poor information given to primary care and inappropriate IR strong opioid prescribing.
Br J Pain. 12(2 Suppl):5–54.
8
Effective Post Operative Pain Management in Recovery Ward: An Audit
Category: Acute Pain
Rachel Bloomfield - Anaesthesia and Pain Medicine Pennine Acute Hospitals NHS Trust, Manchester., Vinod Gadiyar - Anaesthesia and Pain Medicine Pennine Acute Hospitals NHS Trust
Background
Postoperative pain can often be seen as inevitable following a surgical procedure. However, effective management of postoperative pain is achievable, reduces suffering, leads to earlier mobilisation and a shorter hospital stay. Pain continues to be poorly managed in the immediate post-operative period. Ineffective pain relief is the main cause of delayed discharge after day-case surgery(1). Failure of pain management in recovery can result in increased patient suffering, and increased calls for help to busy on-call anaesthetists.
Aims
The aims of this audit were to know the effectiveness of intra and postoperative pain relief in 100 patients from various surgical specialities and age groups. Also we aim to find out if there was a delay in discharging patients from recovery ward due to poor pain control.
Methods
100 data collection forms were completed during intra operative period and recovery for each patient. Patient demographics and data about the type of anaesthetic used and drugs given during the procedure were collected. Patients were then asked to score their pain out of 10 on a dynamic pain scale at three points in time: on waking, 30 minutes later and on discharge from recovery. Also, any analgesics used in the recovery ward were noted.
Results
Audit standard was taken from the Royal College of Anaesthetists which stated that 95% of patients should have a pain score of less than 4 at these three points. We achieved 87% and 83% of patients reporting pain scores of less than 4 on waking and 30 minutes later, respectively. 95% had a pain score of less than 4 on discharged from recovery. Analgesia was best achieved in paediatrics and worst in orthopaedics. Male patients had higher pain scores on average than females. We also found that of those who reported a pain score of 4 or greater on waking, none had a higher pain score 30 minutes later.16% of the population had a delay in discharge from recovery. Of the 13 patients that woke up with a pain score of 4 or greater, 69% had delayed discharged from recovery, indicating that suboptimal postoperative pain management is a key cause of delayed discharge.
Conclusion
Overall the department performed well but was only able to achieve 1 out of the 3 standards. To improve compliance with standards we made a number of recommendations including improving intra operative pain management, documenting patient’s pain scores at these 3 points and acting upon elevated scores with rescue analgesia. We plan to repeat this audit to assess the improvement of the department.
Br J Pain. 12(2 Suppl):5–54.
Assessment & Measurement
9
The Opioid Legacy Patients: 18 Months Experience of a Specialised Opioid Reduction Clinic Within a Secondary Care Pain Clinic
Category: Assessment & Measurement
Kristin Ullrich - Department of Anaesthesia Barts Health NHS Trust, Dr Jayne Gallagher - Clinical Lead Pain Management Barts Health NHS Trust, Dr Angie Alamgir - Lead Psychologist in Pain Management Barts Health NHS Trust
Background
UK pain clinics are adopting responsible opioid prescribing for patients with persistent non-cancer pain in recent years. The British Pain Society helped to raise the Opioids Aware campaign that included recommendations on opioid prescribing for non-cancer pain as well as resources for education and pain management. However due to the legacy of overprescribing of strong opioids since the 1990s a substantial number of chronic pain sufferers continue to take high dose opioids despite their deleterious effects. In 2015 a local audit in our pain clinic showed that 27% of patients were prescribed strong opioids for persistent non-cancer pain and that some patients were taking excessively high doses. That audit concluded that a targeted approach to address the problem of high dose opioid prescribing was necessary and suggested the implementation of a multi-professional specialised clinic. Here we audit the outcomes from the first 18 months of this specialised opioid reduction clinic.
Aims
To describe the patient population referred to a specialised multi-professional pain clinic for patients who require opioid dose reduction.
To evaluate clinical outcomes after the first 18 months of the clinic’s existence.
To benchmark the results against the recommendations of Opioids Aware.
Methods
This is a retrospective audit of routinely obtained patient-reported outcomes. All clinicians in our secondary and tertiary care pain clinics were able to refer patients who had a variety of medication-related issues, including overuse, addiction, difficulties with dose reduction. The clinics were usually staffed by two health professionals, one of whom was a pain consultant. Demographic descriptors were age and gender, we recorded the main pain diagnoses. Morphine equivalent doses of the patients’ opioid intake were calculated using BNF conversion tables. Analysis included median, quartiles, and range of opioid dose at first and most recent contact.
We collected the following patient-reported outcomes on the day of the first opioid reduction clinic appointment: Pain Detect Questionnaire, Health related Quality of Life questionnaire EQ5D-3L, Pain Self Efficacy Questionnaire (PSEQ), Hospital Anxiety and Depression Scale (HADS). At follow up appointments patients were asked to fill in EQ5D-3L and PSEQ.
Results
30 patients were seen at least once in the specialist clinic. 57% were female, median age 49 years. The most common pain diagnoses were widespread pain (40%), failed back surgery (27%), and Ehlers Danlos Syndrome (13%). At the first appointment patients were taking a median opioid dose of 300mg (range 70-4100mg) oral morphine equivalent per day. 83% of patients were taking more than 120mg morphine equivalent per day. 37% of patients also had overuse problems with other drugs, e.g. benzodiazepines. Patient-reported outcomes indicated very poor quality of life and self-efficacy and high incidence of clinical depression and anxiety.
At follow up 85% of patients had achieved a reduction of their opioid intake. The median reduction in morphine equivalent daily dose was 26% (range +10% to -75%). Patient-reported outcomes were no worse than at the first appointment. 53% of patients continue in the opioid reduction clinic aiming for further reduction.
Conclusion
Patients referred to this opioid reduction clinic take extraordinarily high doses of opioids and other centrally acting medications. By comparison, in previous snapshot audit of our primary and secondary care pain clinics the median opioid dose of the group on strong opioids was 67.5mg daily. These patients report very poor health-related quality of life and extremely low self-efficacy regarding their pain management. Due to the very high prevalence of clinically relevant anxiety and depression the clinic was supported by a Clinical Psychologist during recent months. An individualised strategy to reduce the intake of opioids is required for these complex patients.
Br J Pain. 12(2 Suppl):5–54.
10
Do Goals Change Over a Pain Management Course?
Category: Assessment & Measurement
Isabelle Hung - Pain management UCLH, Nadine Bakst - Pain Management UCLH, Dr Anna Sims - Pain Management UCLH
Background
Chronic pain programmes often try to draw focus away from pain reduction/control as the main goal because it is so difficult. Instead, pain management programmes focus on improving quality of life by encouraging participants to engage in other valued activities and goals.
Measuring outcomes in pain management has been varied. Some studies have increasingly tried to capture goal attainment as an outcome. This entails setting goals at the start of, or prior to, the programme, and then rating the extent to which this goal has been achieved. This is challenging, as it assumes that the goals remain the same.
Our pain management programme reflects on what individuals’ values are, and how to build SMARTER goals around them. During each session, participants reflect whether their goal needs changing as they learn pain management skills, become more accepting of pain, or realise that their goal is too easy or ambitious.
Aims
Our aims are to examine:
whether a participant’s goals change; and
why they change.
Methods
A document is given to participants in the penultimate week of the 6-week pain management programme. The form asks participants to self-report: (i) what their goals were at the beginning of the programme; (ii) whether their goals changed; (iii) why they changed; and (iv) what they are now.
All of the competed documents from all 6 groups during 2017 were used.
3 of the group facilitators studied the data to see which goals people had, and their reasons for changing their goals. The group facilitators then met to reach a consensus regarding the response categories. All facilitators then individually went through the data to categorise each response. The last stage involved meeting to agree on the categories which each response fell into, and to discuss any discrepancies.
Results
There were 55 participants, ranging from 21 to 84 years old, of whom 32 had hypermobility spectrum disorder.
Only 13 people did not change their goals. 6 changed goals completely, 24 developed previous goals as well as adding new goals, 3 participants kept their previous goals unchanged and added new goals, and 9 participants developed their original goals.
The most common reasons for changing goals were: (i) news skills being learnt (n=10); (ii) goals were SMARTER (n=9); (iii) goals were more values-based (n=9); and (iv) an increased understanding had led to goals changing/shifting (n=7).
Over 20 goal categories were found. The most common were: (i) to be more active/improve fitness; (ii) to learn new pain management skills; (iii) to socialise more or improve relationships; (iv) work/university related (e.g. increase hours worked). Goals were similar at the end of the programme, except that more specific sports
Conclusion
Only a minority of people self-reported no changes to their goals over the course of a pain management programme. As people learn to reflect on values, learn about goal-setting, and learn pain-management skills, their goals change, develop and often more goals are added. Therefore, measuring goal attainment for specific goals over the course of a pain management programme is too limiting to capture the positive changes that have been made.
Br J Pain. 12(2 Suppl):5–54.
11
Leaner and Stronger: Creating a Short Form of the Adolescent Chronic Pain Acceptance Questionnaire (CPAQ-A8)
Category: Assessment & Measurement
Jeremy Gauntlett-Gilbert - Bath Centre for Pain Services Royal United Hospitals Bath NHS Trust, Geoffrey Duggan - Bath Centre for Pain Services Royal United Hospitals Bath NHS Trust
Background
Pain acceptance is a powerful predictor of distress and functioning in adults and children with chronic pain. It has typically been indexed with the Chronic Pain Acceptance Questionnaire (CPAQ) in adults, which has been widely used in cross-sectional, longitudinal and treatment process studies. The adolescent form of this questionnaire is strongly associated with distress and functioning (McCracken et al. 2010, Eur J Pain), and it has been used to demonstrate that changes in pain acceptance are an essential component of successful rehabilitation for adolescent pain. After much use, a short form of the adult questionnaire was created that retains the original’s factor structure and predictive power. We aimed to create a similar short form for paediatric clinicians and researchers.
Aims
The aim was to create a short form of the CPAQ-A using confirmatory factor analysis, retained the original two-factor structure, and to carry out preliminary analyses of its predictive power.
Methods
Our sample was of 183 consecutive attenders at an adolescent pain rehabilitation programme, who gave written, informed consent to participate for their data to be used for research. The sample was 79% female (98% white British), median age was 15.8 yrs, primarily with diagnoses of Diffuse Pain (35%), CRPS (25%), Back Pain (10%), Headache (10%) abdominal pain (6%) and pain associated with hypermobility (6%). Only 34.6% were in school full time, and of those scheduled to attend, they were missing an average of 3.7 half days per week.
We took the original 20 items and used Confirmatory Factor Analysis to examine single-factor and two-factor structures for the original questionnaire. We then examined the item-total correlations and standardised factor loadings in order to select 8 items (four for each factor) for the proposed short form. We examined the predicted two-factor solution.
Results
We examined the satisfactoriness of the various models using standard indices of fit, where the desired coefficients are suggested to be: RMSEA > .10; TLI, CFI, GFI < .90; AGFI < .80. The single factor solution for the whole scale was, as predicted, inadequate, and the two factor solution was better but only marginally acceptable (RMSEA > .063; TLI, CFI, GFI < .86; AGFI < .83). However, the new 8 items showed a superior fit (RMSEA > .074; TLI, CFI, GFI all < .95; AGFI < .91) and a particularly high level of fit when a single set of errors were correlated (RMSEA > .042; TLI, CFI, GFI all < .96; AGFI < .94) . Six of eight items were the same as in the adult CPAQ-8. There were strong correlations with social and physical functioning, depression, and pain-related fear (r .38 to .64).
Conclusion
The new CPAQ-A8 has similar, but not identical, items to the adult CPAQ-8. Its factor structure and model fit were superior to those of the full-length scale. The scale was similar to the adult CPAQ-8, but with two different items (“My life is going well, even though I have chronic pain”, “I need to concentrate on getting rid of my pain”). The new questionnaire correlates well with functioning and distress.
Br J Pain. 12(2 Suppl):5–54.
12
Survey of Opioid Medications Beyond the Recommended Dose in a Secondary Care Pain Clinic
Category: Assessment & Measurement
Cima Dailami - Anaesthesia and Pain Medicine Pennine Acute Hospitals NHS Trust, Manchester., Vinod Gadiyar - Anaesthesia and Pain Medicine Pennine Acute Hospitals NHS Trust, Joshua Adedokun - Anaesthesia and Pain Medicine Pennine Acute Hospitals NHS Trust
Background
There has been a sharp rise in the prescription of opioids for chronic pain in the United Kingdom . With the rise of opioid use and subsequent rise in opioid related side effects such as dependence, greater attention has been drawn to the safe prescribing of these medications. The Royal College of Anaesthetists (RCoA) states ‘the risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit’. This audit is important as it sheds light on the relevant topic of overuse of opioid analgesia in the UK and whether patients themselves are aware of the side effects and have a desire to reduce or discontinue opioid use altogether.
Aims
The aim of this audit was to investigate the use of opioids in patients attending pain clinics at our Trust. The purpose was to investigate how many patients are taking more than the RCoA recommended amount of opioids and whether they have a desire to reduce or discontinue opioid use.
Methods
Paper questionnaires were designed for patients to complete at their pain clinic appointment, before they saw the Consultant. The questionnaires, consisting of 5 questions, were distributed over a period of 5 months (July - November 2017). The questions included which medications were being used for analgesia, the duration of use and where such medications were initially prescribed. More detailed questions on patients’ awareness of opioid side effects and their desire to reduce or discontinue opioid medications were also asked. These details were verified by the Pain Consultant during the consultation. Only patients who use opioid analgesia were focussed on for this study. The data from these patients were coded and analysed in SPSS version 24.
Results
Of the 292 patients who completed the questionnaire,180(61.6%) were taking opioid analgesia. The most common opioids taken were codeine (40.6%) followed by tramadol (23.3%) and morphine (22.2%).
Of the 180 opioid taking patients, 32(17.8%)were on more than 120mg of morphine or the morphine equivalent per day. The median dose was 164mg. 98 patients (54.4%) have been taking opioids for 12 months or longer, 28 patients have been on opioids for more than 5 years. The majority of patients, 76.1%, had opioids initially prescribed by their general practitioner. Of the 180 patients using opioids 64.4% were aware that dependence is one of the side effects. Patient awareness was less than 33% for 5 other common side effects of opioids. 24.4% of patients were not aware of any of the listed opioid side effects despite taking them. 58.3% patients indicated they would like to reduce or discontinue their opioid use.
Conclusion
17.8% of patients in this audit are on more than the RCoA recommended daily limit of opioid consumption for chronic pain, with median dose of 164mg and maximum dose of 960 mg of morphine equivalent. Alarmingly few patients are aware of the common opioid side effects and 40% of patients would not like to reduce or discontinue opioids.
We recommend that the opioid use be discussed in the clinic. Information needs to be provided and the patients on higher dose be actively encouraged to reduce the dose with support from the pain clinic.
Br J Pain. 12(2 Suppl):5–54.
13
A Feasibility Study of a Computerised Version of the Bath Adolescent Pain Questionnaire: The BAPQ-C
Category: Assessment & Measurement
Abbie Jordan - Department for Psychology University of Bath, Lisa Austin - Department of Health University of Bath, Hannah Connell - Chronic Pain Services Royal National Hospital for Rheumatic Diseases, Rhiannon Edwards - Department for Psychology University of Bath
Background
Responding to a call for more age appropriate, psychometrically robust measurement tools to assess the impact of chronic pain on the lives of adolescents, the Bath Adolescent Pain Assessment Questionnaire was developed (BAPQ: Eccleston et al., 2005). The BAPQ is a self report paper based measure which comprises seven subscales that assess functioning in a range of domains (e.g. family, social, psychological, physical, developmental). Psychometric evaluation of the BAPQ has shown the measure to be robust, with high levels of reliability and validity. Whilst the BAPQ has been adopted internationally, adolescents and clinicians have called for a computerised version of the measure. Such demands reflect a wider call from adolescents to incorporate technology in health based self report assessment (Wallace et al., 2014). In response to these identified needs, a computerised version of the BAPQ was developed for real time completion by adolescents in clinical settings.
Aims
The aim was to establish the usability of a computerised version of the BAPQ (BAPQ-C) with adolescents with chronic pain by:
Administering and evaluating how participants respond to the BAPQ-C through participation in cognitive debriefing.
Examine the usability of the BAPQ-C via completion of a Usability Questionnaire.
Methods
2.1 Participants
14 adolescents, aged 11 – 18 years with chronic pain (> 3 months) were recruited from a residential tertiary care pain management programme.
2.2. Measures
The BAPQ-C comprises an identical version of the original BAPQ, with items presented electronically rather than via a paper based measure. Participants completed the BAPQ-C using a tablet.
A Usability Questionnaire was completed by asking participants to comment on the interface of the BAPQ-C and any difficulties experienced in competing the BAPQ-C.
2.4. Cognitive debriefing
Participants were asked to discuss their experiences of completing the BAPQ-C in real time. A particular focus was placed on questioning participants about reasons for particular responses and ease of response using the tablet. The cognitive debriefing procedure was digitally recorded, with audio interactions transcribed verbatim.
2.5. Ethics
Project ethical approval was granted by University of Bath Department of Psychology Research Ethics Committee and an NHS Research Ethics Committee.
Results
The majority of the participants (n=13) expressed a clear preference for the computerised version of the BAPQ measure, identifying ease and speed of completion as valued attributes.
Evaluation of data from the Usability Questionnaire further supported the overall preference for the BAPQ-C. Specifically, data highlighted how adolescents preferred the online versus paper based tick boxes, appreciated the ease in which mistakes could be corrected, improved online navigation (e.g. drop down boxes) and the universal acceptability of the computerised measure format.
Textual analysis of data from the cognitive debriefing task identified particular reasons for expressed preference for the BAPQ-C. These included ease of use via being able to scroll through sections, an increased sense of personalisation of the measurement tool and the increased ability of adolescents to complete it alone without a scribe. Additionally, adolescents reported finding the BAPQ-C easier to complete via a touch screen than with a pen.
Conclusion
Overall, the computerised version of the BAPQ was well received amongst adolescents with chronic pain. The majority of adolescents (n=13) preferred the BAPQ-C to the paper version as it was quicker to complete, more accessible, and easier to navigate than the paper version. Adoption of the BAPQ-C in clinical contexts may result in positive outcomes for both clinicians and patients. Possible benefits include saved clinician time, reduced physical storage needs, and increased patient satisfaction.
Br J Pain. 12(2 Suppl):5–54.
Cancer Pain
14
Neuropathic Pain and the Use of Gabapentinoids in a Cancer POPULATION
Category: Cancer Pain
Sabina Bachtold - Pain Management The Royal Marsden Hospital, David Magee - Pain Management The Royal Marsden Hospital, Sumankely Tissaweerasingham - Pain Management The Royal Marsden Hospital, Matthew Brown - Pain Management The Royal Marsden Hospital, John Williams - Pain Management The Royal Marsden Hospital, Paul Farquhar-Smith - Pain Management The Royal Marsden Hospital
Background
With early detection of cancer and significant evolution in the treatments offered, the number of cancer survivors has increased leading to a broader challenge of managing pain in this population.
Cancer-related and cancer treatment-related neuropathic pain remains problematic both in terms of analgesia required and the burden of side-effects.
Aims
To determine the prevalence of neuropathic pain in patients attending pain management clinics in a cancer hospital.
To describe the causes of neuropathic pain.
Overview of the use of gabapentinoids in our treatment population.
Methods
Patients seen in the Royal Marsden Pain Management Clinics between January 2016 – November 2017 with documented pain diagnosis and who consented to providing data through a bespoke tablet interface were included. Our database complies with Information Governance requirements and has Research Ethics Committee approval (16/LO/1989).
Analysis first addressed the clinician diagnosis of pain – neuropathic or nociceptive. The use of gabapentinoids was quantified in these 2 groups. The use of DN4 score in this population was assessed and its sensitivity, specificity and accuracy were calculated. The causes of neuropathic pain were further detailed.
Results
541 patients with a recorded clinician diagnosis of neuropathic or nociceptive pain and a DN4 score were included: 42.5% neuropathic pain, 27.3% mixed pain and 30.2% nociceptive pain. Using clinician diagnosis as the standard, DN4 score was calculated to have a sensitivity of 74.8%, specificity of 72.3% and accuracy of 74.1%.
Of those with neuropathic pain, pain after cancer treatment was the most frequent cause followed by cancer related pain and pain unrelated to cancer.
Causes of pain after cancer treatment: 51.6% persistent post-surgical pain; 37.4% chemotherapy induced neuropathy; 15.6% radiotherapy-induced pain and 5.8% had pain secondary to other types of treatment. Some patients had a combination.
44.1% of all patients had taken gabapentinoids at some point, with pregabalin being used in 75% of cases. Out of 119 patients with a clinician diagnosis of nociceptive pain and non-neuropathic DN4 score – 29 patients were found to be taking gabapentinoids.
Conclusion
The prevalence of neuropathic pain in patients being reviewed in pain clinics in a specialist cancer hospital was much higher that reported in the literature.
A large subset (50%) of the population we treat in the outpatients department are cancer survivors suffering from pain caused by one of the cancer treatments, with more than half of all the neuropathic pain being attributed to surgery.
In our population group, DN4 had a lower specificity and sensitivity than previously reported in cancer patients, but this is likely to change as we collect more data.
Br J Pain. 12(2 Suppl):5–54.
15
Persistent Post-Surgical Pain in a Cancer Population
Category: Cancer Pain
David Magee - Pain Management The Royal Marsden Hospital, Sabina Bachtold - Pain Management The Royal Marsden Hospital, Sumankely Tissaweerasingham - Pain Management The Royal Marsden Hospital, Matthew Brown - Pain Management The Royal Marsden Hospital, Paul Farquhar-Smith - Pain Management The Royal Marsden Hospital, John Williams - Pain Management The Royal Marsden Hospital
Background
Persistent post-surgical pain (PPSP) is reported in 15-50% of those undergoing surgical procedures [1]. It influences recovery outcomes and quality of life [2]. The transition from acute to PPSP is a critical process and although currently poorly understood, it is an area of considerable interest and research [3].
Delineating between surgical specialities, procedures and the associated patterns and characteristics of PPSP may help guide the development of targeted interventions to reduce the incidence of this common problem.
Aims
Determine the prevalence of PPSP in patients attending pain management clinics. Compare pain characteristics between those with PPSP and those with non-PPSP pain diagnoses. Identify the commonest surgical specialties in which PPSP is seen and compare pain characteristics amongst these surgical groups.
Methods
Patients seen in the Royal Marsden Pain Management Clinics between January 2016 – November 2017 with a documented pain diagnosis and who consented to providing data through a bespoke tablet interface were included. This database complies with Information Governance requirements and has Research Ethics Committee approval (16/LO/1989).
Prevalence was determined by the proportion of individuals diagnosed with PPSP amongst those attending Pain Management Clinics. The three most common surgical specialties with PPSP were identified. Comparisons were made between patients with PPSP and those without, as well as amongst surgical specialties for the following:
pain severity and interference (Brief Pain Inventory, BPI ?7)
clinician diagnosis of neuropathic pain
screening tool for neuropathic pain (Douleur-Neuropathique-4, DN4 ?4)
anxiety and depression (Hospital Anxiety and Depression Scale, HADS ?11)
Comparisons were assessed using the Chi-Squared test.
Results
A total of 601 patients were included, of which 169 (28.1%) had a diagnosis of PPSP. The commonest surgical specialties were breast cancer surgery (39.1%), sarcoma surgery (14.2%) and head and neck cancer surgery (13.2%).
When comparing patients with PPSP to those with non-PPSP related pain, the BPI identified similar proportions with severe pain intensity (17.6% vs 18.6%) and interference (39.6% vs. 34.7%). 81.1% of those with PPSP were diagnosed with neuropathic pain by clinicians. This was significantly greater than those who presented with all other pain diagnoses (p<0.005).
HADS identified a higher likely prevalence of anxiety in the PPSP group (35.7% vs. 28.4%) although this was not statistically significant. However, the likely prevalence of depression, which was also higher in the PPSP group (63.7% vs. 48.1%), did have statistical significance.
No significant differences in pain severity, interference, anxiety, depression or neuropathic features were seen when surgical groups were compared.
Conclusion
PPSP was diagnosed as the cause of pain in approximately one third of the patients attending pain clinics at a specialist cancer centre. 39.1% of these patients had undergone breast cancer surgery. A neuropathic component to the pain experienced was more common in those with PPSP. The presence of this particular type of pain has been reported to have a greater impact on quality of life [4]. This may explain the higher likely prevalence of anxiety and depression encountered in the PPSP cohort.
Br J Pain. 12(2 Suppl):5–54.
16
Incidence and Characteristics of Pain in Patients Attending Medical Day Units
Category: Cancer Pain
Martin Galligan - Acute Pain Homerton University Hospital, Farzan Baksh - Pain Management Royal Marsden NHS Foundation Trust
Background
Cancer pain is arguably one of the most common and debilitating symptoms that can occur at any point during cancer treatment. The incidence of pain is estimated at 39.3% following curative treatment, 55% during treatment and 66.4% in advanced disease. The cause of pain is multifactorial and can be a combination of nociceptive and neuropathic pain with one third of people reporting neuropathic pain.
Aims
Aim of the audit was to identify the incidence and characteristics of pain in patients attending the medical day unit and to identify if these symptoms where being managed appropriately.
Audit standards where based on current estimations of pain in this patient population from review of literature.
Methods
Patients attending medical day units were asked to complete a series of validated questionnaires using a hand held tablet over a period of one week.
They were asked to complete brief pain inventory, Douleur Neuropathique 4 (DN4), patient neurotoxicity questionnaire (PNQ), FACT-GOG NTX and hospital anxiety and depression scale (HADS). Additional information regarding tumour group, chemotherapy agent and support from specialist teams was also collected.
Results
84 patients where approached to take part, 72 agreed to take part and 12 refused.
55% reported pain scores ranging from mild to severe.
24% scored highly on DN4 scale which indicates neuropathic pain. 30% of patients scored highly on FACT COG NTX scale which is another indicator of neuropathic symptoms and 7% reported moderate symptoms on the PNQ.
14% had been seen by specialist pain/palliative care service.
23% scored symptoms of anxiety and 30% report depression
Conclusion
The audit has given us an insight into the unmet needs of this patient population, although we cannot draw firm conclusion surrounding these symptoms it has identified that this patient group could benefit from specialist pain input.
It has allowed us to build closer relationships with the medical day units, improved engagement in pain education with appointment of pain link nurse to champion pain awareness /education. This increased awareness of pain and CIPN has resulted in an increase in referrals to pain clinics.
Br J Pain. 12(2 Suppl):5–54.
Education
17
Online Postgraduate Education - More than Knowledge Acquisition
Category: Education
Sarah Henderson - Edinburgh Medical School University of Edinburgh
Background
Online learning is becoming an important growth area for many higher education (HE) institutions and there has been significant global expansion in the delivery of postgraduate taught programmes that allow participants to study on a part-time basis while continuing to work.
Such programmes have several advantages: in particular, they avoid the necessity of physical presence on campus thereby reducing disruption to residential, financial and professional circumstances. Additionally, the worldwide reach of the internet enhances the potential for meaningful international interaction amongst online students and programme staff.
The development of transferable skills has become key to HE policy and institutional marketing. Broadly speaking, transferable skills are seen as the types of flexible skills and dispositions, which graduates require to thrive in a modern healthcare structure, economy and culture. Arguably, such attributes have the potential to enable graduates to adapt effectively to ongoing change in their personal and professional lives.
Aims
This research seeks to examine the additional gains from participation in online postgraduate programmes, over and above additional clinical knowledge, that, in theory, have the potential to transcend disciplinary boundaries and ‘transfer’ to social, intellectual and professional contexts different to those in which they were acquired.
Methods
25 MSc graduates (in either Pain Management or Clinical Education) from a Scottish University were asked to participate in the research. Of these, 17 agreed to take part. The participants were drawn from a range of healthcare professions, representing a cross-section of professions and cultural backgrounds. Ethical approval was granted by the University’s ethics committee. Participants were assured that contributions would be anonymised and confidential. Interviews were semi-structured and flexible: certain areas of interest were addressed in each interview with questions open-ended to allow for additional questions as the interviews progressed. Interviews were recorded and transcribed. Three pilot interviews were conducted and informed the final design of the interview schedule.
Data from the transcripts were analysed inductively and iteratively, and initially coded independently by three investigators. Focusing on recurring themes within the data, each investigator identified emerging themes; these were then compared collectively and refined in light of this comparison.
Results
A number of recurring themes were highlighted within the data:
Academic voice - Most interviewees suggested that the most important outcomes of their participation is the significant enhancement of their academic voice.
Critical analysis skills - For the majority of participants, the concept of critical analysis, ubiquitous in social science, was relatively new and for some initially challenging.
Commitment to ongoing scholarship - One of the themes that emerges consistently and clearly from the data is that the experience of high-level scholarship students gained through programme participation has, for the majority of them, contributed to an ongoing commitment to scholarship.
Inter-professional and international understanding - The nature of online delivery affords a clear opportunity for international communication and interaction which is highly valued by participants.
Autonomy and self-efficacy - A raised level of confidence amongst the research participants is a recurring theme in the data
Conclusion
Online postgraduate education is a rapidly growing area within higher education and the transferable skills that are gained from these activities are seen in areas that reach beyond knowledge acquisition. The skills gained have potential to provide impetus for on-going professional development and the development of the life-long skills that support for the delivery of modern healthcare in the current economic, social and cultural climate.
Br J Pain. 12(2 Suppl):5–54.
18
Knowledge and Confidence Related to Pain Management of Healthcare Profession Students in Scotland
Category: Education
Chris Seenan - Physiotherapy Glasgow Caledonian University, Heather Sauverwald - Physiotherapy Glasgow Caledonian University, Heather Harrison - Pharmacy NHS GG&C, Joanna McParland - Psychology Glasgow Caledonian University, Neil Clark - Physiotherapy NHS Fife, Mick Serpell - Medicine University of Glasgow, Brian Addison - Pharmacy Robert Gordon University, Patricia Roche - Medicine University of Edinburgh, John Bremner - Patient Representative Pain Concern, Jennifer Tocher - Nursing University of Edinburgh, Sarah Henderson - Medicine University of Edinburgh, Chee-Wee Tan - Physiotherapy Queen Margaret University
Background
Chronic pain is one of the most common reasons for primary care consultations and has been identified as the leading cause of disability in the Global Burden of Disease Survey. Despite the prevalence, impact and cost of pain, management of the condition by healthcare professionals remains suboptimal. Pre-registration education has been identified as a contributing factor to this with teaching related to pain representing less than 1% of content in undergraduate courses.
Aims
To investigate the level of pain knowledge and confidence in final year healthcare profession students in Scotland
Methods
Cross-sectional survey design. A short questionnaire was developed based on the IASP and BPS pain curricula with the aim of measuring 1) knowledge and understanding of pain management and 2) levels of confidence to implement this knowledge and understanding (Pain Understanding and Confidence Questionnaire (PUnCQ)). All final year students in healthcare professional pre-registration courses in Scottish universities were invited to complete the PUnCQ online. Data were analysed using descriptive statistics.
Results
Surveys were sent to 1200 students and 133 completed (10% response rate). Participants represented 6 healthcare professions from 5 different universities. Generally, understanding of pain was good with at least 50% of students selecting the correct answer in all but two aspects (Further investigations and Red flags). Confidence was rated as moderate (mean rating 4-7/10) for all questions. Students reported most confidence in relation to: describing and explaining pain; assessment and onward referral; social factors; pacing and self-management advice and signposting further information (mean rating 6.03-6.98/10). Least confidence was reported in relation to: neurophysiology of pain; theories of pain and the WHO analgesic ladder (mean rating 4.55-4.84/10).
Conclusion
Final year pre-registration healthcare students generally have a good understanding of most of the main concepts relating to pain management. However, they are only moderately confident about using this knowledge and understanding. Eighty five percent of respondents felt that they needed more education on pain management. This might suggest that further education should be simulation/ scenario based to allow development of confidence in reasoning. Limitations in healthcare professional pre-registration education related to pain need to be addressed so that graduates are prepared to manage pain effectively and meet this significant societal & healthcare challenge.
Br J Pain. 12(2 Suppl):5–54.
19
Attitudes and Beliefs Relating to Pain Management Among Undergraduate Students in Six Health Care Programmes
Category: Education
Desiree Tait - Nursing and Clinical Sciences Bournemouth University, Carol Clark - Human Sciences and Public Health Bournemouth University, Rachel Bellamy - Human Science and Public Health Bournemouth University
Background
Pain management is a global priority as the costs to society through health provision and the loss of productivity are significant. It affects approximately one fifth of the population of whom half record chronic pain. Chronic pain is complex, often accompanied by co-morbidities and is difficult to manage. Pain management requires a holistic approach that involves multiple health professionals and pain sufferers working together. There is a requirement for health professionals to understand pain, and how it is best managed so that they can confidently work together and with pain sufferers to support a holistic approach. Increased education relating to pain correlates positively with changes in attitudes to pain, and improves health professionals’ decision making. However, hours spent engaged in undergraduate pain education is limited and most of the time delivered uni-professionally. There is a limited understanding of the attitudes and beliefs of undergraduate health professionals to pain management.
Aims
The aim of this study was to explore attitudes and beliefs to pain management among undergraduate health care students using a short 10 item questionnaire.
Methods
The study sample consisted of students (n=217) from a Faculty of Health and Social Sciences in a University in the UK. After University Ethics approval was obtained students received an invitation email to take part in an online survey. A total of 537 second year students were invited of whom 40% responded by completing a questionnaire from the following programmes; midwifery, nursing, operating department practice, occupational therapy, physiotherapy and paramedic science. Programmes were reviewed to explore current shared learning around pain management. The questionnaire consisted of 10 items with a 6 point Likert scale, divided into 3 factors relating to attitudes and beliefs about; 1 ‘Chronic pain’; 2 ‘Living and working with chronic pain; 3 ‘Sedation and pain relief’. SPSS, v23 was used for the data analysis which included demographic characteristics, Mann Whitney U was used to explore differences between the scores and of students in different professional programmes.
Results
Student participants consisted; midwifery (n=32) 15%; nursing (n=55) 25%; occupational therapy (n=13) 6%; Operating department practice (n=7) 3%; paramedic science (n=58) 26%; Physiotherapy (n=52) 24%. The average ages of the participants ranged from 24-31 years in the programmes of whom 75% were female. There was no evidence of planned shared learning around pain management. The total scores for the 10 items ranged from 37 to 41. There were no significant differences between professions for the total scores. The three factors were analysed. 1.’Chronic pain’; there were no significant differences between professions; 2.’Living and working with chronic pain’; physiotherapy students scored significantly higher than midwifery students (U=667.50, r=0.13, P<0.01), there were no significant differences between the other professions. 3.’Sedation and pain relief’ nursing scored significantly higher than both physiotherapy (U=953.0, r=0.09,p<0.01) and paramedic science (U=1078.50, r=0.08, p<0.01) there were no significant differences between the other professions.
Conclusion
This study provides new knowledge relating to attitudes and beliefs to pain management among students on six health care programmes. Total scores of the questionnaire indicated no significant differences between professions. Physiotherapy students showed greater understanding about ‘living and working with chronic pain’ than midwifery students. This may reflect current education which focuses on chronic pain management and rehabilitation. While midwifery education considers acute pain management associated with pregnancy and labour. Nursing students showed greater understanding relating to ‘sedation and pain relief’ than physiotherapy and paramedic science students which may reflect their focus relating to care of surgical patients.
Br J Pain. 12(2 Suppl):5–54.
20
Development of an Interprofessional Questionnaire to Identify Attitudes and Beliefs Relating to Pain Management in Students on Multiples Health Programmes
Category: Education
Carol Clark - Human Sciences and Public Health Bournemouth University, Desiree Tait - Nursing and Clinical Sciences Bournemouth University, Rachel Bellamy - Human Sciences and Public Health Bournemouth University
Background
Pain management is a key public health problem costing over £10 billion per annum and involves complex multi-professional perspectives in the provision of care. Pain sufferers however often perceive that management of their pain is not effective. Pain sufferers want to be partners in their pain management and to have confidence in the people managing their pain. To achieve a gold standard there needs to be meaningful interprofessional engagement in pain education. . Currently few Higher Education institutions engage in shared pain education between health professions and time spent on content is considered inadequate. Understanding different professional attitudes to pain management, starting at undergraduate level, may provide a basis from which to support the future education of students and promote a more holistic confident approach. There is a requirement to establish students’ attitudes and beliefs in order to focus education resources appropriately
Aims
To show the development and exploration of the validity and reliability of a short questionnaire to assess attitudes and beliefs about pain management in undergraduate professional health programmes.
Methods
A literature search was undertaken to find attitudes to pain questionnaires for health professionals and seven validated questionnaires were identified. University Ethics approval was obtained. The items from the questionnaires were collated and duplicates removed. These were then reviewed by health professionals for content and face validity using the Delphi method, leaving a total of 30 questions. A total of 537 second year students were invited to participate, 217 completed (40% response rate) from midwifery, nursing, operating department practice, occupational therapy, physiotherapy and paramedic science programmes. A group of 22 students answered the questionnaire twice. Item consistency response was reviewed. Cronbach’s alpha was used to measure internal consistency, factor analysis with varimax rotation was used to identify groupings of items, the Bland and Altman method and inter correlation coefficient (ICC) were used for test re-test reliability.
Results
Results for all 30 items were obtained from; 32 midwifery, 55 nursing, 13 occupational therapy, 7 operating department practice; 56 paramedic science and 52 physiotherapy students. Items that represented consistent knowledge were removed, leaving 22/30 items. Factor analysis was performed and items relating with a factor loading threshold of 0.4 and an Eigen value of > 1.0 were kept. Ten items were kept. Factor analysis identified 3 groupings of items which related to attitudes and beliefs about: ‘Chronic Pain’; Living and working with chronic pain; Sedation and pain relief. For the three groupings overall Alpha’s ranged from 0.719 to 0.610 indicating good internal consistency. The test-retest ICC for each of the items ranged from 0.542 to 0.962 and the Bland and Altman method revealed 95% of the points lay within the limits of agreement.
Conclusion
This research contributes to knowledge relating to attitudes and beliefs to pain management by students on health profession programmes. It reports on the development and initial validation of a short questionnaire to capture these attitudes and beliefs. This questionnaire can be used to assess students’ understanding across multiple health programmes and this knowledge will contribute to the development of materials to enhance the education of students as they seek to become to holistic confident practitioners.
Br J Pain. 12(2 Suppl):5–54.
Epidemiology
21
Chronic Pain Following Breast Cancer Surgery
Category: Epidemiology
Dr Tariq Suleiman - Department of Breast Surgery Royal Victoria Infirmary, Dr Ben Goodman - Department of Anaesthesia Royal Victoria Infirmary, Dr Jonathan Womack - Department of Anaesthesia Royal Victoria Infirmary
Background
Breast cancer is the second commonest cancer worldwide, affecting >55,000 women each year in the UK. The outcomes of treatment are very good, with 78% surviving over 10 years. Chronic post-surgical pain affects 14-60% of breast cancer patients, and is a major cause of morbidity after oncological cure. Identified risk factors for its development include younger age, more invasive surgery, adjuvant radiotherapy and poor post-operative pain control. Regional anaesthetic techniques have become commonplace in our institution, allowing for procedures such as mastectomies to be undertaken as day cases. However, once patients leave hospital, we know little about how their pain is affecting them. In an era of excellent oncological outcomes for breast cancer, improving long term quality of life by investigating the incidence and modifiable risk factors for chronic post-surgical pain is imperative.
Aims
We aimed to investigate the prevalence and associations of chronic pain following breast surgery in our hospital. We estimated that a target sample size of approximately 100 would give us a snapshot of the incidence of pain, and might allow identification of modifiable risk factors for quality improvement.
Methods
Following ethical and institutional approval, patients attending eight consecutive breast review clinics in March 2017 were asked to complete a Modified McGill Pain questionnaire. Additional clinical details were collected by a junior doctor. Exclusion criteria were: surgery within 8 weeks of clinic, significant missing information in patient notes, and non-cancer surgery. GraphPad Prism 7 software was used for statistical analysis. The Chi squared test was used to investigate associations of chronic pain with patient and treatment factors. Student’s t-test was used for analysis of differences in age between the two groups.
Results
Of 297 patients given questionnaires, 98 (33%) were returned. After application of the exclusion criteria, data from 93 patients remained for analysis. Fifty (53.8%) described persistent pain following surgery. The mean age of the cohort was 60 years. Three factors were associated with an increased incidence of chronic pain: younger age (p=0.02), breast pain prior to surgery (p=0.015) and suboptimal postoperative pain control (p=0.019). The incidence of pain was similar following mastectomy (47%) and wide local excision (56%). Use of regional anaesthetic techniques (n=24) and adjuvant cancer therapy (n=89) was not associated with differences in chronic pain in this sample. 47% of patients rated their pain as severe, with 58% reporting it impacted on at least one of sleep, ADLs, QOL or anxiety. Of the patients describing chronic pain, 28% required regular analgesia.
Conclusion
In keeping with published literature, our data identified younger age, breast pain prior to surgery, and poor postoperative pain control as risk factors for the occurrence of chronic pain following breast cancer surgery. However, our sample size was insufficient to draw firm conclusions on all risk factors. Furthermore, convenience sampling methodology might have impacted the results, as patients with pain might be more likely to complete the questionnaire. Our data confirm the significant burden chronic pain has on patients’ quality of life. We aim to undertake further prospective work to identify patients with modifiable risk factors for chronic post-surgical pain.
Br J Pain. 12(2 Suppl):5–54.
Evidence & Guidelines
22
Critical Appraisal of Published Systematic Reviews oF Therapeutic Lumbar Facet Joint Injections
Category: Evidence & Guidelines
F. Morell Ducos - Anaesthesia and Pain Medicine Royal Free Hospital, S. Snidvongs - Pain and Anaesthesia Research Centre St Bartholomew’s Hospital, V. Mehta - Pain and Anaesthesia Research Centre St Bartholomew’s Hospital, R. Taylor - Institute of Health Research University of Exeter Medical School
Background
Low back pain (LBP) causes more global disability than any other condition, and has a lifetime prevalence of up to 85% with economic costs reported at £12.3 billion per annum in the United Kingdom alone. Common contributors to LBP in adults are thought to include lumbar facet joint components. LBP thought to be facetogenic in origin is commonly treated with interventions that include intra-articular facet joint injections of steroids and/or local anaesthetic (FJIs), peri-articular medial branch nerve blocks, and radiofrequency denervation of the medial branch nerves innervating the joints. The National Institute for Health and Care Excellence (NICE) guidelines for managing LBP (NG59, 2016) make specific ‘do not use’ recommendations for FJIs due to insufficient high quality evidence supporting their use, recommending instead targeting the medial branch nerves. However, intra-articular FJIs remain in common use.
Aims
To carry out a systematic review identifying existing systematic reviews and meta-analyses of randomised controlled trials (RCTs) of adult participants with chronic LBP undergoing intra-articular lumbar FJIs with a therapeutic substance, in order to assess their methodological quality.
Methods
A protocol with the inclusion criteria was developed prior to the literature search, with reference to the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guidelines. To be included, the population must contain adult participants with chronic LBP, undergoing intra-articular lumbar FJIs with a therapeutic substance as their main intervention. Articles reviewing other therapeutic interventional pain procedures were also included if therapeutic lumbar FJIs were reviewed also. All comparators were included. The outcomes were not limited in the search strategy. Only systematic review papers of RCTs and meta-analyses were included.
Search terms were developed with librarian assistance. Medline, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched, and additional studies identified from citation tracking and reviewing the references of existing studies. The search period was 1966 - 2017, without language restrictions. Two reviewers independently screened and assessed eligible full-text articles.
Results
The Medline search identified 123 results, with 11 full-text articles assessed for eligibility after screening. The Embase search identified 144 results, with 10 articles assessed for eligibility. The CENTRAL search identified 163 results. One was screened and assessed for eligibility. When the results from the 3 databases were combined, 122 duplicates were identified. Citation tracking and reference checking identified a further 3 papers. No meta-analyses of therapeutic lumbar FJIs were identified.
The scope of the 11 reviews was described in terms of study population, interventions, comparator, outcome and types of study design; and heterogeneity between the scopes of the reviews was also assessed. The methodological quality of the systematic reviews was also assessed using the “assessment of multiple systematic reviews” (AMSTAR) checklist.
The 11 systematic reviews identified a total of 14 RCTs between them. None pooled the results of their findings due to clinical heterogeneity.
Conclusion
Of the 11 included reviews, 3 found FJIs to be ineffective; 4 found limited evidence to support their use, and 3 did not find sufficient evidence. AMSTAR scores varied widely. The evidence varied between the reviews, even those analysing the same studies. None carried out meta-analyses, and the evidence was based on small numbers of RCTs.
Further high quality systematic reviews are required to summarise the evidence for decision makers; any new information from a well-conducted systematic review may lead to guideline changes, with implications for future commissioning of pain services in the UK.
Br J Pain. 12(2 Suppl):5–54.
Experimental (Basic) Science
23
Concurrent Validity and Reliability of an Expensive Weighted Needle Pinprick Stimulators
Category: Experimental (Basic) Science
Arosha Ijaz - School of Clinical and Applied Sciences Leeds Beckett University, sabri Garoushi - School of Clinical and Applied Sciences Leeds Beckett University, Osama A Tashani - School of Clinical and Applied Sciences Leeds Beckett University
Background
Pinprick stimulators are part of quantitative sensory testing of pain and perception thresholds. One of the standard stimulators are manufactured by MRC, Heidelberg, Germany, and validated by the European Federation of Neurological Societies. However, these stimulators are expensive. Instead we have re-examined an old inexpensive, easy to use, weighted needles pinprick stimulators which can be used in limited resources countries. The method used to design these weighted needles could easily be replicated if the validity and reliability of this simple device is established.
Aims
The study aim was to investigate the concurrent validity and reliability of an inexpensive weighted needles designed at Leeds Beckett University’ pain Laboratory. These stimulators were compared to the pinprick stimulators manufactured by MRC.
Methods
Twenty participants were recruited by word of mouth to this cross-over study, all participants were healthy (age ranges from 20-57 years, 10 women).The weighted needles consisted of a series of 22-gauge needle connected to 1 ml plastic syringe freely movable inside 2 ml syringe. The different weights of 1 ml syringe achieved through shortening of the 1 ml syringe or adding very small metals and plastics inside it. The weight of the 7 graded weighted needles ranged from (1.8 – 3.4g). The MRC device consisted of 7 different Pinprick stimulators labelled by the force exerted by them in mN through a weighted metal connected to a needle and moving freely inside a metal tube. The experimental procedure involved application of the two pinprick units in a randomised ascending and descending order three times with a response threshold set at what weight or force the participant felt the sharpness of the needle applied. Geometric mean of the three applications was then calculated.
Results
Cronbach’s alpha for weighted needles pinprick thresholds was (0.671, p=0.002) suggesting an acceptable internal consistency. However, MRC pinprick stimulators values’ Cronbach’s alpha was higher at (0.971, p=0.0001). Interclass correlation between the geometric mean of weighted needles and MRC pinprick stimulators was significantly high at (0.783, p=0.0001) suggesting that the concurrent validity of the weighted needles pinprick device is very good.
Conclusion
The results suggested that the weighted needles is a valid and reliable method to measure mechanical pinprick response. This makes the weighted needles a useful neuropathy and sensory testing tool in poor countries as the information from this study is easily available and the device can be replicated at low cost.
Br J Pain. 12(2 Suppl):5–54.
Interventional Pain Management
24
The Meridian Balance Method Electro-Acupuncture Treatment on Chronic Pelvic Pain in Women: A Three-Armed Randomised Pilot Study Using a Mixed Methods Approach
Category: Interventional Pain Management
Ooi Thye Chong - The Simpson Centre for Reproductive Health The University of Edinburgh
Background
Chronic pelvic pain (CPP) is a major women’s health issue. About 6% to 27% of women worldwide suffer from CPP. In UK, CPP is found to be as common as asthma and back pain and has been highlighted as a key area of unmet need. CPP is estimated to be responsible for 30% of gynaecological consultations and a 45 % loss of work productivity, leading to significant socioeconomic costs. Current medical and surgical treatments even if helpful, are associated with unacceptable side effects. Large-scale studies have demonstrated that acupuncture is effective for other chronic pain conditions. We hypothesised that the meridian balance method electro-acupuncture (BMEA), combined with traditional Chinese medicine health consultation (TCM HC) may be an effective adjunct in the management of CPP. In our study, the combination of BMEA + TCM HC is called BMEA treatment, distinguishing the two components of an acupuncture treatment.
Aims
To determine the feasibility of a future large-scale trial to evaluate the effectiveness of the BMEA treatment for CPP in women. The primary objectives were to determine the recruitment and retention rates. The secondary objectives were to evaluate the effectiveness of the interventions and acceptability of the study methods.
Methods
This was a three-armed randomised pilot trial using a mixed methods approach. Thirty women (30) were randomised into: the BMEA treatment (group 1), TCM HC (group 2) or Standard Care (group 3). Women with a history of CPP for longer than six months, aged 18 years old or above, have an average numerical pain score of at least 4 out of 10 in the previous week, were able and willing to comply with the interventions were included. Women were excluded if they were pregnant, had a history of malignancy, taking regular anticoagulants, had severe needle phobia and a pace maker in situ. Interventions’ effects were assessed by validated pain, physical and emotional functioning questionnaires, completed at weeks 0, 4, 8 and 12. Three focus groups discussions and semi-structure telephone interviews to capture the participants’ experience of the study were conducted. Focus groups discussions were audiotaped, transcribed and thematically analysed.
Results
Of the 59 women who were referred to the study, 30 women (51%) were randomised. There was a statistically significant difference in retention rates between the three groups. The retention rates were 80% (95% CI 74-96), in group 1, 53 % (95% CI 36-70) in group 2 and 87% (95% CI 63-90) in group 3. (Chi-square test, p=0.08) Qualitative data showed that most participants had a favourable trial experience and the methodology was generally acceptable. The quantitative data suggested that the meridian BMEA could be a useful adjunct to standard care.
Conclusion
Our study has successfully demonstrated the feasibility of a large-scale trial for CPP in women. The recruitment and retention rate achieved in our study will allow us to determine the optimum design and data for power estimation for a future study.
Br J Pain. 12(2 Suppl):5–54.
25
Tertiary Return to Work Interventions for Chronic Pain: a Systematic Literature Review
Category: Interventional Pain Management
Paulina Wegrzynek - Psychology Bath Spa University
Background
Pain is defined as chronic when it persists over 3 months or beyond expected healing time. UK figures show that approximately 28 million adults suffer with CP. Musculoskeletal disorders (often used as a proxy for CP) remain the second biggest reason for being off work, leading to 30.8 million workdays lost in 2016.
The social and economic implications of CP are incredibly broad and represent significant challenges for stakeholders, including workers, employers, the government, and the healthcare providers. The costs linked to CP sickness absence exceed those associated with cardiovascular and oncological problems.
Return to work (RTW) with CP can be a complex process in which physical and psychosocial elements interplay. Tertiary, individual RTW interventions are reactive and aimed at employees who experience an event of sickness absence. However, the effectiveness of RTW interventions for workers with CP is unclear.
Aims
Our review aim was to summarise the available evidence to determine which tertiary interventions are successful in promoting RTW in workers suffering with CP. We aimed to investigate any type of individual RTW interventions, including those with credible psychological components, but which do not target any specific concept or trait.
Methods
In October 2016, we systematically searched PsycINFO, EMBASE, MEDLINE, PubMed, Science Direct, Cochrane Library of Clinical Trials, Google Scholar, and Open Grey databases for randomised controlled trials (RCTs) of individual interventions for workers with CP. Search terms were based on the Boolean method and databases were searched from inception. We manually checked the reference lists of all included articles. Only full-text articles, published in English in peer-reviewed journals were considered. We excluded studies where participants were under the age of 18.
The primary outcome was RTW. We also extracted secondary outcomes including pain disability and employee psychosocial/affective factors. Study appraisal was based on the Cochrane Risk of Bias Tool and methodological quality assessment, and we assessed the inter-rater reliability. The findings from included trials were synthesised in a narrative format due to the heterogeneity of retrieved data.
Results
The initial search identified 1682 studies. We deemed 14 RCTs and follow-up (FU) studies, published from 1994 to 2016, of sufficient quality to be included in the current review. Study randomised population sizes ranged from 103 to 654 workers and included both men and women. Type of CP, occupation, and the length of sickness absence varied across the trials.
RTW definitions varied greatly. Seven papers reported statistically significant results and effect sizes to suggest that examined interventions promote RTW among CP patients. Multidisciplinary treatments comprising psychological therapy, physical training and workplace elements seem most effective, whereas some interventions led to delayed RTW, particularly when used on their own (e.g. exercise or CBT). Workers with different risk profiles respond better to treatments of varying intensity which address the risk of non-RTW. Although not all CP patients returned to work post-intervention, in most cases the secondary outcomes (e.g. quality of life) improved.
Conclusion
There is no conclusive evidence to fully support any specific RTW intervention for CP patients. However, multidisciplinary approaches appear to be most successful for this population group, and future productivity gains and compensation cost savings may justify implementation of multidisciplinary interventions even at a higher initial delivery cost. Stratifying interventions for CP patients could help improve overall effectiveness of RTW efforts. Future research could also optimise operationalisation of RTW outcome, although varying compensation systems make this idea challenging. Varying results regarding RTW, together with evidence from previous research suggest that compensation policy is an important area to consider.
Br J Pain. 12(2 Suppl):5–54.
26
Does Health-Related Quality of Life Improve Following Pain Management Interventions?
Category: Interventional Pain Management
Alia Ahmad- Pain Management Barts Health, Charlotte Guest - Pain Management Barts Health, Athina Karavasopoulou- Pain Management Barts Health, Akorfa Fiamavle- Pain Management Barts Health, Helen Bonar- Pain Management Barts Health, Kirstie Emmerson- Pain Management Barts Health, Mirja Shaw- Pain Management Barts Health, Joanne Lascelles- Pain Management Barts Health, Lorena Warde- Pain Management Barts Health, Hanna Kotas- Pain Management Barts Health, Paolo Pais- Pain Management Barts Health, Rajeev Sharma- Pain Management Barts Health, Georgina Wilson- Pain Management Barts Health, Vivek Mehta- Pain Management Barts Health
Background
Chronic pain represents a major health burden in Europe and the United Kingdom (UK), in which 14.3% of the population are living with chronic pain that is moderately or severely disabling. Many patients suffering chronic pain report being less able or no longer able to take part in various daily activities, such as walking, driving, working outside their home and sleeping. The EQ5D-5L questionnaire is a standardised tool used in clinical trials and routine data collection worldwide that evaluates patient reported outcome measures. The questionnaire is a generic measure of health status developed by the EuroQoL Group, an international research network established in 1987 by researchers from Finland, the Netherlands, Sweden, and the UK. The EQ5D-5L defines health in terms of five dimensions: mobility, self-care, usual activities (work, study, housework, family, or leisure), pain or discomfort, and anxiety or depression.
Aims
The primary purpose of this service evaluation was to evaluate the improvement in quality of life (QoL), function, and overall health before and after various pain interventions for chronic pain.
Methods
The sample included adult patients suffering chronic pain that underwent a pain intervention. There was no exclusion criteria, however the following limitations occurred; time constraints on the day of the procedure, language barrier, learning difficulties, patient refusal and no research assistants present at weekends to collect any pre-intervention data. The pain interventions were performed as a day case at a central London teaching hospital. The research team distributed the questionnaire for the patients to complete prior to their scheduled pain intervention. Patients were followed up by the clinical nurse specialists between eight-to twelve weeks after their intervention during either a routine telephone or face-to-face appointment where post-intervention questionnaires were collected. All data collected was entered into an electronic database for analysis and the data collection started on 1st August 2017.
Results
N=26 patients completed both the pre and post intervention questionnaire from 1st August to 1st December 2017. The majority of patients reported low back pain (n=16). N=19 patients reported a decrease in the severity of their pain, with n=12 patients who had facet-joint injections (FJI) reported 35% pain decrease and those who had a combined FJI/caudal injection (n= 5) reported 45% decrease in their pain intensity. A percentage change in “health-related quality of life index” revealed that pain treatments benefited patients on average by 86% for combined FJI and caudal, and 70% change in facet joint injections alone. An “overall health” increase of 60% was seen in the majority of patients who had pain interventions. Finally, n=14 patients were satisfied with their pain intervention.
Conclusion
Although more patient data will be collected over the forthcoming months, our results suggest pain interventions, particularly combined FJIs and caudal in addition to FJIs alone have a significant impact in improving patients’ quality of life and pain intensity. This includes improvements in mobility, self-care, usual activities (work, study, housework, family, or leisure), pain or discomfort, and anxiety or depression.
Br J Pain. 12(2 Suppl):5–54.
27
Assessment of Outcomes Following Interventional Procedures for Pain Management - 5 Years of Outcomes in Glasgow
Category: Interventional Pain Management
Dr Clare Louise Bridgestock - Pain Management New Victoria Hospital, Dr Lars Williams - Pain Management New Victoria Hospital
Background
A patient questionnaire to assess outcomes after interventional procedures for pain management was introduced within our health board in Spring 2011 after a successful pilot. Ongoing follow up for patients should only be arranged after return of this questionnaire, requiring engagement from patients with the service and allowing appropriate return appointments to be made. This also allows both procedure specific and operator specific outcomes to be evaluated.
We have collated outcome data from 1/08/11 to 31/07/16, having previously published after 1 year as a comparator. We strive to deliver a safe and effective interventional service, with a key focus on improving physical function. Regularly reviewing our outcomes allows us to ensure that all procedures are performing as expected, and to inform the Pain Management service regarding morbidity.
Aims
Report on the findings of 5 years of outcomes following interventional procedures, considering particularly duration, efficacy and side effects
Inform patient information regarding efficacy, impact and side effects prior to intervention
Establish a base line prior to introduction of psychological screening as a pre-requisite to first interventional procedure
Methods
The original outcomes questionnaire was developed by a multi-disciplinary team, then validated and further modified after a pilot study. Every patient attending for an interventional procedure for pain management in Greater Glasgow and Clyde is given the questionnaire immediately after their procedure.
Data recorded on the questionnaire includes date and procedure performed and operating physician. The patient is asked to complete to complete the questionnaire at eight week after intervention, answering questions on duration and degree of pain relief, changes in analgesic use, quality of life, sleep and mobility. There is also a specific field for detailing side effects. The patient is asked to return the questionnaire by post to the pain department.
Data from completed questionnaires is inputted into a Microsoft Access database.
Results
Outcome data from 1/08/11-31/07/16 was analysed, a total of 3092 completed questionnaires, with estimated return rate of 45%. The most commonly performed procedures were sacro-iliac joint injection, lumbar facet joint injection, caudal epidural, trigger point injections and lumbar nerve root block.
Overall, 61% of patients reported more than 30% pain relief and 49% of patients have a reduction in pain for more than 5 weeks. If a positive response is defined as >30% relief for >4 weeks, 45% could be defined as responders. These figures all show a slight increase as compared to our first year or results.
35% of responders reduced their analgesic intake, 50% reported improved sleep, 55% reported improved mobility and 74% reported an improvement in their quality of life.
24% of patients complained of side effects related to the procedures, most commonly pain in the area of injection.
Conclusion
In a proportion of patients, interventional procedures provide a period of reduction in pain which may lead to improvement in sleep, quality of life and mobility and a reduction in analgesic medications.
Since data collection was completed, we have obtained funding to pilot a psychological assessment of patients prior to first interventional procedure, to assess whether this method of selection further improves our results.
Our growing database of operator and procedure-specific outcomes, allows us to provide accurate information to patients and audit our own practice, as well as monitor morbidity of procedures, essential as part of our governance process.
Br J Pain. 12(2 Suppl):5–54.
28
Review of the Use of Botulinum Toxin for Myofascial Pain in the Pain Clinic
Category: Interventional Pain Management
Catherine James - Pain Management Royal Surrey County Hospital NHS Trust, Rachel Townsend - Pain Management Royal Surrey County Hospital NHS Trust, Rachel Davies - Pain Management Royal Surrey County Hospital NHS Trust, Allister Dow - Pain management Royal Surrey County Hospital NHS Trust, Daniela Tonucci - Pain Management Royal Surrey County Hospital NHS Trust
Background
Myofascial pain is commonly observed in the pain clinic. Treatment modalities include physiotherapy, acupuncture, medication, psychology, and needle-based interventions. Injection of local anaesthetic and either steroid or botulinum toxin (BTX) into trigger points is routinely performed at our pain clinic, and associated with variable success rates. Anecdotally, our overall impression was that BTX is an effective and useful treatment for the management of myofascial pain and one to which patients should have access. In response to an initiative through the Clinical Commissioning Group, the Hospital was required to review its use of BTX across all clinical specialties. Accordingly, the pain clinic undertook an audit of the efficacy of BTX as a treatment for myofascial pain. During the review period, the use of BTX was suspended until the Drugs and Therapeutics Committee (DTC) had evaluated the results and confirmed that the treatment should be reinstated.
Aims
To investigate the efficacy and viability of BTX as a treatment option for patients with myofascial pain.
Methods
A retrospective analysis was conducted. A total of 18 patients were identified during 2016 who had received BTX treatment for myofascial pain. A questionnaire was developed and posted to the patients for them to complete and return. The questionnaire remained anonymous, but standard patient demographics were collected. Questions covered previous treatment use, current medication use, utilization of other healthcare-related services (e.g., general practitioner consultations), and aspects relating to mental health and mood. Patients were asked to rate the efficacy of their BTX treatment (as percentage pain relief), report their level of activity and state any changes to their medication regimen following BTX treatment. Patients also had the opportunity to provide specific comments about the BTX treatment
Results
Overall, 15/18 patients returned questionnaires. Of those who responded, 87% (n=13) were female, 80% (n=12) were aged 31–50 years, 80% (n=12) had documented low mood, and >50% were employed. Prior to BTX administration, 53% (n=8) were receiving antidepressants (of whom six [75%] patients attributed their pain to this medication), 100% (n=15) were receiving opioids, 73% (n=11) were receiving at least one anti-neuropathic medication, 87% (n=13) had received physiotherapy (of whom most had 10+ sessions), 100% (n=15) had received acupuncture (of whom >50% had 10+ sessions), and 60% (n=9) attended their surgery either weekly or monthly because of their pain. Most patients received BTX to their shoulders, neck or upper back. Overall, 73% (n=11) reported >50% pain relief, 47% (n=7) reduced or stopped their anti-neuropathic medication, and 67% (n=10) reduced or stopped their opioids. A reduction in other healthcare-related service utilization was also noted.
Conclusion
The findings from this retrospective analysis indicated that BTX treatment for myofascial pain led to favourable outcomes, in terms of patient function and reduced reliance on other healthcare-related services. Based on these data, the DTC reinstated the use of BTX for myofascial pain at our pain clinic. Nevertheless, as BTX is a relatively expensive treatment option, we have produced strict selection criteria to help guide clinical decisions relating to its use.
Br J Pain. 12(2 Suppl):5–54.
Neuropathic Pain
29
Painful Vulvodynia Alleviated by Topical Gabapentin: A Two-Centre Survey of Treatment Safety and Efficacy
Category: Neuropathic Pain
Edward Keevil - Anaesthetics Cardiff and Vale University Health Board, Sharmila Khot - Anaesthetics Cardiff and Vale University Health Board, David Nunns - Obstetrics and Gynaecology Nottingham University Hospitals NHS Trust, Girish Patel - Dermatology Hywel Dda University Health Board, Sarah Hiom - Research and Development St Mary’s Pharmaceutical Unit, Vanessa Hodgkinson - Pain Medicine Nottingham Hospitals NHS Trust
Background
Vulvodynia is a devastating condition that significantly affects a woman’s quality of life and emotional well-being. The prevalence of vulvodynia has been estimated as 9-18%. It is one of the most common causes of sexual pain in premenopausal women, with associated low conception rates.
The International Society for the Study of Vulvovaginal Diseases defines vulvodynia as vulvar pain of at least three months duration, without clear identifiable cause, which may have potential associated factors. It is thought to present as a neuropathic pain syndrome and is treated with systemic neuropathic pain medications.
The use of systemic medications is associated with intolerable side effects, insufficient long-term pain relief and drug interactions. Topical analgesia may offer an alternative treatment option.
Aims
Topical gabapentin has been reported to be effective in the treatment of vulvodynia, although the numbers involved in these studies were small. The purpose of this patient survey was to determine the impact of topical gabapentin use on self-reported pain, patient functioning and patient satisfaction in patients presenting with vulvodynia.
Methods
The survey was conducted at Cardiff and Vale University Health Board (Cardiff) and Nottingham University Hospitals NHS Trust (Nottingham). Patients prescribed topical gabapentin from 2014-2016 were identified from databases held by the pain clinic (Cardiff) and gynaecology outpatients (Nottingham). Ethics approval was not required as this was a service evaluation as confirmed by the respective audit departments. Patients were assessed using a ten point numerical scale to quantify pain relief immediately after commencing the treatment, pain relief after 6 months of treatment and overall satisfaction with the product. Patients were also questioned on a ten point numerical scale (-5 to 5) to assess the effect of topical gabapentin on their mood, sleep and activity levels. Additionally, patients were asked for qualitative feedback on the product and any adverse effects.
Results
A total of 54 patients received treatment with gabapentin gel (Cardiff 24, Nottingham 30). Of these, 27 patients were successfully contacted (Cardiff 17, Nottingham 10). Improved pain was reported by 14 of 27 patients (Cardiff 7/17, Nottingham 7/10). After 6 months of treatment 12 patients continued to experience pain relief (Cardiff 5, Nottingham 7).
The mean reduction in pain among those responsive to treatment was 66% immediately (Cardiff 74%, Nottingham 58%) and 49% after 6 months (Cardiff 48%, Nottingham 50%).
Amongst those who reported a benefit, mean satisfaction scores were 7.6/10 (Cardiff 8.2/10, Nottingham 7/10). Improved sleep was reported by 5 patients, improved mood by 10 patients and increased activity by 8 patients. Decreased sleep was reported by 1 patient, decreased mood by 2 patients and decreased activity by 1 patient.
Reasons for discontinuing the treatment were lack of efficacy (12 patients) and local irritation (2 patients).
Conclusion
The findings of improved symptoms, along with the corroboration of results from two trusts, support the efficacy of topical gabapentin in the treatment of vulvodynia. Women report satisfaction with the quality of the product and improvement in quality of life indicators such as mood, sleep and activity levels.
Br J Pain. 12(2 Suppl):5–54.
30
An Investigation into Frequency Parameters And Variable Electrode Array Response with Medtronic Restore Sensor Technology in Patients with Intractable Neuropathic Pain Who Have Not Had Spinal Surgery
Category: Neuropathic Pain
Georgina Wilson - Pain and Anaesthetics Barts Health NHS Trust, Joanne Lascelles - Pain and Anaesthetics Barts Health NHS Trust, Kavita Poply - Pain and Anaesthetics Barts Health NHS Trust, Serge Nikolic - Pain and Anaesthetics Barts Health NHS Trust, Vivek Mehta - Pain and Anaesthetics Barts Health NHS Trust
Background
Spinal Cord Stimulation (SCS) is an effective therapy for patients with intractable neuropathic pain. Traditionally, SCS is used for patients with neuropathic pain following Failed Back Surgery Syndrome (FBSS). However, SCS is increasingly being used in patients with intractable neuropathic pain who have not undergone previous spinal surgery. A side effect of conventional SCS parameters is the onset of paraesthesia, which can cause significant patient discomfort. Recently, studies have aimed to deliver energy to the spinal cord below the threshold for paraesthesia in order to reduce associated discomfort and increase the tolerability of SCS treatment. One method to achieve this involves High Density (HD) SCS which delivers higher pulse density through combinations of frequency and pulse width. Nonetheless, data in the use of paraesthesia-free stimulation in patients with intractable neuropathic pain who have not undergone previous spinal surgery is limited.
Aims
The primary objective is to investigate the clinical response following implant with Medtronic RestoreSensor neurostimulator system and High Density (HD) spinal cord stimulation in patients with lumbar radiculopathy who have not undergone any spinal surgery. The secondary objectives are to investigate the effect on quality of life and adverse events.
Methods
This study is an open label, single-centre pilot study. Patients with intractable neuropathic pain (n=20) due to undergo Spinal Cord Stimulation as part of their standard treatment for lumbar neuropathic pain are being recruited. All patients will undergo trial stimulation for at least one week. Pain scores (Numerical Rating Scale, NRS) and data from self-report questionnaires (Oswestry Disability Index (ODI), Pain and Sleep Questionnaire (PSQ), Patient Global Impression of Change (PGIC), will be collected pre-implant and at 4 and 12 weeks post-implant.
Results
This study is on-going and we will present the up-to date interim analysis at BPS. At present, 8 patients (7 female, 1 male) have been enrolled into the study. All have received permanent implant. Six patients have completed 4-week follow-up visits and 4 patients have completed 12-week follow-up visits. At baseline, the mean NRS score for lower back pain and leg pain were 7.79 ± 1.41 and 5.88 ± 2.02 respectively. At 4-weeks post-implant, the average reduction in lower back pain is 5.56?± 2.85 (?63.01% vs. baseline) and 2.56 ± 1.92 (-57.77% vs. baseline) for leg pain. Furthermore, a reduction in ODI scores of an average 21.01 ± 24.28 (35.93% vs. baseline). We will also report the 12-week follow-up data at BPS.
Conclusion
Currently, the interim data of this study demonstrates HD SCS may be an effective therapy to reduce lower back and leg pain in patients who have not previously undergone previous spinal surgery.
Br J Pain. 12(2 Suppl):5–54.
31
Point Prevalence of Painful Diabetic Neuropathy in THE Middle East and North Africa: A Systematic Review with Meta-Analysis
Category: Neuropathic Pain
Sabri Garoushi - School of Clinical and Applied Sciences Leeds Beckett University, Osama A Tashani - School of Clinical and Applied Sciences Leeds Beckett University, Mark I Johnson - School of Clinical and Applied Sciences Leeds Beckett University
Background
Painful Diabetic Neuropathy (PDN) is a common complication of diabetes. Over recent decades there has been a rise in the prevalence of diabetes in the Middle East and North Africa (MENA). It is suspected that this will be accompanied by an increase in PDN. Epidemiological research on PDN is needed to inform health policy in the MENA region.
Aims
The aim of this systematic review of was to estimate the point prevalence of PDN in countries from the MENA region.
Methods
Cross-sectional or longitudinal studies that reported the prevalence of adults with PDN in the MENA region were sought by searching three computerised databases (Medline via web of science, PubMed and Science Direct). Titles and abstracts were reviewed and screened independently by two researchers (SG and OAT). Data extracted were; age, sex, body mass index, sample size, type and duration of diabetes, and point prevalence of PDN. PDN point prevalence was calculated as event rate (i.e. proportion out of 1) and used to produce the overall prevalence in the region using Comprehensive Meta-analysis software.
Results
Searches identified 1657 records. The full texts of 14 records retrieved following removal of 600 duplicates and exclusions of 1043 abstracts. Five studies were eligible for review following screening of full text reports. Four of the five reports described surveys of PDN conducted in one country: Saudi Arabia (1 report), Turkey (2 reports), Algeria (1 report). One report described surveys conducted in Egypt, Lebanon, Jordan and Gulf States. The Douleur Neuropathique 4 (DN4) questionnaire was used in seven of the surveys and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale in one survey. The prevalence of PDN was 65.3% for Saudi Arabia, 14% and 23% for Turkey, and 45% for Algeria. The prevalence of PDN was 53.7% in the study that combined estimates from Egypt, Lebanon, Jordan and Gulf States. Overall, the prevalence of PDN in people with diabetes was 43.2% (95%CI=30.1%-57.2%, 8 surveys, 7806 participants, 3761 women).
Conclusion
The prevalence of PDN in people with diabetes from the MENA region was 43.2% (7806 participants) and higher than estimates from other regions of the world such as the UK (30.2%) and the USA (11%).
Br J Pain. 12(2 Suppl):5–54.
Non-Pharmacological Pain Management
32
Tailored Aerobic Exercise Improves Sense of Wellbeing With Little Effect on Pain in Complex Regional Pain Syndrome- A Service Development Project
Category: Non-Pharmacological Pain Management
Emma Houlihan - CRPS RNHRD, Royal United Hospitals Bath NHS Foundation Trust, Jane Hall - CRPS RNHRD, Royal United Hospitals Bath NHS Foundation Trust, Alison Llewellyn - CRPS RNHRD, Royal United Hospitals Bath NHS Foundation Trust
Background
Complex Regional Pain Condition (CRPS) is a painful and debilitating condition. Kinesiophobia and subsequent deconditioning is common in chronic CRPS, as is secondary depression. Regular exercise, with recommendation to engage in moderate or vigorous intensity physical activity for a certain amount of time per week, has been proven to enhance mood as well as reduce the risk of chronic illnesses. However, our patients at a tertiary CRPS centre report that many physical activities which could improve cardiovascular fitness provoke their CRPS pain and enhance a downward spiral of physical inactivity, despite generalised exercise being a central component in long-term condition management. As part of the 2-week rehabilitation programme patients are introduced to various physical activity strategies with the aim of enhancing adoption to long-term commitment. We wished to examine the effect of acute bouts of supervised tailored cardiovascular exercise in on pain intensity and patient perception of well-being.
Aims
To evaluate if tailored aerobic and strengthening exercise sessions impact on pain and sense of well-being in patients with chronic CRPS completing a 2 week residential rehabilitation programme.
Methods
Patients completing a 2 week residential rehabilitation programme attended 3-4 group cardiovascular training sessions of 30 minutes duration. Sessions comprised individualized exercises focusing on aerobic fitness and strength using cardio and weight machines in a bespoke gym. Exercises were prescribed and supervised by the programme physiotherapist following comprehensive biopsychosocial assessment as part of the rehabilitation plan. Sessions were attended by the programme cohort and could include between 4 to 8 patients at any one time. Prior to gym attendance explanation and discussion of the deconditioning cycle and the role of physical activity and exercise in management of long-term CRPS was provided using a motivational interviewing style. Pain and well -being were measured before and after each session using 10cm visual analogue scales (VAS:no pain/worst imaginable pain; worst you could feel/best you could feel ). Exertion was captured via Borg’s Scale of Perceived Exertion (RPE) at end of each session.
Results
Over a 5 month period, 28 patients, including 16 females, with a mean age of 55 and mean duration of CRPS of 4 years -participated in the sessions. All patients had one affected limb including 15 patients with upper limb CRPS. Sense of well-being, on the 10 cm VAS improved immediately after each session (S1:1.9, S2:2, S3:1.7, S4:1.6cm) with cumulative improvement of 1.8cm (SD:0.16). Pain intensity increased immediately after each session (S1:0.6, S2:0.9, S3:0.3, S4:0.6) with cumulative increase of 0.6 (SD: 0.2). No patient missed further sessions or programme because of lasting pain increase. Cumulative subgroup analysis showed the sense of well-being improved in most participants (80%) or remained the same (14%). Cumulative subgroup analysis showed pain intensity worsened in 45%, improved in 15% and remained the same in 40%. Average RPE was 5 (SD: 0.16), representing moderate effort across all sessions.
Conclusion
Despite increase in pain for some patients sense of well-being improved for the majority. Importantly pain increase did not affect engagement with gym or rehabilitation programme attendance. Of consequence was patients’ ability to exercise at a moderate intensity consistently over the sessions, suggesting that continued engagement could enhance cardiovascular fitness. Ongoing data collection with more patients will enable examination of relationships between pain intensity, sense of well-being and RPE as well as adherence to regular physical activity on discharge from programme. These results may initiate greater interest in engagement with and effect of regular physical activity in CRPS.
Br J Pain. 12(2 Suppl):5–54.
33
Clinical Effectiveness of a Cognitive-Behavioural Pain Management Programme
Category: Non-Pharmacological Pain Management
Hayley Slater - Doctorate in Clinical Psychology Lancaster University, Ian Fletcher - Doctorate in Clinical Psychology Lancaster University, Zoey Malpus - South Manchester Pain Management Service University Hospital of South Manchester
Background
Background: Cognitive-behavioural Pain Management Programmes (PMPs) are the recommended evidence-based treatment for chronic pain associated disability and distress. Existing research has assessed the efficacy of PMPs when implemented under idealised research conditions. Much of the current research is limited, however, in terms of external validity and further research is required to assess the effectiveness of PMPs when implemented in real-world clinical settings. Additionally, the way in which effectiveness is measured requires consideration. The majority of existing research has assessed PMP impact through conventional statistical analysis, indicating when a statistically significant change has been made following intervention. A statistically meaningful change, however, does not necessarily equate to change which is clinically significant. This crucial distinction has implications for both research and routine clinical outcome monitoring, with analysis of clinical significance offering potential to better understand the real impact treatment is likely to make in the day-to-day lives of recipients.
Aims
Aims: The aim of the current study was to use reliable change and clinically significant change methodology to evaluate the clinical significance of outcomes from a PMP following treatment and at follow-up. Conventional statistical analysis has also been carried out for comparison.
Methods
Methods: Data was collected from 199 participants who completed the 10-day PMP between 2010 and 2017. Group sizes ranged between five and ten people. The PMP was delivered in a community setting by multidisciplinary staff from an urban NHS Pain Centre. Measures of depression, pain-related-anxiety, perceived disability, pain acceptance, pain intensity, and physical functioning were taken pre- and post-treatment and at 6- and 12-month follow-up intervals. Clinical cut-scores were established for psychological measures based on externally validated thresholds or available normative data from similar clinical populations. Reliable change index methodology was used to establish whether change in scores represented a ‘true’ change beyond that attributable to measurement error and clinically significant change analysis was undertaken to assess whether any observed change fell within or shifted two standard deviations towards the non-clinical range. A repeated measures ANOVA was also carried out in order to compare any findings of statistical significance.
Results
Results: Approximately 50% of the sample were found to achieve a reliable improvement in pain-related disability and anxiety post-intervention. This reduced to around 40% for depression and pain-acceptance. The majority of the remaining participants were found to make no change while a small number of the sample (0.5-4.4%) were observed to make a reliable deterioration. On all measures any observed reliable change was found to be sustained proportionately at 12-month follow-up. Results from the clinically significant change analysis revealed that the highest proportion of clinically significant improvement was made in perceived disability (46%), followed by depression (36%), and pain-acceptance (35%). Comparison of means from pre-intervention to each follow-up point found medium to large effect sizes for all psychological variables and measures of physical functioning and a small effect size for pain intensity. Pairwise comparisons of group means across time points showed a significant effect (p<.05) on all psychological measures.
Conclusion
Conclusion: Comparison of statistically and clinically significant results reveals the discrepancy between how these different types of analysis give meaning to outcome data. While conventional statistical testing of the PMP outcomes defined all observed changes as significant, tests of reliable and clinically meaningful change revealed a more varied picture. These results demonstrate the importance of differentiating clinical and statistical significance and of emphasising the clinical meaningfulness of outcomes as a truer reflection of the impact of interventions. Additionally, it is suggested that the personal significance of any change should be considered as a key factor in monitoring of outcomes.
Br J Pain. 12(2 Suppl):5–54.
34
Does Patients’ Perception of Improvement Following a Pain Management Programme, Match Reported Minimally Clinically Important Differences?
Category: Non-Pharmacological Pain Management
Leila Heelas - Physiotherapy Oxford university Hospitals NHS FT, Sandra Wiltshire - Psychological Medicine Oxford University Hospitals NHS FT, Amanda Wall - Physiotherapy Oxford University Hospitals NHS FT, Karen Barker - Physiotherapy Oxford University Hospitals NHS FT
Background
Effectiveness of pain management programmes for chronic pain is well established. Large samples attending highly intensive programmes have been evaluated to determine clinically reliable change, but patients’ impression of change has not been recorded. Lack of measurement of factors important to patients, such as relationships and social interaction, has been highlighted (C de C Williams, 2017). Morley and Thorne (2009) suggested a mean change of 2.09 in pain interference, as measured by the Brief Pain Inventory (BPI), could be considered acceptable to patients. Currently data is unavailable for changes in pain acceptance. A greater understanding of the percentage of patients that perceive improvement following treatment, may assist with patient decision making and informed consent for treatment. Furthermore, changes on outcome measures for this ‘improved’ cohort may assist with benchmarking services nationally, especially since the inception of the King’s Fund’s Getting It Right First Time (GIRFT, 2017) model in the NHS.
Aims
To evaluate clinical outcomes for patients attending a pain management programme to determine whether patients who rated an improvement on a Global Impression of Change Score, achieved mean changes in BPI that were consistent with ‘acceptable’ change, and to determine mean changes on other outcomes in this population.
Methods
A battery of validated questionnaires were completed by patients attending a 36 hour (standard) interdisciplinary pain management programme at pre-treatment and three months post rehabilitation, between 2015 - 2017. The programme was based on the Acceptance and Commitment Therapy psychological model, with emphasis on enhancing psychological flexibility, present-moment awareness, and a willingness to pursue values based goals.
The percentage of patients that scored between 5 and 7 (improved) on the Global Impression of Change Score was calculated. Pre and post mean and standard deviations (SD) were calculated on the Brief Pain Inventory – Interference Scale (BPI), Chronic Pain Acceptance Questionnaire (CPAQ-8), Generalised Anxiety Scale (GAD-7), Patient Health Questionnaire (PHQ-9) and the Tampa Scale of Kinesiophobia (TSK). Effect sizes were calculated, using a correlation co-efficient for inter-related measures.
Ethical Approval: All patients consented to their outcome data being used for service evaluation. The Joint Research and Development Committee LREC was not required.
Results
Complete 3 month data was available for 164 patients (62% of the total cohort) who received treatment.
79 patients (48%) reported an improvement. Mean pre –post changes (SD) in the improved / complete cohort were :
PHQ-9 13.5 (5.6) – 10.1 (6) / 13.9 (5.8) – 11.0 (6.5)
GAD – 7 9.6 (5.7) – 6.8 (5) / 10.3 (5.8) – 7.5 (5.4)
BPI 7.3 (1.7) – 5.1 (2.2) / 7.5 (1.9) – 5.4 (2.4)
TSK 37.5 (9.4) – 31.2 (9.4) / 38.4 99.4) – 33.2 (10.1)
CPAQ 19.6 (8.9) – 24.5 (9.4) / 18.8 (8.2) – 23.2 (9)
Effect sizes in the improved / complete cohort for the PMP were:
PHQ-9 (0.7 / 0.5)
GAD -7 (0.6 / 0.5),
BPI (1.2 / 0.9),
TSK (0.8 / 0.5),
CPAQ (0.8 / 0.5)
Conclusion
Mean changes on the BPI in the improved cohorts of the PMP were 2.2 which mirrors the acceptable change cited by Thorne and Morley (2009). Although effect sizes in the total cohorts were generally moderate to large, less than 50% of patients considered these changes as acceptable.
Clinical Importance: Clinicians may consider revising the previously considered estimate of a 1 point change on the BPI post treatment as clinically meaningful (National Pain Audit 2012). An understanding of changes expected following a standard pain management programme may assist clinicians when advising patients of the risks and benefits of treatment.
Br J Pain. 12(2 Suppl):5–54.
35
Paediatric Pain Management @ OXCYPP
Category: Non-Pharmacological Pain Management
Konrad Jacobs - OXCYPP - Oxford Centre for Children and Young People in Pain Oxford University Hospitals, Julia Smith - OXCYPP - Oxford Centre for Children and Young People in Pain Oxford University Hospitals, Annemarie van Es - OXCYPP - Oxford Centre for Children and Young People in Pain Oxford University Hospitals, Kathy Bailey - OXCYPP - Oxford Centre for Children and Young People in Pain Oxford University Hospitals
Background
We have been treating children and young people with chronic pain for more than 10 years at the NOC. The service is a separate arm of Paediatric Rheumatology. We see children from Oxfordshire (about 50%) and the surrounding counties. The service is one of only a handful comprehensive pain services in the country for children and adolescents. We provide outpatient treatment, pain management groups and intensive rehabilitation programmes.
Aims
To report on the effectiveness of our multi-disciplinary non-pharmacological intensive treatment programme at OXCYPP
Methods
We collect outcome data prior to the patient’s entry into our service, at the end of an intensive rehabilitation programme, 6 weeks after a programme and 6 months after a programme.
Results
Satisfaction levels with the service are very high and our outcomes at 6 months are very good compared to pre-treatment functioning. Physical functioning, social functioning, emotional functioning and school functioning improve significantly compared to pre-intervention levels Our intervention leads to a significant reduction in A&E attendance and outpatient appointments with secondary care and allied health professionals.
Conclusion
The outcomes of the multi-disciplinary pain management intervention at the Oxford Centre for Children and Young People in Pain are very good in every respect: satisfaction with the service, functional outcomes as well as a reduction in A&E attendance and consultations with other clinical professionals.
Br J Pain. 12(2 Suppl):5–54.
36
Using Flo to Engage Patients’ on Tayside Pain Management Programme
Category: Non-Pharmacological Pain Management
Paulene Madoc-Jones - Tayside Pain Service, Ninewells Hospital, Dundee NHS Tayside, Judith Linskell - Tayside Pain Service, Ninewells Hospital, Dundee NHS Tayside, Lynne Sheridan - Tayside Pain Service, Ninewells Hospital, Dundee NHS Tayside, Dr Jonathan Todman - Clinical Health Psychology, Ryehill Health Centre, Dundee NHS Tayside
Background
Tayside Pain Management Programme (PMP) was started in 2016. It is an 11 week programme based on an Acceptance and Commitment Therapy (ACT) approach. An early audit revealed issues with both patient drop out rates and the level of ongoing engagement with programme tasks between sessions. Previous studies have indicated that homework completion has a small to medium effect in improving psychological outcomes (Mausbach et al, 2010, Kazantzis et al 2016) and there is evidence that mobile technologies can be a useful aid in improving task completion between sessions (Tang and Kriendler, 2017).
FLO is a home and mobile health monitoring solution that uses a simple text messaging system to support people managing their own health conditions. Rather than requiring an app or other technology to be downloaded, FLO requires only that patients have a phone that allows text messages.
Aims
This is a pilot project to assess the use of FLO as a tool to improve engagement with our PMP by increasing the number of interactions with patients between the weekly group sessions. We aim to investigate patients’ experience of using FLO in an ACT based PMP and to explore clinicians’ experience of using FLO in an ACT based PMP.
Methods
FLO was piloted with one group of our PMP. An explanation of FLO was given at their first session and patients’ consent obtained. Patients were invited to enrol with FLO the following day via a text message.
Patients were sent two messages each week to promote engagement with the topics covered in the group and to reinforce homework completion. Some of the messages required a response. Depending on the patients’ response, a further message was sent to offer advice and encouragement. If they failed to respond, a second message was generated, encouraging them to respond.
Additional messages were sent as a reminder of any cancelled sessions due to public holidays or change of venue. All messages were signed by FLO to give the text message a more human element.
Patient experience of using FLO was measured using a patient evaluation questionnaire. Clinical experience of using FLO was also explored.
Results
Initial response from the use of FLO within the PMP was very positive, with 100% sign up rate following the first PMP session. Early patient feedback from the first half of the course has been positive. A clear majority of patients indicated satisfaction with the number of text messages received. Clinicians found FLO user friendly. It also allowed more efficient use of clinical time. Full results from this pilot will be available in February.
Conclusion
A successful pilot of FLO in the PMP setting has been well received by both patients and staff. We hope that the increased professional support throughout the programme will encourage patients to take more responsibility for the self-management of their chronic pain condition. Further results will be described once our trial has concluded.
Br J Pain. 12(2 Suppl):5–54.
37
Engaging Men in a Group Pain Management Programme: Outcomes and Issues
Category: Non-Pharmacological Pain Management
Sarah Edwards - Pain Management, National Hospital of Neurology and Neurosurgery University College London Hospitals NHS Trust, Julia Cambitzi - Pain Management, National Hospital of Neurology and Neurosurgery University College London Hospitals NHS Trust, Katie Herron - Pain Management, National Hospital of Neurology and Neurosurgery University College London Hospitals NHS Trust, Craig Crawley - Pain Management, National Hospital of Neurology and Neurosurgery University College London Hospitals NHS Trust, Terrance Ramrattan - Pain Management, National Hospital of Neurology and Neurosurgery University College London Hospitals NHS Trust, Katrine Petersen - Pain Management, National Hospital of Neurology and Neurosurgery University College London Hospitals NHS Trust
Background
Men are less likely than women to engage in health services (e.g. Wang et al., 2013). Mutual unconscious biases within the male patient and the healthcare professional mean that discussion of emotional health is likely to be avoided (Kingerlee et al., 2016). Within the context of persistent abdomino-pelvic pain (APP), there are multiple physiological, psychological and social factors which lead to differences in pain experiences for men and women (e.g. Curran, 2015).
The UCLH team run a gender-specific APP pain management programme (PMP), ‘Link’. Our clinical experience is of greater difficulty in recruiting and thus referring men to a group self-management programme, compared to women. We notice that men tend to opt for individual rather than group therapy, and have developed ideas about why this might occur. However, once engaged on a programme, we observe that male patients make equivalent progress to female patients.
Aims
We aimed to discover whether men are less likely than women to be referred to a group PMP rather than individual self-management sessions, as they progress along the APP pathway, and to examine why any differences may occur. We also aimed to compare PMP outcomes for men and women.
Methods
Referral numbers from January 2017 to date were extracted for men and women at different stages of the APP pathway at our Centre. Data was collected for referrals at the following four pathway stages: initial review with a medical consultant; self-management group information session; specialist group PMP, ‘Link’; and individual pain management Psychology sessions.
Discussion with multidisciplinary team members elicited suggestions to why there might be referral differences between men and women, and these suggestions were grouped into themes. PMP outcome data was analysed, in the domains of pain intensity, self-efficacy despite pain, and unhelpful thinking. Male and female data were analysed separately, comparing baseline with one-month and nine-month follow-up.
Results
Referrals analysis showed that the male:female ratio was approximately 1:2.5 for initial review at the APP service. It increased slightly, to 1:3, for self-management information sessions. The male:female ratio rose to 1:5 for the group PMP. It fell, to approximately 1:2, for individual self-management sessions.
Themes elicited from the MDT about this tendency to refer male patients to individual therapy included: longer waiting times for the male PMP; higher reluctance and anxiety expressed by men about being in a group and sharing experiences, and less willingness to agree to try this; clinician assumptions that such barriers, and others e.g. men getting time off work, were insurmountable.
Outcome data for the PMP showed statistically significant reductions in various domains for both genders. Effect sizes (d) were higher for men for pain intensity and self-efficacy despite pain, but were higher for women for unhelpful thinking about pain.
Conclusion
Fewer men than women are referred to the specialist APP team. This gender disparity increases as patients progress along the pathway towards the group PMP, but decreases for individual sessions. A mix of service-related, patient and clinician factors may contribute to this bias. However, when men do attend a PMP, their outcomes are equivalent to women’s.
Male engagement in services has been identified as an area of public health which needs improvement (e.g. DoH/ Mens Health Forum, 2008). Our team are working to increase gender equality in access to our specialist PMP.
Br J Pain. 12(2 Suppl):5–54.
38
Helping Patients to Reduce Pain Medication on a Combined Physical and Psychological Treatment Programme: A Clinical Audit
Category: Non-Pharmacological Pain Management
Harriet Smith - Department of Musculoskeletal Medicine Royal Orthopaedic Hospital Birmingham, David Rogers - Department of Musculoskeletal Medicine Royal Orthopaedic Hospital Birmingham, Gurjit Bhogal - Department of Musculoskeletal Medicine Royal Orthopaedic Hospital Birmingham
Background
Low back pain is the leading cause of disability world-wide. The Functional Restoration programme at the Royal Orthopaedic Hospital, Birmingham is a combined physical and psychological programme (CPPP) designed to treat patients with persistent back pain as recommended by NICE. Many patients who attend the Functional Restoration Programme are taking pain medication and reduction of medication is a common goal for patients, who are often experiencing side effects from their medication. Non-steroidal anti-inflammatory drugs, skeletal muscle relaxants, opioids and tricyclic antidepressants have been shown to be effective for short term pain relief but there is a paucity of evidence for long-term benefits of these medications. Pregabalin and gabapentin are increasingly used in sciatica but a recent study in NEJM (March 2017) looking at the use of pregabalin in sciatica found no significant improvement in pain and significantly more side effects.
Aims
To identify the analgesics used by patients attending the Functional Restoration Programme and the cost associated with these medications
To compare these medications with recommendations from the literature
To evaluate the number of patients able to reduce their medication and the cost saving associated with this
Methods
Data was collected from patients attending the Functional Restoration Programme from October 2016 to May 2017. Patients were asked to record their use of medication at the beginning and end of the course. All patients received education regarding the risks and benefits of using long term pain medication from an orthopaedic physician. Those who expressed a wish for help reducing their medication were given support from an orthopaedic physician to reduce their usage. Completed datasets (medication pre and post course for the patient) were inputted into Microsoft Excel, which was used for data analysis. Medication costings were obtained from the pharmacy at the Royal Orthopaedic Hospital.
Results
Completed datasets were obtained from 47 patients. The most commonly used medications in this group of medications were non-steroidal anti-inflammatory drugs (29%), weak opioids (26%) and paracetamol (20%). 16% of patients were taking neurolytic agents.
30 of these patients (67%) reduced their use of pain medication following the Functional restoration programme. No patients increased their use of pain medication. This translated to a total cost saving of £3728.64/year for the cohort of 47 patients, which is a saving per patient/year with decreased medication of £124.29. The medications with the greatest cost saving were gabapentin/pregablin (£2258.88 per year), weak opioids (£2007.06 per year) and NSAIDs (£1086.96 per year).
Conclusion
There is a disparity between the pain medication patients are taking and the literature recommendations. A multidisciplinary CPPP can be used to help patients reduce or stop their pain medication. Weak opioids, NSAIDs and paracetamol are the most commonly prescribed pain medications in this group. Spending is highest for anti-epileptics, NSAIDs and weak opioids: these pain medications had the largest cost saving. A separate service evaluation on the same cohort of patients has demonstrated significant improvements in pain self-efficacy and back disability at 27 month follow up.
Br J Pain. 12(2 Suppl):5–54.
39
A Study to Compare the Effects of Kinesiology Tape and Non-Elastic Surgical Tape on Sensory Perception to Noxious and Non-Noxious Mechanical Stimuli in Healthy Participants
Category: Non-Pharmacological Pain Management
Hannah V. Wilson - Centre for Pain Research, School of Clinical and Applied Sciences Leeds Beckett University, Peter Francis - School of Clinical and Applied Sciences Leeds Beckett University, Mark I. Johnson - Centre for Pain Research, School of Clinical and Applied Sciences Leeds Beckett University
Background
Kinesiology tape has longitudinal elastic qualities and is used to treat musculoskeletal pain (Kase et al., 2003, Montalvo et al., 2014). Non-myelinated (C fibres) and myelinated (A? fibres) nociceptive afferents provide the peripheral input to drive pain perception, whereas low threshold myelinated afferents (A? fibres) provide the peripheral input to drive non-painful mechano-perception (Dubin and Patapoutian, 2010). Quantitative sensory testing can be used as a proxy measure of the activity of peripheral afferent fibres.
Aims
To compare the effect of kinesiology tape with a non-elastic surgical tape (DuraporeTM tape) on sensory perception to noxious and non-noxious mechanical stimuli in healthy adult participants (<18 years).
Methods
This was a repeated measures experimental study whereby participants were randomised to receive either kinesiology tape (Tiger K TapeTM at 50% stretch, n=24) or non-elastic surgical tape (DuraporeTM, n=25) using block randomisation. Tape was applied above the bicep brachii muscle of one arm (randomly selected, intervention arm), whilst the contralateral arm was not taped (control arm). Data was collected before and whilst tape had been in situ for 10 minutes. The primary outcome was the pre-post percentage change difference in pressure pain threshold (pressure algometry – C fibres) between taping groups. Secondary outcome measures included the pre-post percentage difference in mechanical pain threshold (PinPrick test – A? fibres) and of mechanical detection threshold (Von Frey filament test – A? fibres) between taping groups.
Results
Between-group unpaired t-test analysis revealed no statistically significant differences between taping groups for pressure pain threshold for (i) the intervention arm (P=0.22) or (ii) the control arm (P=0.65). Within-group paired t-test analysis found no statistically significant differences in pressure pain threshold between the intervention and control arm for kinesiology tape (P=0.30) or non-elastic surgical tape (DuraporeTM tape, P=0.22). There was no statistically significant difference between taping groups for either mechanical sensitivity threshold or mechanical pain threshold for (i) the intervention arm (P=0.21, P=0.47 respectively) or (ii) the control arm (P=0.39, P=0.31 respectively). Within-group analysis found no statistically significant differences between the intervention and control arm for mechanical sensitivity threshold (kinesiology tape: P=0.12, non-elastic surgical tape: P=0.53) or mechanical pain threshold (kinesiology tape: P=0.83, non-elastic surgical tape: P=0.88).
Conclusion
There was no differences between kinesiology and non-elastic surgical tape on sensory perception to noxious and non-noxious mechanical stimuli.
Br J Pain. 12(2 Suppl):5–54.
40
Interdisciplinary Pain Management Programme for Veterans
Category: Non-Pharmacological Pain Management
Jannie Van Der Merwe - The Pain and Neuroscience Centre The King Edward VII’s Hospital, London, Andrew Baranowski - The Pain and Neuroscience Centre The King Edward VII’s Hospital, London, Suzanne Brook - The Pain and Neuroscience Centre The King Edward VII’s Hospital, London, Claire Fear - The Pain and Neuroscience Centre The King Edward VII’s Hospital, London, Maxwell J Benjamin - Psychology Barking, Havering and Redbridge University Hospital NHS Trust, Dominic Aldington - The Pain and Neuroscience Centre The King Edward VII’s Hospital, London, Gerald Libby - The Pain and Neuroscience Centre The King Edward VII’s Hospital, London
Background
The Veteran chronic pain population present with high co-morbidity posing unique challenges to the access and delivery of pain management; such as Post-Traumatic Stress Disorder that is more prevalent in this population (Otis, Keane, Kems, Monson, & Scioli, 2009). It is well documented that Chronic Pain and PTSD are mutually maintaining conditions and that there are several pathways by which both disorders may be involved in the escalation of symptoms and distress following trauma; including anxiety and hyperarousal, behavioural avoidance, emotional lability, and an attentional bias toward somatic cues. Despite these issues, there is relatively little research into the veterans’ personal accounts of their pain experience or the examining of outcomes of pain management programmes tailored specifically to address the veteran population, particularly in the United Kingdom. Such data are needed to help refine pain management programmes for veterans.
Aims
To evaluate treatment outcome in a veteran sample, suffering from chronic pain, who have participated in an interdisciplinary pain management programme.
To investigate the correlation between chronic pain and PTSD.
To gain a better understanding of veterans’ pain experience from a bio-psycho-social perspective to inform treatment aims and optimise outcome.
Methods
The quantitative aspect of the study examines the programme’s main outcome measures, which are primarily psychometric questionnaires widely used within the management of pain, functional outcome measures, medication reduction and the attainment of specific personal goals of subjects attending the programme. The Impact of Event Scale has been added to assess distress caused by traumatic events. It also measures physical outcome by using the widely used measurement of stand ups completed in one minute. Questionnaires are being administered on the initial assessment day and days 1; 5; 8 and 10 of the pain management programme (PMP).
The study also incorporates written replies from veterans regarding personal gain from attending the PMP and overall feedback regarding more subtle changes and personal goals.
Results
A small sample of twenty-six veterans attended. The sample for the poster will grow to an estimated fifty-five participants.
Clinically positive changes were observed from assessment to the final day of the programme (mean score):
Improvement in mood (CORE-10)
Increased self-efficacy (PSEQ)
Reduction in negative rumination and attending to pain as a threat (PCS)
Reduction in fear of movement/re-injury (TSK)
Veterans demonstrated greater confidence in applying strategies to manage mood and optimise quality of life despite their chronic pain. Improved activity management and veterans reported an overall greater understanding of pain mechanisms and the role of the Central Nervous System.
Decrease in pain medication use and greater understanding of the optimal management of pain medications.
According to the IES-6, 50% of the veterans who attended the first three programmes, indicated a slight reduction in their trauma scores. Correlations between PTSD and pain severity, self-efficacy, catastrophizing, kinesiophobia will be reported.
Conclusion
Despite high co-morbidity under the veteran chronic pain population, there is relatively little research into the examining of outcomes of pain management programmes tailored specifically to address the veteran population. Such data are needed to help refine pain management programmes for veterans.
Veterans with both chronic pain and high co-morbidity may need tailored interdisciplinary pain management programmes to create an emotionally safe treatment environment where the veteran culture and shared experiences are being respected and accommodated.
The treatment model should enhance veterans with high co-morbidity to address pain-related fears and to engage in their journey to maximise quality of life.
Br J Pain. 12(2 Suppl):5–54.
Older People
41
Across the Lifespan: Chronic Pain-Related Disability at Different Developmental Stages
Category: Older People
Authors: Jeremy Gauntlett-Gilbert - Bath Centre for Pain Services Royal United Hospitals Bath NHS Trust, Abbie Jordan - Department of Psychology University of Bath, Meghan McMurtry - Department of Psychology University of Guelph, Line Caes - Department of Psychology University of Stirling, Hannah Connell - Bath Centre for Pain Services Royal United Hospitals Bath NHS Trust
Background
Most adults with chronic pain are treated in clinical services that do not emphasise developmental factors. However, exceptions exist; there are specialist clinical services for young adults, and some studies have focused specifically on the treatment of older adults (e.g. McCracken and Jones, 2012, Pain Medicine, 13, 861-867). However, this area remains under-researched and there are no published models of how chronic pain-related disability, and its mechanisms, might change over the course of adulthood.
Aims
We aimed to examine impact of age on functioning (social and physical), and to look at the correlates of functioning in different age bands across adulthood.
Methods
We examined a database of 805 adults who attended a residential or inpatient specialist pain rehabilitation programme, and who consecutively gave written, informed consent for their data to be used for research. The participants experienced a range of pain diagnoses (largely musculoskeletal). This dataset was split into three:
aged 25 or younger; N = 119, age 20.9 yrs, 87% female, chronicity median 60 mths, 98% white British.
aged 26-54; N = 545, age 41.5 yrs, 65% female, chronicity median 85 mths, 96% white British
aged 55 +; N = 141, age 60.1 yrs, 64% female, chronicity median 170 mths, 96% white British
All participants completed a battery of questionnaires that measured functioning (physical and psychosocial), pain-related fear, acceptance (pain acceptance and general acceptance), and valued living. They also completed directly measured physical functioning tests – timed walk and sit-to-stand.
Results
Looking at the whole database (n = 805), there were few overall correlations between age and functioning, and those found were small in magnitude (all correlations with self-report measures accounted for < 1.5% of the variance, though some reached significance due to large N). The ability to accept pain, and emotions in general, did not change with age. The largest correlations showed that increasing age was associated with decreased sit-to-stand performance (r = -.21, p < .001) and rapid walk distance (r = -.16, p < .001). Thus, we examined correlations within the age bands; usual pain and present pain were correlated with self-reported functioning much less closely for younger adults (average r = .12) compared to the middle age band (average r = .26, more than 4x as much variance). Success in valued living was only associated with physical functioning for those under 55.
Conclusion
There were few global relationships between age and functioning, other than a small decline in objective physical functioning with increased age. Age had no impact on the ability to accept pain or other difficult emotions, albeit in a treatment-seeking population. There was evidence that functioning was associated with different variables in different age bands; pain was less closely associated with physical and psychosocial functioning for young adults, and older adults showed no relationship between physical functioning and valued living success. These preliminary findings have clear implications for the aims and targets of pain management treatment.
Br J Pain. 12(2 Suppl):5–54.
42
Lidocaine Patches for Use in Elderly Patients with Chest Trauma
Category: Older People
Amelia Davies - Anaesthetics North Bristol Trust, Helen Williams - Anaesthetics North Bristol Trust, Janine Mendham - Anaesthetics and Pain Medicine North Bristol Trust, Edd Carlton - Emergency Medicine North Bristol Trust
Background
Rib fractures represent the most common non-spinal fracture in the elderly. Pain from rib fractures can compromise normal respiratory function, resulting in hypoventilation and atelectasis. As a result, over 15% of older patients with rib fractures suffer respiratory complications, including pneumonia and death. Currently, the mainstay for the treatment of rib fracture pain is opioid analgesia. This is associated with multiple, dose related side effects, such as constipation and delirium. Therefore elderly patients with rib fractures remain a vulnerable group, susceptible to both the primary injury and analgesic side effects.
In small trials topical lidocaine patches have been associated with reduced opioid requirements and decreased pain scores in patients with rib fractures. However, there is no evidence to support their use in the elderly population and the potential benefits in improving respiratory and frailty outcomes are uncertain.
Aims
We aimed to assess the incidence of respiratory and frailty complications (namely delirium and constipation) in elderly patients (aged ? 65 years) with rib fractures who did or did not have a lidocaine patch applied.
Methods
In a prospective service evaluation all patients admitted to our major trauma centre (North Bristol Trust) over a 6-month period (December 2015-May 2016) who were prescribed lidocaine patches by the acute pain team were identified through pharmacy records. Patients aged <65 years or who had significant injury to another body region were excluded from analysis. A matched cohort who did not have lidocaine patches prescribed was identified through the TARN (Trauma Audit and Research Network) dataset. Electronic patient record screening was undertaken. The primary outcome was the incidence of respiratory complications during inpatient stay (clinical diagnosis of pneumonia or death). Secondary outcome measures were the incidence of frailty syndromes during inpatient stay and hospital length of stay.
Results
In total, 28 patients had lidocaine patches applied, median age 80 years (Interquartile range [IQR} 73-89). A further 18 matched patients did not have lidocaine patches (median age 79 years; IQR 68-89). There was no statistical difference in rates of respiratory complications between the groups (patch group 15/28 (54%), no patch group 8/18 (44%), p=0.51). There was, however, a significant difference in rates of frailty syndromes – delirium and constipation (patch group 3/28 (11%), no patch group 9/18 (50%), p=0.004). Median length of stay was 12 days for both groups.
Conclusion
Whilst the use of topical lidocaine patches in elderly patients with rib fractures is not associated with a reduction in respiratory complications, their use may lead to reduced rates of frailty syndromes, which are recognised common side effects of opioid analgesic regimens. This effect is likely due to the patches providing effective local analgesia, and thus, reducing systemic opioid analgesia requirements. A randomised controlled trial to further explore the potential benefits of topical lidocaine patches in elderly patients with rib fractures is recommended.
Br J Pain. 12(2 Suppl):5–54.
Other (Audit)
43
Chronic Post-Surgical Pain (CPSP) After Total Knee Replacement (TKR) – Has Enhanced Recovery Programmes Worsened Incidence?
Category: Other (Audit)
Claire Seeley - Anaesthetics and Pain Royal Berkshire Hospital, Katie Pavel - Anaesthetics and Pain Royal Berkshire Hospital, Maeve Graham - Anaesthetics and Pain Royal Berkshire Hospital, Deepak Ravindran - Anaesthetics and Pain Royal Berkshire Hospital
Background
It is known that up to 10-34% of patients following TKR can develop chronic post surgical pain (CPSP) (Beswick et al 2012). Enhanced Recovery Programme (ERP) is an evidence based model of care to reduce perioperative morbidity, accelerate patient rehabilitation and shorten hospital stay. It was introduced at the Royal Berkshire Hospital in the same year for elective knee replacements. A total of 200 patients were audited at 2 separate intervals in 2010 (at the beginning of ERP) and 2014 (after ERP was embedded) evaluating its impact on a wide variety of surgical and anaesthetic outcomes. Use of regional techniques and PCA use dropped significantly in the 2014 cohort with only 14% patients achieving a numeric rating score (NRS) < 5 on D1 post-op. While the ERP should theoretically improve perioperative pain management, there is very little data on how ERP affects the incidence of CPSP.
Aims
The primary aim of this study was to evaluate the incidence of CPSP in this cohort of 200 patients over a 7-year period and to review any differences in the incidence since the introduction of the ERP for elective knee replacement.
Audit standard used was a CPSP incidence <20%
Methods
After hospital ethics approval was granted, we designed a questionnaire to identify key points relating to the development of CPSP following elective total knee replacement and delivered it via a telephone survey. We followed the International Association for Study in Pain (IASP) criteria for CPSP – ongoing pain lasting >3 months post-op, different to pre-operative knee pain, localised around surgical area, and exclusion of trauma/ infection to the knee/documented surgical error. In addition to the demographic data, we also recorded analgesic choices, information provided pre and post operatively and any further interventions and hospital visits and ongoing pain clinic/surgical care. We also enquired about all overall patient satisfaction and outcome. Additional data was also collected to note to identify differences in CPSP between the cohorts and to compare the two groups with regards to clinical care and identify changes that may have impacted on post operative pain control.
Results
The survey was carried out from October to December 2017. The demographic data of the 200 patients were a median age of 75.5 90M 110F, distributed similarly across the two cohorts.
A 53% (106/200) response rate was achieved, with a median age of 75.5, 50M 56F.
All the patients who responded were at least 36 months post total knee replacement. The incidence of CPSP in the 2010 cohort was 14.3% (7/49) and this had increased to 21.1% (12/57) in the 2014 cohort.
Of these 19 patients who developed CPSP, 6 were previously or currently under a pain clinic, 7 sought further analgesic advice during orthopaedic clinics and 17 had seen their GP for ongoing pain issues. Two patients were having ongoing requirements for strong opioids or neuropathic agents, with 15 still having a daily analgesic requirement, managing with weak opioids/NSAIDs/Paracetamol and topical medications.
Conclusion
Overall incidence of CPSP in our local population for elective knee replacement is 18%. However, in our study, the incidence of CPSP has worsened by 50% after the establishment of ERP. The reasons for this worsening are multifactorial but is congruent with our previous audit results that had shown an increase in post-operative pain scores in the 2014 cohort. Enhanced Recovery Programme has been adopted with great enthusiasm and has numerous potential benefits. However, there may be a subset of patients that may not benefit from this protocol based approach, and are therefore at a higher risk of
Br J Pain. 12(2 Suppl):5–54.
44
An Audit of Chronic Pain After Breast Cancer Surgery with Perioperative Thoracic Paravertebral Block
Category: Other (Audit)
Danielle Reddi - Pain Management University College London Hospital, Ming Fung - Anaesthetics Royal Free Hospital, Ali Mofeez - Anaesthetics and Pain Management University College London Hospital
Background
Chronic pain after surgery is increasingly recognized as a cause of post-operative morbidity. Rates of chronic pain after breast surgery have been estimated at 20-30%, with severe pain affecting 5-10% (Kehlet 2010). A Cochrane review suggested that thoracic paravertebral block (TPVB) reduces persistent pain after surgery compared to conventional analgesia, with a number needed to treat of 5 (Andreae 2012).
Aims
The aim of our retrospective audit was to quantify rates of chronic pain after breast surgery in patients receiving TPVB, and to assess for the presence of neuropathic pain.
Methods
Women who had undergone breast cancer surgery with TPVB at least 3 months ago were identified from a single centre database of patients between 23/10/2014 and 25/02/2016. Patients were excluded if they were unable to speak English due to the follow up being carried out by telephone. Written records were accessed where details from the database were unclear. Patients were telephoned and pain was assessed using the Brief Pain Inventory and self-report Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS). If patients could not be contacted on the initial phone call then 2 further attempts were made. Patients with post-operative complications such as infection were also excluded.
Results
Thirty-seven women eligible for inclusion were identified and 25 were contacted. Eleven women could not be contacted by telephone. One patient did not speak English and was excluded. Seven patients reported ongoing discomfort related to surgery. Using the BPI, the worst pain ranged from 0-8/10, the least pain 0-5/10 and average pain ranged from 0-8/10 over the last 24 hours. Some patients had not had pain in the last 24 hours. One patient was using analgesia specifically for the post-surgical pain and reported 40% pain relief. Two patients reported interference with activity, mood, walking, relationships or enjoyment of life. Pain affected work in 3 cases and in 3 cases pain affected sleep. On further questioning using the S-LANSS in patients reporting persistent pain 5 of 7 patients had a score consistent with a neuropathic pain. The mean duration of follow up was 241 days, range 105-407 days.
Conclusion
Our findings demonstrate chronic pain in 7/25 (28%) of patients undergoing breast cancer surgery with TPVB, although it was only moderate or severe in 2 patients and mild in the other 5 patients. Of the women with chronic pain 5/7 (83%) experienced pain with a S-LANSS score suggestive of neuropathic pain (? 12/20). Chronic pain after breast cancer surgery has been reported as being predominantly neuropathic in nature and our findings are consistent with this. This audit was a small retrospective study. Further work should focus on a randomized controlled trial, comparing TPVB against standard multimodal analgesia.
Br J Pain. 12(2 Suppl):5–54.
45
The Role of Sacral Nerve Stimulation in Managing Chronic Pelvic Pain
Category: Other (Audit)
Terrance Ramrattan - Pain Management at National Hospital for Neurology and Neurosurgery University College London Hospital, Andrew Baranowski - Pain Management at National Hospital for Neurology and Neurosurgery University College London Hospital, Julia Cambitzi - Pain Management at National Hospital for Neurology and Neurosurgery University College London Hospital, Moein Tavakkoli - Pain Management at National Hospital for Neurology and Neurosurgery University College London Hospital, Saeid Elsawy - Pain Management at National Hospital for Neurology and Neurosurgery University College London Hospital
Background
Chronic pelvic pain (CPP) is a persistent pain condition that may affect somatic and visceral areas in the pelvis. Managing chronic pelvic pain can be challenging. Often patients go through a multitude of conventional treatments (surgery, injections, medications, physiotherapy, psychology, pain management programmes) which they find ineffective. When treatments fail, patients become disheartened.
Sacral Nerve Stimulation (SNS) is well established in the management of urinary and bowel dysfunction. However, SNS has expanded beyond its established use to include bladder pain syndrome/interstitial cystitis. Furthermore, pilot studies have shown that SNS can be beneficial for managing chronic pelvic pain. SNS involves stimulating the sacral nerves which in turn may inhibit the perception of pain.
It is currently recommended that SNS for CPP is only used in specialist CPP centres. The author’s place of work is one such centre. We share our experience of using SNS for CPP.
Aims
By means of a service evaluation, we aim to determine the following:
if pain is reduced in the short and long-term.
if medications are reduced.
the effect of SNS on bladder, bowel and sexual function.
Methods
SNSs implanted from January 2007 to December 2016 were included. Both retrospective and prospective data were collected between March and May 2017. Follow-up was by means of a telephone questionnaire to determine if pain was controlled by SNS. The primary outcome was pain reduction measured by the Numerical Rating Scale. Secondary outcomes consisted of medication, bladder, bowel, sexual function and Patient Global Impression of Change (PGIC).
N=29 implanted with SNS. 18 females (mean age 51.16), 11 males (mean age 64.5) with a history of CPP for 7.17 years (mean). CPP diagnoses treated with SNS were; bladder pain syndrome (n=9), pudendal neuralgia (n=6), chronic pelvic pain syndrome (n=6), coccydynia (n=2), vulvodynia (n=2), testicular pain (n=1), anal pain (n=1), tenesmus (n=1), perineal pain (n=1). From the sample, three patients died through natural causes, three patients were explanted and four patients were lost to follow-up. Seventeen were followed-up over 3 to 113 months.
Results
Pain relief
Mean baseline pain score was 8.58. Mean pain score after implant was 5.29 (38% reduction in pain) and mean pain score at long-term follow-up was 5.17 (40% reduction in pain) compared to baseline.
Medication
Seventy percent (n=12) reduced analgesics. Seventy-six percent of patients (n=13) are still using analgesics whilst twenty-four percent completely stopped analgesics.
Bladder Function
Fifty-eight percent (n=10) reported bladder problems prior to implant. Eighty percent (n=8) reported improvement (mean 59%) in bladder function with SNS.
Bowel Function
Seventy percent (n=12) reported bowel problems. Forty-one percent (n=5) reported improvement (mean 38.2%) in bowel function with SNS.
Sexual Function
Forty-one percent (n=7) reported pain interfered with sex. Twenty-eight percent (n=2) reported improvement (mean 37.5%) in sexual function with sns.
PGIC
Eighty-eight percent (n=15) reported improvement in PGIC scores with a SNS. Twenty percent (n=2) reported no improvement.
Conclusion
This service evaluation has highlighted that sacral nerve stimulation may be implanted in a wide variety of chronic pelvic pain diagnoses. Furthermore, SNS has shown to be beneficial in reducing pain in patients with chronic pelvic pain. SNS may also have a positive impact in reducing medication and improving bladder and bowel function. Overall, most patients were satisfied with the efficacy of their SNS as reflected by the improvement in PGIC. Based on our evaluation, SNS is beneficial in managing CPP. However more robust studies such as randomised controlled trials are needed.
Br J Pain. 12(2 Suppl):5–54.
46
A Service Evaluation Examining the Current Non-Medical Prescribing Practice for Pain Patients in a Central London Hospital
Category: Other (Audit)
Helen Bonar - Pain Management Barts Health, Kirstie Emmerson - Pain Management Barts Health, Athina Karavasopoulou - Pain Management Barts Health, Charlotte Guest - Pain Management Barts Health, Akorfa Fiamavle - Pain Management Barts Health, Mirja Shaw - Pain Management Barts Health, Lorena Warde - Pain Management Barts Health, Hanna Kotas - Pain Management Barts Health, Saowarat Snidvongs - Pain Management Barts Health, Joanne Lascelles - Pain Management Barts Health
Background
Almost 10 million individuals living in Britain suffer pain daily resulting in a major impact on their quality of life and more days off work (BPS, 2016). Pain management remains a challenging task and despite recent advances, pain is often undertreated or untreated. Pain is a growing area of non-medical prescribing. It is therefore essential that non-medical prescribers (NMPs) maintain their competence and skills in order to improve patient outcomes and overcome some of the barriers to effective pain management. Studies have shown that NMPs are well integrated and established practitioners that manage a variety of conditions and provide access to medicines (NHS i5 health, 2015).
Aims
The aim of this service evaluation was to examine the current non-medical prescribing practice for pain patients in a central London hospital. Furthermore, to assess the performance and compliance of NMPs working in pain management and evaluate patient outcomes based on the prescribers’ recommendations.
Methods
Pain clinical nurse specialists at a large teaching hospital in London, developed a questionnaire following the Nursing and Midwifery Council (NMC) standards of practice for independent nurse prescribers in order to assess their current prescribing practice. The questionnaire consisted of 18 questions which included: demographics, patients’ presenting condition and clinical speciality, rationale for prescribing and patient satisfaction. Additionally, pre and post prescribing amendments, pre and post pain intensity scores, and prescription details were obtained. The NMPs firstly identified adult pain patients from different specialities. Following a detailed pain assessment and history taking, the decision was then made to change, add and/or titrate their current analgesic regime. The NMPs acted in accordance with the NMC standards of practice and informed patients of their actions at all times. Finally, patients were followed up as per our routine pain management standard of care.
Results
A total of n=31 questionnaires were completed during a 2 month time frame. The female/male ratio was approximately 1:1. The majority of patients were overall satisfied with the pain management received (n=22). N=19 patients were satisfied with the amendments made by the NMPs and n=26 with an NMP prescribing again. Most of the patients felt they were involved in the decision making process (n=20) and informed (n=16) regarding the amendments. N=9 patients did not know that the prescriber was a nurse NMP. In 54% of cases the reason for prescribing was based on the assessment of patients; 17% was due to change in condition and 17% was attributed to adverse drug reactions. The NMPs changed (45%), added (26%) and titrated (3%) analgesic regimes including most commonly antineuropathics (n=7) and opioids (n=14). Pain intensity scores improved following NMP prescription amendments with 26% reduction in patients reporting moderate to severe pain.
Conclusion
Despite limitations, this service evaluation has shown the efficacy of NMPs working in pain management. Pain intensity scores improved alongside patient satisfaction. Furthermore, patients were content having NMPs make amendments and felt involved in the prescribing process. To improve the strength of this service evaluation a larger cohort of patients examining prescribing practice in pain management is needed in the future.
Br J Pain. 12(2 Suppl):5–54.
47
1000 Telephone Follow-Ups Post Pain Interventions
Category: Other (Audit)
Dr Frances Leung - Department of Pain management Chelsea and Westminster Hospital NHS Foundation Trust, Dr Ian Goodall - Department of Pain management Chelsea and Westminster Hospital NHS Foundation Trust, Sarah Thomas - Department of Pain management Chelsea and Westminster Hospital NHS Foundation Trust, Dr Glyn Towlerton - Department of Pain management Chelsea and Westminster Hospital NHS Foundation Trust, Dr Rahul Seewal - Department of Pain management Chelsea and Westminster Hospital NHS Foundation Trust, Dr Ben Thomas - Department of Pain management Chelsea and Westminster Hospital NHS Foundation Trust, Dr Bianca Kuehler - Department of Pain management Chelsea and Westminster Hospital NHS Foundation Trust
Background
Data collection is an important part of pain management and delivering a first-class pain service. Clinical commissioning groups (CCG) expect outcome information on clinical effectiveness. This data can inform practice and has a direct impact on patient care.
Nurse-led telephone clinics have been running for years at the Chelsea and Westminster Hospital. They were started to relieve pressure on medical clinicians in the pain department and to allow patients to be reviewed sooner and to reduce follow up waiting times following pain procedures. Patients were asked about the effectiveness of the pain procedure, overall pain reduction and lasting benefit. Depending on the results patients’ are discharged, reviewed again in clinic, rebooked for another procedure or referred to another specialty.
Aims
The primary aim of this audit was to examine the value of pain interventions, from the perspective of clinicians and patients. Other aims were to assess pain reduction, the length of time pain reduced, how many patients were discharged and how patients were followed up.
Methods
We introduced a database to record patients outcome following pain procedures in 1st June 2014 for our nurse-led telephone follow-up clinic. We retrospectively analysed the data of first 1000 entries from this database including data from 1stJune 2014 to 7thJanuary 2016.
Patients were categorised into 4 groups: those who had an increase in pain, those who had a decrease in pain, those with no change following intervention, and DNAs. Patients who had language barriers or communication difficulties were not given telephone follow-ups. Outcomes were analysed and missing/additional information were sort from patients’ records.
Results
Of 1000 episodes, 660 reported reduction in pain, 46 increased in pain, 149 no change to pain and 135 DNAs, 10 incomplete database.
Of those who had pain reduction following the intervention, 79% reported more than 50% pain relief. 121 required outpatient follow-up, 174 discharged, 95 to be discussed with the consultant for ongoing management, 270 had appropriate onward referral to other specialties or therapies.
Patients whose pain increased, 78% were booked for outpatient appointment, 2 were discharged.
Patients whose pain remained unchanged, 67% were booked for outpatient appointment, 12 were discharged, 18 were discussed with consultant regarding ongoing management.
Out of 135 who did not attend the telephone follow-up, 80% were discharged according to hospital policy.
Overall, only 27% followed up by specialist pain nurses required doctor review in our outpatients department. 297 were discharged after telephone follow-up. This has considerable potential for demonstrating cost saving within our department.
Conclusion
Nurse-led telephone follow-up clinics are a valuable way of collecting essential outcome data following pain interventions. The results showed that many patients can have a big improvement in pain following these interventions.
Research examining telephone follow-up clinics in pain management is sparse. Data collection for most pain services is poorly collected outside of specific audits or research projects. There must be a change in order to provide meaningful data for service improvement.
This also emphasises the invaluable role of skilled knowledgeable specialist nursing staff in the management of pain patients.
Br J Pain. 12(2 Suppl):5–54.
48
Chest Trauma Pathway and Effects of Regional Anaesthesia at a Major Trauma Centre
Category: Other (Audit)
Authors: David Hutchins - Anaesthesia & Pain Plymouth Hospitals NHS Trust, Tom Nightingale - Anaesthesia & Pain Plymouth Hospitals NHS Trust, Lindsey Pollard - Anaesthesia & Pain Plymouth Hospitals NHS Trust, Mark Rockett - Anaesthesia & Pain Plymouth Hospitals NHS Trust
Background
Trauma is the leading cause of death in patients under 45 years old, and carries complex clinical and non-clinical management challenges. Derriford hospital in Plymouth is the Major Trauma Centre (MTC) for the Peninsula Trauma Network.
Plymouth’s Trust guidelines state all patients with chest injuries should be referred to the in-patient pain service (PS). For patients with significant chest injury (a chest trauma score of equal/over 21), the guideline states a regional anaesthetic (RA) technique should be considered as part of a multimodal management approach.
There is significant morbidity and mortality associated with poorly managed chest trauma and rib fractures due to poor analgesia, inadequate provision of respiratory and physiotherapy intervention, and resulting atelectasis and respiratory tract infections. Therefore, it is critical as a MTC that chest trauma is managed effectively and efficiently. This will help facilitate good outcomes for individuals, the population, and the wider trauma network service.
Aims
Our overall aim was to develop an overview and understanding of the current chest trauma patient pathway and audit against our Trust guideline. More focussed “sub-aims” were also to assess referral frequency to pain services and assess the benefits of associated regional anaesthetic (RA) interventions.
Methods
Inclusion criteria were all patients (adult and paediatric) presenting to the MTC with chest trauma from April 1st to November 1st 2017.
The Trauma Audit Research Network (TARN) database was interrogated to collect records on various data fields including mechanism of injury, injury severity score, and destination ward. This data was then cross-referenced with the in-patient pain services’ database, to assess referral frequency. This information was then further paralleled to the on-going continuous chest trauma analgesia audit run by the pain service. This collated details of pain severity, chest trauma score, RA intervention modality and pre-and post RA peak flow scores from day 0 to day 4, post RA insertion. Peak flow performance was taken as a surrogate marker for respiratory effectiveness and pain severity (or conversely, analgesic effectiveness) during forced active respiration.
Results
214 patients were included. The most frequent mechanism of injury was a fall from less than 2meters (42%).
Eleven different wards received patients following admission, most frequently the Intensive Care Unit (30%), Cardiothoracics (24%), and the Emergency Admissions Unit (21%).
The mean injury severity score (ISS) was 20. 48% patients were referred to the PS. The mean ISS of patients referred to the PS was 23.5. The mean ISS of patients not referred was 17.9.
The mean ISS of patients receiving RA was 21.4. The mean ISS of patients referred to the PS but not receiving RA was 22.7.
72% included in the trauma analgesia audit had “severe” pain prior to RA, with 81% reporting “mild” pain post-intervention. Mean peak flow results pre-RA were 169 L/minute, and 254 L/minute (33% increase) following RA. The most commonly utilised techniques were Serratus Anterior plane (45%) and Erector Spinae plane block (36%).
Conclusion
Fewer than half of patients are referred to PS, contrary to Trust guidelines. RA reduces pain and increases peak flow, potentially increasing patient satisfaction and reducing complications.
Trauma patients are managed on eleven different wards & not a single sub-specialised location.
Patients with higher ISS are often anaesthetised for theatre. These patients are unlikely to receive a form of RA initially. This may explain the inverse relationship between the ISS of patients receiving RA, and those not receiving RA.
Awareness of the guideline and RA benefits amongst all members of the multidisciplinary trauma team must be improved.
Br J Pain. 12(2 Suppl):5–54.
49
Local Experience of Capsaicin 8% Patch for Knee Pain
Category: Other (Audit)
Fiona Bull - Anaesthesia and Pain Medicine NHS Tayside, Jennifer Gray - Pharmacy NHS Tayside, Michael Neil - Anaesthesia and Pain Medicine NHS Tayside
Background
There have been a number of reports of the use of capsaicin 8% patches in peripheral neuropathic pain secondary to sources not including post-herpetic neuralgia, HIV related neuropathy or diabetic neuropathy. These studies in general comprise small numbers of patients with mixed pain aetiologies and mixed responses. Capsaicin cream has been successfully used to treat knee pain from osteoarthritis but there are no published data about the experience of this patient group with the high strength patch. Anecdotally it was felt that locally this patient group may be experiencing significant benefit.
Capsaicin is a potent agonist at the transient receptor potential vanilloid 1 (TRPV1) receptor. It is a lipophilic, non-water soluble compound. There is little systemic absorption from topical application. TRPV1 receptors are ligand gated non-selective cation channels. They are activated by increases in temperature (between 37 and 45 degrees Celsius), fall in pH (<6.0) and endogenous lipids.
Aims
We aimed to review our local patient group who had received treatment with capsaicin 8% patch over the last 12 months. Of these patients, we chose to select those who had received treatment for knee pain and review their response.
Methods
We identified the patients who had received capsaicin 8% patch within our health board over the 12 months from pharmacy records. We then performed a retrospective notes review audit to identify those patients that had received treatment for knee pain. From this patient group, we collected data on how many treatments they received and treatment outcome.
Results
We identified 17 patients from our cohort of 57 that received treatment with capsaicin 8% patch in 2017 for knee pain. Their pain diagnoses varied between post-surgical neuropathic pain, mixed nociceptive/ neuropathic pain secondary to osteoarthritis knee and peripheral neuropathic pain affecting the knee. Of this group, 8 (47%) patients received repeat treatments while the remainder had a single treatment. Of the patients treated 10 (59%) received benefit, 4 (24%) no benefit, 1 was lost to follow-up and it was unclear from 2 patients notes whether there was benefit to them from the treatment.
Conclusion
Locally we have identified a small group of patients in whom capsaicin 8% patch has been effective in improving knee pain. For some of these patients this has meant discontinuation of medicine and delay/ cancellation of planned surgery due to significantly improved pain levels. This is a limited retrospective audit of practice that may indicate an area for future investigation.
Br J Pain. 12(2 Suppl):5–54.
50
Fasting and Sedation for Elective Pain Procedures: A Comparison Between Ipswich Hospital and National Practices
Category: Other (Audit)
Damian Laba - Anaesthetic and Pain Management Ipswich Hospital NHS Trust, Parveen Dhillon - Anaesthetic and Pain Management Ipswich Hospital NHS Trust
Background
There is a wide variation in sedation practice in pain procedures ranging from no sedation to routine use. In the United Kingdom, deep sedation requires the same level of care as general anaesthesia, and many practitioners follow standard 2-4-6 hour fasting guidance to avoid potential loss of airways and pulmonary aspiration. However, pre-operative fasting for sedation is controversial and considered unnecessary by some authorities. Potential downsides of fasting include discomfort for the patient and potential risks of hypoglycaemia in diabetics. Moreover, NICE guidance on children’s sedation accepts no fasting before sedation if the sedation is minimal or moderate and the patient will maintain verbal contact with the practitioner. It is also recognised that clinicians choosing to sedate patients without fasting should be prepared to justify this choice.
Aims
This study examines local and national practices for fasting and sedation in pain procedures. It also assesses whether there is scope for developing separate guidance in our Trust where no fasting is permitted in selected groups of patients where minimal sedation is used.
Methods
In the first instance, we performed an audit in our Trust during 3 consecutive weeks. The audit proforma included several questions related to fasting and sedation. Regarding fasting, patients were asked whether they followed standard written pre-op instructions where rules 2-4-6 applied, or were given different (verbal) instructions. Diabetic patients were asked if they experienced symptoms of hypoglycaemia. Concerning sedation, questions included: drugs, dose and whether patients were offered sedation or asked for it. Finally, the time between leaving the theatre and time ‘ready-for-discharge’ was recorded for sedated and non-sedated patients.
In the national survey, an online questionnaire was sent via professional group email to pain physicians containing similar questions regarding fasting protocols, sedation and diabetic considerations.
Results
All audit patients (n=53) were sent written instructions to fast prior to procedure. However, 7 patients (13%) received verbal instructions advising not to fast. 26 patients (49%) received sedation, where 22 were given anxiolysis with Midazolam (average dose 2.8 mg) and 4 received a combination of Midazolam and Fentanyl.
Six patients (11%) were diabetic and 2 of them had symptoms of hypoglycaemia.
The average ‘ready-for-discharge’ time in sedated patients was 62 minutes and non-sedated 52 minutes.
The national survey (n=52) revealed that 20% of clinicians do not use sedation at all. Sedation use depends almost exclusively on patient and surgical factors. Minimal and conscious sedation stands for 94% of sedation procedures.
25% of clinicians instruct not to fast prior to procedure even where sedation is considered. Only 12% use separate guidelines specific to pain procedures.
74% of clinicians use Midazolam. 33% of clinicians use separate guidance for diabetic patients.
Conclusion
The survey and the local audit showed that practices regarding sedation and fasting vary. The pre-op instruction with 2-4-6 rules is the most common. A proportion of clinicians advise their patients not to fast prior to sedation. The minimal or conscious sedation with Midazolam is the most common level of sedation. Insulin diabetic patients remain at risk of symptomatic hypoglycaemia after the starvation period.
The study rationalises a change in current protocol on fasting for pain procedures with minimal sedation in selected group of patients.
Br J Pain. 12(2 Suppl):5–54.
51
A Thematic Analysis of Individuals’ Experiences of Living with Complex Regional Pain Syndrome Whilst Accessing Care from a Community Pain Service
Category: Other (Audit)
Chris Barker - Community Pain Lancashire Care NHS Foundation Trust
Background
Refractory Complex Regional Pain Syndrome (CRPS) is a relatively rare and debilitating condition, with limited research and understanding of the condition. Little is known how best to support those with this condition in the long-term
Aims
A service evaluation was conducted to explore both individuals’ experiences of living with CRPS and also their experiences of a Community Pain Service.
Methods
All current patients of a Community Pain Service with a diagnosis of CRPS were invited and all participated. Seven patients volunteered and each participated in their own semi-structured qualitative interview. This was audio recorded and transcribed verbatim, and subsequently anonymised. Transcriptions were coded and analysed using a staged process of thematic analysis.
Results
Four themes were revealed from the coded transcripts. 1. Impact of CRPS (including physical, psychological & societal issues), 2. Knowledge, Understanding and Awareness (lack of, and desire for more amongst healthcare, individuals & wider society), 3.Coping and Living Well with CRPS (difficulty living with, and keeping going), and 4. Treatment and Care. (including limited treatment options, experiences of healthcare, and hoped for future care)
Conclusion
Participants described the profound impact of living with CRPS, and what helps them to live well with the condition. Participants discussed their hopes for increased knowledge, understanding and awareness of CRPS, which they experienced as lacking systemically. Participants spoke of their wish for more research to build understanding and effective treatment options. All participants valued the specialist knowledge and understanding of the Community Pain Service, often in contrast to negative wider experiences with other healthcare professionals who were experienced as having limited/no understanding of the condition. These descriptions offer insight into the condition; implications for future practice are discussed
Br J Pain. 12(2 Suppl):5–54.
52
Provision of Patient Information in the Pain Management Service Outpatient Clinic: An Audit to Determine How Information is Provided and How Helpful Patients Consider it to be
Category: Other (Audit)
Victoria Woolger - Pain Management Service Ashford & St Peters’ Hospitals NHS Foundation Trust, Chertsey, UK, Rajib Dutta - Pain Management Service Ashford & St Peters’ Hospitals NHS Foundation Trust, Chertsey, UK
Background
As part of the care of patients attending our Pain Clinic we provide information about treatment, medications and Pain Management Programme (PMP). Information leaflets take the form of locally produced peer reviewed leaflets that comply with our Trust’s standards, as well as leaflets endorsed in the field of pain published by the British Pain Society. The leaflets are given to patients during their initial Consultant assessment and subsequently in a Nurse or Consultant follow-up clinic as required. Information about treatments, medicines and PMP is also given verbally during the outpatient consultation.
In order to ascertain whether we were meeting best practice standards in the provision of written information about pain management (Royal College of Anaesthetists 2012) we conducted an audit. Pain Clinic attendees being reviewed post-treatment were surveyed to determine i) how patients received information about their treatment, medicines and PMP and ii) how helpful they deemed this information to be.
Aims
To determine the percentage of patients that had been given an information leaflet about their treatment, medicines and PMP, and how helpful the patient considered this to be.
To determine which source of information patients thought was the most helpful.
Methods
The nurse completed a questionnaire in consultation with each patient reviewed post-treatment in Nurse follow-up clinic over a period of four weeks during October to November 2017. We excluded distressed patients and those for whom English was not their first language. A total of 55 patients were sampled.
The patients were asked whether they had received information about treatment, medicines and PMP by way of leaflets, clinician explanation, from the internet or by talking to family and friends. We used a five-point Likert Scale: ‘extremely helpful’, ‘very helpful’, ‘somewhat helpful’, ‘not so helpful’, ‘not at all helpful’ to measure the patient’s impression of the level of helpfulness of each of these sources of information (Likert 1932).
Simple statistical methods were used to determine results.
Results
91% of the 55 patients were given an information leaflet ahead of treatment graded as very helpful. 49 of the 55 patients took medication. Of these 55% received written information regarding medicines graded as very helpful. PMP was part of the care plan for 40 of the 55 patients. Of these 43% received written information about PMP graded as somewhat helpful.
Clinicians gave verbal information to patients about treatment, medications and PMP. For each of these aspects patients rated this as very helpful. The mean score of level of helpfulness of clinician explanation across the three categories was higher than the mean scores for written information. For PMP the clinician explanation was noted to be significantly more helpful than the written information.
Patients also talked to family and friends and searched the internet for information about treatment, medications and PMP. Patients found this to be somewhat helpful.
Conclusion
This audit has highlighted areas of good practice in the provision of information to patients and some needing improvement.
The majority of patients undergoing treatment were provided with leaflets and clinician explanation which they considered very helpful. For those receiving medications the written information and clinician explanation was again considered very helpful when provided but this needs to increase. For PMP more patients need to receive written information as well as the information itself improving.
Maintaining currency of our website and sharing the link with patients may increase the use and value of the internet as an information source.
Br J Pain. 12(2 Suppl):5–54.
53
Lidocaine Plasters for Patients With Complex Cardiothoracic Disease- an Audit of Clinical Use by Non-Pain Specialists
Category: Other (Audit)
Maria K Stasiowska - Critical Care & Anaesthesia Royal Brompton & Harefield NHS Foundation Trust, Dr Sian Jaggar - Critical Care & Anaesthesia Royal Brompton & Harefield NHS Foundation Trust
Background
Lidocaine ‘Versatis®’ 5% medicated plasters are currently licensed for symptomatic relief of neuropathic pain associated with previous herpes zoster infection (post-herpetic neuralgia PHN) in adults 1.
Lidocaine plasters can be used in cases of localised neuropathic pain other than PHN, which is unresponsive to standard anti-neuropathic agents. However, it is recommended that only specialist clinicians commence such off-license use, on a 2 – 4 week trial basis. Topical lidocaine should not be not started or continued in the primary care setting 2.
Adult patients undergoing cardiothoracic procedures are at high risk of developing neuropathic-type acute and chronic post surgical pain 3. Many require multimodal analgesia and in-patient specialist pain involvement, to achieve adequate pain control.
Lidocaine plasters have few side effects and can potentially optimise acute pain management in patients with complex cardiorespiratory disease.
Aims
Analyse lidocaine plaster use by non-pain specialists, in adults with pain due to cardiothoracic disease.
Explore the type of pain treated with topical lidocaine.
Look at multimodal analgesia in adults undergoing complex cardiothoracic procedures.
Assess degree of acute pain service involvement in complex inpatient pain management.
Methods
The inpatient electronic prescribing database identified 61 patients who were prescribed lidocaine patches during their hospital stay between March and July 2017. Data from 2 patients was excluded due to incomplete records.
All inpatient records were subsequently scrutinized for written evidence about pain assessment (severity, location, presence of neuropathic features, presumed cause) pain management by the surgical, medical and acute pain teams; multimodal analgesia prescribed and discharge instructions for the GP regarding long-term analgesia.
The results were reported in a narrative form, or using histograms and pie charts where appropriate. We used medians, minimum and maximum variables to describe continuous data and frequency tables and overall percentages for categorical data. We chose to present data from surgical and medical cardiothoracic inpatients separately as they present with very different inpatient pain management problems.
Results
59 patients were prescribed Versatis® during their admission. Median age was 51 (18 – 87), 34 were female 25 were male.
85% were advised to continue the plasters after discharge.
Medical inpatients received lidocaine predominantly for non-procedure related pain due to underlying fractures or pneumothorax. 42% described the pain as myofascial or mechanical, only 8% had a clear neuropathic component. The acute pain team was involved in only 25% of cases. Patients received concurrent opioids (79%), paracetamol (67%) and gabapentinoids (46%).
Surgical inpatients (35) received lidocaine for acute incisional pain from thoracotomies (34%), VATS (37%) and surgical drains (17%). In 71% cases the pain was acute and nociceptive. only 9% reported a neuropathic component. The pain team was involved in 71% of cases. Concurrent analgesia included opioids (94%) paracetamol (86%), nonsteroidals (17%), gabapentinoids (51%) and paravertebral blocks (31%).
Conclusion
Lidocaine plasters are used off-license, by non-pain specialists to manage poorly controlled pain in patients with significant cardiothoracic disease.
Clinicians should limit their use to patients with clear neuropathic-type pain and regularly involve acute pain services in their care. Discharge plans should include clear instructions for GPs to re-evaluate lidocaine treatment efficacy after 2 – 4 weeks.
We recognise the comparative costs of using systemic anti-neuropathics versus lidocaine plasters for localised neuropathic pain. However in this context, their use is often limited in patients with severe cardiorespiratory disease, due to their systemic side effects.
Br J Pain. 12(2 Suppl):5–54.
54
Tens Audit: It’s Effectiveness for Long-Term Use in Chronic Pain
Category: Other (Audit)
Jing Lee - Pain Medicine Worcestershire Royal Hospital, Heather Buckley - Pain Medicine Worcestershire Royal Hospital
Background
Transcutaneous Electrical Nerve Stimulation (TENS) is a non-invasive peripheral stimulation technique used to relieve pain utilizing the “Gate Control Theory”. It generates electric currents, delivered across intact skin via adhesive electrode pads, activating underlying nerves. Systemic reviews have focused on short-term efficacy with variable and inconclusive results due to poor methodology and small sample size. A recent meta-analysis of RCT’s by Johnson (2014) demonstrates strong evidence for the use of TENS for musculoskeletal and post-operative pain, and moderate evidence for neuropathic pain.
Aims
We conducted an audit as a clinical governance project to investigate the effectiveness of TENS for long-term use in patients with various types of chronic pain.
Methods
100 consecutive adult patients with miscellaneous pain types of greater than 3 months duration were recruited in our nurse practitioner-led pain management clinic. Appropriate user instructions were given to patients, including application of high-frequency conventional TENS and low-frequency acupuncture-like TENS, with treatment duration of 1-1.5 h and 15-30 min respectively.
Patients with cardiac pacemaker, epilepsy, pregnancy, and skin condition, ischaemic tissue or thrombosis over the application site were excluded.
Patients were followed up at 1, 3, 6 and 12 months by telephone, face-to-face in clinic or by posts.
Acceptance of any significant clinical benefits were defined by a reduction of visual analogue or numerical rating scale for pain of equal to or greater than 2, as well as record of benefits gained from easing of pain when performing activities of daily living, reduction in medication and improvement of sleep pattern.
Results
100 adult patients were recruited (72 females and 28 males).
At 1 month – 63 (63%) patients found TENS beneficial; the remainder found no benefit or discontinued TENS for various reasons.
At 3 months – 53 (53%) found TENS beneficial; the remainder no longer experienced benefit after 3 months’ use or discontinued TENS for other reasons.
At 6 months – a further 7 patients dropped out due to having no further benefit or other reasons. However, 46 (46%) patients continued to use TENS as it remained beneficial to them.
At 12 months – with such period of long-term use, a significant number of patients (40 = 40%) remained who continued to find TENS beneficial.
Conclusion
The results demonstrate that a significant number of patients with chronic pain continue to find benefit from the TENS at 12 months. This audit lends support for our continuing provision of TENS therapy as a useful option in our pain management clinic. Moreover, TENS is a safe and inexpensive tool to manage pain independently with few side effects.
Br J Pain. 12(2 Suppl):5–54.
Other (research)
55
Developing a Behaviour Change Intervention for Delivery within a Multidisicplinary Pain Clinic
Category: Other (research)
Joanne Marley - Chronic Pain Clinic Belfast Health and Social Care Trust, Dr John O’Hanlon - Chronic Pain Clinic Belfast Health and Social Care Trust, Dr Mark Tully - Centre for Public Health Queens University Belfast, Dr Alison Porter Armstrong - Centre for health and rehabilitation technologies Ulster University, Professor Brendan Bunting - School of Psychology Ulster University, Professor Suzanne McDonough - Centre for health and rehabilitation technologies Ulster University
Background
Persistent musculoskeletal pain (PMP) is associated with the development of numerous health conditions, including cardiovascular disease, stroke and depression. PMP also increases an individual’s risk for all-cause early mortality. Improving health behaviours such as increasing levels of physical activity, can attenuate these risks. Improving health behaviours has an important role in reducing pain and disability associated with PMP. However, pain poses a particular challenge when it comes to addressing health behaviours for both the sufferer and their healthcare providers. Pain poses a particular challenge to physical activity behaviours. To address this, in line with Medical Research Council guidelines for complex intervention development, a series of studies were conducted to inform the development of a behaviour change intervention within a multidisciplinary pain clinic.
Aims
Understand factors influencing the physical activity behaviours of patients attending a multidisciplinary pain clinic and the clinical practice behaviours of healthcare professionals with regards to promoting behaviour change. Use this information to systematically develop and pilot a behaviour change intervention in a multidisciplinary pain clinic.
Methods
A systematic review and meta-analysis to explore the effectiveness of interventions in increasing physical activity levels in adults with PMP.
- Focus groups to explore barriers and facilitators to –
- Engaging in physical activity in adults with PMP who are accessing pain clinics (18)
- The promotion of physical activity by multidisciplinary healthcare professionals (6), and non-NHS service providers (exercise professionals/charity organisations) (14)
Participatory workshops using consensus methods to optimise intervention content and mode of delivery with individuals with PMP (20) and multidisciplinary healthcare professionals (52)
A one-year pilot of a behaviour change intervention delivered in a multidisciplinary pain clinic.
Results
Twenty studies involving 3,441 participants were included in the review. Interventions achieved small to moderate effects in improving subjectively measured PA. Techniques that may be associated with more effective PA interventions included – ‘goal setting behaviour’, ‘self-monitoring behaviour’ and ‘social support’.
Factors influencing uptake or promotion of PA varied across the different groups but issues relating to the environment, knowledge, beliefs about consequences and beliefs about capabilities featured prominently in all groups.
Using the results from these two studies and guided by the behaviour change wheel, two multifaceted behaviour change interventions were developed and subsequently optimised through participatory workshops. The Active Living with Persistent Pain intervention targets changing PA behaviours in adults with PMP and The Active Living with Persistent Pain – Training Programme, which targets changing clinical practice behaviours to improve the promotion of PA.
Conclusion
The findings have informed a pilot project that commenced in November 2017 and to date a total of 120 participants have been recruited into the project. Analysis is ongoing and the intervention will be refined on an iterative basis based on the results of both quantitative and qualitative outputs.
Br J Pain. 12(2 Suppl):5–54.
56
Exhibiting Pain: Using Creativity to Express Pain
Category: Other (research)
Susanne Main - Wellbeing, Education and Language Studies The Open University
Background
The incommunicable and subjective nature of chronic pain causes great distress to many people who may feel that their experience is being ignored. Given the invisibility of the condition and its seemingly unshareable nature, some people use creative methods to both cope with the effects of living with pain, as well as to express and communicate it. This PhD research has arisen through an interest to explore how creativity may expand the options for expressing chronic pain and enhancing communication of the condition.
Aims
To explore the potential value of using creativity to improve communication of chronic pain. Assessing if online galleries may effectively share creative depictions of life with pain, helping to increase understanding of the condition. Examining what benefits are experienced from sharing creative works about life with chronic pain.
Methods
Two forms of online exhibitions displayed the creative depictions of life with chronic pain, made by those with the condition. Social media was chosen as it is an easily accessed format which is used regularly by a large number of people. This included a WordPress blog site (functioning as a standard website for visitors) and a group in Facebook. Audience responses to the individual works and exhibitions as a whole were collected. Focus group discussions about interpreting the works, viewing and creating them took place in the Facebook group. This included 64% of people who had created the works, some who had pain but did not take part in creative activities, and other interested parties. Data has been analysed using thematic and content analysis.
Results
Over the 22 weeks of data collection, the WordPress site drew 1395 visitors from across the globe, who on average viewed the site five times each. Viewing creative depictions of life with chronic pain helped to increase awareness of some of the unforeseen aspects of living with pain. For example, audience members were surprised that the works focused less on physiology and symptoms and more on the psychological and social aspects of living with chronic pain (such as the invisibility of the condition). People with pain expressed a sense of reduced isolation through viewing the works. Those who had created the works found value in sharing them and finding others who use the same approach to communicate their pain. They also expressed gratitude in response to the opportunity to share their works and pain experience. Both sites are valuable in providing support and reducing isolation for people with chronic pain.
Conclusion
Online exhibitions are an effective way to reach a broad spectrum of people who have a genuine interest in learning more about chronic pain and the role of creativity in expressing this. Both sites are still being used by visitors, though not for research purposes. Members of the Facebook group continue to use it and express their pleasure at the support they find from sharing their works with others who have chronic pain. The sharing of creative works, and discussions around these, fosters a sense of belonging, enabling those living with chronic pain to feel that their experiences are recognized.
Br J Pain. 12(2 Suppl):5–54.
57
Discharged with a Feeling of Being Dismissed: A Qualitative Study
Category: Other (research)
Kathrin Braeuninger-Weimer - Psychology Royal Holloway University
Background
Previous research in people with musculoskeletal low back pain (MLBP) in primary care shows that a reliable and valid measure of consultation-based reassurance enables testing reassurance against patient’ outcomes. Little is known about the role of reassurance in people with MLBP consulting spinal surgeons, especially in cases where surgeons recommend not to have surgery. There might be several reasons to exclude surgery as a treatment option, that range from positive messages about symptoms resolving to negative messages, suggesting that all reasonable avenue of treatment have been exhausted.
Aims
The aim is to explore patient’s experience of consultation-based reassurance in people with MLBP who have been recently advised not to have surgery.
Methods
Semi-structured interviews were conducted with 30 low back pain patients who had recently consulted for spinal surgery and were advised that surgery is not indicated. Interview were audio recorded and transcribed, and then coded using NVIVO qualitative software and analysed using the Framework Analysis.
Results
Most patients reported feeling dismissed and discouraged. They considered that consultants were better in relationship building and data gathering than in providing cognitive and generic reassurance. Major emerging themes included the complexity and confusion of their NHS journey, lack of continuity-of-care, lack of information for their condition and a sense of dismissal. Patients reported that they needed reassurance through clear explanations and discussion of pain management, but instead were discharged into a void.
Conclusion
Effective communication with patients attending surgical settings to consult about their back pain is important, especially when no active treatment is being offered.
Br J Pain. 12(2 Suppl):5–54.
Paediatric
58
#ItDoesntHaveToHurt: A Mixed Methods Evaluation of Parent Engagement in a Knowledge Translation Intervention to Improve Children’s Pain Management
Category: Paediatric
Christine T Chambers - Departments of Psychology and Neuroscience, Pediatrics, Dalhousie University & Centre for Pediatric Pain Research, IWK Health Centre, Erice Ehm - Yummy Mummy Club & Erica Ehm Communications, Melanie Barwick - Research Institute, The Hospital for Sick Children, Jackie Bender - Faculty of Public Health, University of Toronto, Marsha Campbell-Yeo - Faculty of Nursing, Dalhousie University, G Collier - Nova Scotia Health Research Foundation, Ran Goldman - Department of Pediatrics, University of British Columbia, Jeff Mogil - Faculty of Science, McGill University/Universite McGill, Kathryn O’Hara - School of Journalism & Communication, Carleton University, Ottawa, Canada, Bonnie Stevens - Faculty of Nursing, The Hospital for Sick Children, Jennifer Stinson - Faculty of Nursing, The Hospital for Sick Children, Anna Taddio - Faculty of Pharmacy, University of Toronto, Holly Witteman - Department of Family & Emergency Medicine, Université Laval (Laval University), Justine Dol - Centre for Pediatric Pain Research, IWK Health Centre & Faculty of Health Dalhousie University
Background
The failure to meaningfully and actively engage patients and caregivers in health research and care has been identified as a barrier to uptake of research findings and improvements in care delivery. There is a growing international effort towards patient engagement in health research and care. Patient engagement in research is promoted to improve the relevance and quality of the research, but there is a need for empirical data to inform the process and conceptual basis for patient engagement in research. #ItDoesntHaveToHurt is a highly successful parent-directed knowledge translation intervention using social media to target parents to improve children’s pain management. A panel of 9 parents was actively engaged in this initiative, providing guidance on project design, implementation, and evaluation. The engagement of parents in this project offered an opportunity to study the process of parent partnerships in research
Aims
The aim of this research was to provide a mixed methods evaluation of the engagement of the parent panel in the #ItDoesntHaveToHurt project. The goal was to better understand parents’ understanding of their experiences in the project.
Methods
A group of 9 parents (3 fathers, 6 mothers) who were engaged as patient parent partners in co-creating the #ItDoesntHaveToHurt initiative were interviewed at the conclusion of their involvement in the project. Parents completed a structured survey (the “Patients as Partners in Research: Patient/Caregiver Surveys – End Project Survey”) developed by the Patients Canada organization to evaluate patient engagement in research. The 41-item survey assess patient experiences in the following areas: participation in the project, understanding roles, comfort participating on the research team, spreading results, feeling supported, handling expenses, and an overall assessment.
Survey response were analyzed using mixed methods; descriptive statistics were used to summarize responses to quantitative questions, and thematic content coding was used to identify key themes that emerged from parents responses to the open-ended survey questions.
Results
Survey results indicated that parents felt listened to (100%), that meetings respected their schedule (77%), and that they were able to share their personal experience as a patient as part of the team (100%). Parents reported feeling comfortable with the project (M = 6.56, SD = .53) and that their comments impacted project decision making (M = 5.63, SD = 2.00). When asked to identify lessons learned from parenting with researchers from the parent perspective, the top beneficial reasons were related to: a) learning and using effective communication and social media to share research evidence; b) the power of partnership and collaboration; and c) the usefulness of #ItDoesntHaveToHurt content to their own lives. Areas identified for improvement included: a) unclear communication on expectations and opportunities for involvement and b) short timeline for feedback.
Conclusion
The results of this study contribute to a much needed empirical basis for patient and family engagement in health research. Parents were generally positive about their experiences engaging and felt involved in the work. Future work will need to address challenges identified including improving communication on expectations for involvement and orientation to the project to improve patient engagement and evaluate solutions. The implications of this research in informing current conceptual models and frameworks of patient engagement in health research will be explored.
Br J Pain. 12(2 Suppl):5–54.
59
Long-Term Outcomes in Children with Complex Regional Pain Syndrome: A Cross-Sectional Study
Category: Paediatric
Richard F Howard - Department of Anaesthesia and Pain Medicine Great Ormond Street Hospital, Matthew A Jay - Department of Anaesthesia and Pain Medicine Great Ormond Street Hospital, Judy Peters - Clinical Neurosciences UCL, Suzanne Lilley - Department of Anaesthesia and Pain Medicine Great Ormond Street Hospital, Jane McNicholas - Department of Anaesthesia and Pain Medicine Great Ormond Street Hospital, Ruth Bayliss - Department of Anaesthesia and Pain Medicine Great Ormond Street Hospital, Lauren Trotman - Department of Anaesthesia and Pain Medicine Great Ormond Street Hospital, Glyn Williams - Department of Anaesthesia and Pain Medicine Great Ormond Street Hospital
Background
Complex Regional Pain Syndrome (CRPS) – pain disproportionate to any inciting event; signs and symptoms of autonomic nervous system dysfunction (e.g. vasomotor, sudomotor or trophic changes or asymmetry); and decreased range of motion in the affected body part – can occur in children and although rare is associated with significant impairment of quality of life (QoL) including school absence, anxiety or depression and decreased socialising. The epidemiology of CRPS in children differs from adults in that there is a greater female predominance and the lower limb is much more frequently involved. Many authors have also suggested that the outcome and prognosis for recovery are better in children but because of its rarity (incidence ~1.16 per 100,000 children per year), there is very limited epidemiological data available to support this.
Aims
We aimed to describe long-term outcomes in children with CRPS who had been discharged from the specialist children’s pain service at Great Ormond Street Hospital.
Methods
We identified all CRPS patients discharged before 31 December 2016 from electronic records. After conducting a case-note review, patients were invited by post to a telephone interview (10 minutes), for which a closed-question schedule was developed. We attempted to contact respondents by telephone with calls made at different times of day on different days to reduce selection bias.
The primary outcome was pain status categorised as: recovered (no pain); CRPS-site pain; chronic pain (CP) elsewhere; both CRPS-site pain and other CP. Secondary outcomes were average pain intensity over the previous month on a 0 to 10 numerical rating scale, adverse QoL impact and healthcare utilisation. Adverse QoL impact was measured by asking whether pain had interfered in the past 6 months with education/work; leisure; socialising; sleep; and mood. Healthcare utilisation was measured by asking whether respondents had consulted a healthcare professional (HCP) in the previous 6 months for pain.
Results
Of 93 patients, 68 (73%) had a telephone interview, which were conducted between 4 months and 12 years after discharge (median: 27 months). 76% had been discharged due to symptom resolution or optimal functioning.
Just 19% of respondents recovered; 30% had CRPS-only pain; 9% had other CP; and 41% had both CRPS-site and other CP. Intensity ranged from 0 to 10, with median 6.0 (IQR 4.0, 7.6).
A minority who recovered reported adverse QoL impact (<15% on any domain). Larger proportions reporting CRPS-site pain reported impact (14% to 62% depending on the domain); as did those with other CP or both CRPS-site and other CP (e.g., in those with both, 54% to 89% reported impact on the various domains). Differences were statistically significant (p<.01).
In patients who recovered or had CRPS-site pain 25% consulted an HCP, compared to 100% (other CP) and 70% (both CRPS and other CP, p<.01).
Conclusion
Children who presented with CRPS continued to have significant pain-related problems and QoL impairment long after discharge. Many children continued to seek healthcare advice after discharge, though this was most clearly associated with the development of CP at another site. To date this is the largest study we know of on CRPS in children, and these results challenge the expectation that the prognosis of CRPS in children is better than in adults. Further study to identify risk factors for poor recovery is called for.
Br J Pain. 12(2 Suppl):5–54.
60
Under-Deployment of Multimodal Analgesia at a Paediatric Tertiary Hospital: A Cohort and Data Linkage Study Exploring Inter-Ward Variation and Risk Factors
Category: Paediatric
Matthew A Jay - Department of Anaesthesia and Pain Medicine Great Ormond Street Hospital, Richard F Howard - Department of Anaesthesia and Pain Medicine Great Ormond Street Hospital
Background
Nurse- or patient-controlled morphine analgesia (N/PCA) is frequently used for the management of moderate to severe postoperative pain in children. When using morphine N/PCA, the administration of paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) is often recommended to reduce morphine requirements, opioid complications and achieve synergistic analgesia: such a technique is referred to as ‘multimodal analgesia’ (MMA) and has become a basic standard of good clinical care.
Clinical staff can use their judgment on whether to prescribe or administer MMA to individual patients and so it is important to explore and rectify possible reasons for under-deployment of MMA in order to improve this component of clinical care. The routinely collected clinical and administrative data at our institution enabled us to do this by exploiting variation in the use of MMA across different wards.
Aims
To explore variation in, and risk factors for, prescriptions and administrations of paracetamol and NSAIDs in postsurgical children receiving N/PCA across different clinical areas of a tertiary children’s hospital.
Methods
We conducted a cohort study using routine data. All postsurgical patients receiving N/PCA between 2012 and 2016 were identified from the acute pain database – a prospective data collection system with electronic bedside data entry by trained clinical nurse specialists. Information on whether paracetamol or NSAIDs were prescribed and administered was obtained from the hospital’s electronic prescribing database. Data on potential risk factors and confounders were extracted from these sources and the patient administration system. Variables included age, sex, socioeconomic position, surgery (grouped using OPCS-4 procedure codes), clinical characteristics (ICD-10 diagnosis codes), N/PCA details, adjuvants, contraindications and year.
Funnel plots were used to visualise variation in prescriptions and administrations. Bayesian hierarchical, cross-classified, logistic regression was then used to quantify how much of the variation was attributable to the observed risk factors. These models accounted for patients attending more than once, sometimes on different wards.
Results
In 5,337 episodes (4,498 patients) across 28 person-years’ observation, 49% were female and median age was 6.1 years. Most common surgeries were urinary (19%), digestive/abdominal (18%), nervous system (13%), and skull and spine (13%). Ninety-four percent had a chronic condition, 40% a life-limiting/life-threatening condition and 25% neurodisability.
Prescription and administration rates of paracetamol were high across the hospital (99% and 98%, respectively), with minimal inter-ward variation. NSAIDs were prescribed in 70% of episodes and administered in 58%. There was a large degree of variation in these rates with most wards falling above or below 99.9% statistical confidence limits (i.e., p<0.001). Preliminary results indicate that contraindications explained about 10% of this variation. Other risk factors had minimal impact on the amount of variation observed. Further analyses are currently underway to explore risk factors for NSAID administration in more depth and whether these vary by ward.
Conclusion
This study revealed significant under-deployment of NSAIDs, but not paracetamol, to postsurgical patients receiving N/PCA. Further, rates of NSAID administration varied widely across the different clinical areas of the hospital. Very little of this variation was explained by patient clinical or demographic characteristics, indicating that provider-level factors, such as staff training and attitudes, may be more important. Despite the presence of well-established hospital-wide education and training programs this study implies that clinical care may benefit from better training of clinical staff targeting specific areas of practice.
Br J Pain. 12(2 Suppl):5–54.
Primary Care
61
Bridging the Gap - Providing a Specialist Pain Service at a Gp Practice - A Pilot Study
Category: Primary Care
Deborah McDaid - Pain Management Service Great Western Hospital NHSFT, Benjamin Spencer - Medicines Optimisation Pharmacist Swindon CCG, Lucy Williams - Pain Management Service Great Western Hospital NHSFT
Background
Persistent pain is a major cause of suffering and ill health in the UK with approximately one in five people affected. A tiny proportion are referred to a Pain Clinic and services are under such pressure that there is little capacity to address unmet need.
Management in primary care is heavily focused on prescribed drugs, including opioids. There are significant side effects associated with the use of high dose opioids. Prescriptions may be continued despite inadequate evidence of benefit. There is not always sufficient emphasis on management of patient expectation and promotion of self-care.
There are significant drug costs for local CCGs. Particular problems have been raised with pregabalin and opioid transdermal patches.
A pilot study was initiated at one GP practice. Patients were reviewed by a Pain Specialist Nurse for one morning a week in a 3-hour clinic with a focus on opioid reduction and promotion of non-drug management.
Aims
Provide access to specialist pain management in primary care which may prevent the need for referral to a pain clinic.
Support drug dose reduction specifically in patients taking strong opioids.
Promote non-drug self-management strategies. Advice and signposting to internet and local resources.
Generate cost savings for practice and CCG.
Methods
Patient cohort was identified by the Pharmacist using ‘clinical reporting’ on SystmOne using the following criteria:
Prescribed morphine sulphate daily dose equivalent of greater 120mg
Prescribed opioid transdermal patches
Prescribed morphine sulphate daily dose equivalent of less than 120mg
Patients referred into the service for pain management review by GP
Patients with a diagnosis of cancer or under palliative care team were excluded
Patients were sent an invitation letter and opioid aware leaflet inviting them to make an appointment with Pain Specialist Nurse. The Pain Specialist Nurse was an Independent Prescriber experienced in facilitating Pain Management Programmes.
A SystmOne template was used to record pain assessment data including the British Pain Inventory. Medication was reviewed and dose reduction plans initiated. Education was provided on resources to support non-drug pain management strategies.
Data was recorded at baseline, 6 week and 3 month intervals
Results
Out of the 71 patients invited to attend a clinic, 19 patients made an appointment for the pain clinic. 3 patients were referred into the clinic via their GP from within the practice. This equates to a response rate of 30.9%.
After the 6-week follow-up, there was a total reduction in morphine sulphate daily dose equivalent of 1630.20mg, an average of 74mg per patient.
After 6 weeks, there was a total reduction in the prescribing costs for pain medication of £934.76. This equates to £8101.21 of annualised savings.
The 6-week cost for running the clinic was £334.62
This is a benefit/cost ratio of £2.79.
Conclusion
As a pilot study, interim results have proved encouraging with significant cost savings demonstrated following a relatively short intervention in a targeted cohort of patients.
Significant reductions in opioid doses were achieved in this patient group. Further follow up will identify if this change was sustained.
Further data will be presented on the qualitative aspects of the pilot including feedback from patients and GPs on the experience of being able to access specialist pain advice at primary care level.
The data so far supports the aim to expand the initiative to other local GP practices.
Br J Pain. 12(2 Suppl):5–54.
Psychology
62
An Experimental Investigation of the Vocalisation of Pain in Men and Women
Category: Psychology
Edmund Keogh - Psychology University of Bath, Imogen Wells - Psychology University of Bath, Anthony Little - Psychology University of Bath
Background
Pain can be communicated through both verbal and nonverbal cues. Nonverbal pain behaviours include facial expressions (e.g., grimace), body posture (e.g., guarding) and vocalisations (e.g., crying). These nonverbal cues can function as signals to others that a person is in pain, and that help is required. Therefore, the detection and accurate understanding of such signals of pain is a key element of caregiving. Previous research has often focused on facial cues associated with pain but less is known about other channels of communication, such as the voice. Furthermore, there is variation in how people signal pain to others, which needs to be better understood. Since there are known sex differences in pain and how it is expressed, male-female difference might also exist. However, we do not yet know whether such sex differences translate to how pain is expressed through vocal cues.
Aims
The aim was to examine the vocal characteristics of pain as expressed by adult males and females. We sought to compare the vocal properties of vocalisations during a painful experience, with those produced when not in pain. We also examined exaggerated and suppressed pain vocalisations, under these two pain-related conditions.
Methods
Following ethical committee approval, 41 pain-free adults (20 females, 21 males) were recruited into the study. Participants were asked to vocalise the letter combination “ah” under three different sets of vocalisation instructions: 1. as natural as possible, 2. exaggerating pain, and 3. supressing pain. Each of these three vocalisations conditions were conducted twice: once whilst experiencing pain, and again when not in pain. Pain was induced using a cold pressor task, and participants completed the vocalisation task whilst their hand was in the water once pain threshold had been reached. Vocalisations were digitally recorded, and voice samples were analysed using the software package Praat. Samples where filtered separately for males (75-300Hz) and females (100-500Hz), and key outcome variables, pitch (Hz) and intensity (dB), were extracted for analysis. Mean and variation (SD) values were extracted for both variables.
Results
Mean pitch was highest in the exaggerated pain condition (F(2,78)=50.78, p<.001), and amongst females (F(1, 39) = 121.34, p<.001). A significant interaction between vocal instruction and sex (F(2,78)=8.33, p<.001) indicated amongst females, the exaggerated vocalisation showed a greater difference from the other conditions; this difference was less pronounced in men. Greater variation in pitch was found when in pain (F(1,39) = 15.69, p<.001), and when exaggerating pain (F(2,78)= 96.26, p<.01). A significant interaction between pain and vocalisation instructions (F(2,78)=6.40, p<.01), reflected in greater variation when attempting to suppress pain in vocalisations produced during the pain experience condition. For mean intensity, vocalisations were at their loudest when in the exaggerated or suppressed pain condition (F(2,78)=12.24, p<.001), and amongst females (F(1, 39) = 61.60, p<.001). For variation in intensity, a main effect of sex was found (F(1, 39) = 8.17, p<.01). Females exhibited a wider range compared to males.
Conclusion
The current study presents promising results around the utility of using an experimental approach to the manipulation, and measurement, of pain-related vocalisations. The approach was particularly sensitive to task instructions to exaggerate and supress pain, although less sensitive to a manipulation of actual pain experience. Since the level of induced cold pain was at threshold, one possibility could be that increasing the intensity of pain or changing the type of pain (e.g., heat) would have a more obvious effect on vocalisations. This study represents the start of a promising new line of research investigation into pain communication via vocal cues.
Br J Pain. 12(2 Suppl):5–54.
63
Psychological Predictors of Outcome from Interventional Analgesic Procedures in Chronic Low Back Pain: A Feasibility Study
Category: Psychology
Pernille Frisvoll - Pain Management Programme NHS Greater Glasgow & Clyde, Lars Williams - Pain Service NHS Greater Glasgow & Clyde, Martin Dunbar - Pain Management Programme NHS Greater Glasgow & Clyde
Background
Non-surgical, invasive procedures (including facet and sacro-iliac joint injections, radiofrequency denervation procedures, and caudal epidural injections) used in the treatment of chronic low back pain (CLBP) carry rare but significant risks, are expensive to perform, and are not supported by a strong evidence base [1]. Ongoing local audit of injections for CLBP carried out in the Glasgow Pain Service consistently shows that response to these procedures is variable [2].
There is a small body of research suggesting that emotions and beliefs can influence the outcome of spinal surgery [3], and dorsal column stimulator implantation [4], so it is possible that these factors may account for some of the variability in response to injections for CLBP. Very few studies have examined psychological factors as predictors of outcome from injections for CLBP, and those that have are of poor methodological quality [5].
Aims
To conduct a feasibility study investigating the role of psychological variables as predictors of outcome from non-surgical, invasive procedures for back pain, which will allow a large scale, prospective, observational study to be designed that will examine these relationships fully.
Methods
Research and ethics committee approval was sought and granted. All patients attending the secondary care pain clinic at the Victoria Hospital, Glasgow who were listed for an injection (steroid or radiofrequency) for the treatment of CLBP between July 2016 and April 2017, were invited to participate in the study. Invitation took the form of a study pack sent to all eligible patients by post. Patients opted in to the study by returning a consent form along with completed baseline questionnaires (N=86). Participants were then followed up by a research assistant, and sent further questionnaires to complete at 6 (N=65) and 10 weeks (N=48) following their injection procedure.
Outcome measures were pain (11-point numerical rating scales) and disability (Roland and Morris SIP). Predictor variables were: psychological distress (HADS); pain-related fear (TSK); pain catastrophising (PCS) and adult attachment style (ECRM-16)
Results
Statistical analyses were performed using the lme4 [6] package in R [7]. We found that pain decreased significantly between time 1 and 2 (t(62) = 6.14, p < .001) and time 1 and 3 (t(45) = 3.49, p < .001). Disability decreased significantly between time point 1 and 2 (t(64) = 3.29, p < .001), but not significantly between time 1 and 3 (t(47) = 1.50, p = .14).
Mixed linear models were fitted to the data to assess any relationships between psychological variables and changes to pain and disability over the three time points. We found that anxiety, depression, and pain catastrophising were positively related to pain and disability, but they were not predictive of changes in these over time. Pain related fear and anxious attachment was positively related to disability but not pain, and neither was predictive of changes in these over time.
Conclusion
Undergoing injections, whether steroid or radiofrequency, was associated with reduced pain, and to a lesser extent, disability. At a simple level many of the psychological predictors were related to pain and disability in predicted ways. However, we found no evidence that emotional problems, beliefs, attachment insecurity or attachment avoidance predicted the degree of benefit to pain and disability from receiving injections.
Br J Pain. 12(2 Suppl):5–54.
64
I Know I Can Do it Because I’ve Drawn it: A Longitudinal Case Study Combining Interviews With Drawings to Illustrate Taking Back Control from Chronic Pain
Category: Psychology
Isabella E Nizza - Department of Psychological Sciences Birkbeck, University of London, Jamie A Kirkham - Chronic pain 2Kent Community Health NHS Foundation Trust, Jonathan A Smith - Department of Psychological Sciences Birkbeck, University of London
Background
While quantitative paradigms have produced scales and models of pain, qualitative studies have offered an understanding of the complexities of living with it. Interpretative Phenomenological Analysis (IPA) has provided rich accounts of the existential impact of chronic pain: its grounding in phenomenology and hermeneutics makes it particularly suitable to explore the complex and emotionally-laden experience of pain, while its idiographic commitment allows the idiosyncratic aspects of chronic pain to emerge. The deep impact, elusiveness and indefinability of chronic pain call for innovative research approaches. The use of participant drawings to guide interviews has shown great potential for the ability of drawings to express the inexpressible and elicit deep reflection. Although many studies have evaluated the effectiveness of Pain Management Programmes (PMPs), insight into the longitudinal trajectory of patients who attend them is limited.
Aims
The aim of the poster is to present a single case taken from a large longitudinal study designed to explore how the sense of self and its relationship with pain as expressed through drawings evolved when sufferers attended a multidisciplinary pain service and participated in a PMP.
Methods
The patient presented in this case study is a 47-year old, diagnosed with fibromyalgia, degenerated discs and depression, who had been in pain for 3 years. She was interviewed on joining the service, after attending a PMP and six months later. At the start of each interview, she drew a picture of her pain and a picture of herself and the images were used to guide a discussion on the impact the pain was having on her life. At later interviews, she also reviewed her previous drawings. Transcripts and drawings were analysed inductively and longitudinally using IPA. The poster will present the results from the longitudinal analysis of the pain drawings.
Results
Initially, the participant’s pain was an overwhelming and crushing presence, which was affecting her ability to lead a ‘normal’ life and isolating her socially. As she learnt to self-manage her pain, the pain itself seemed to occupy less space in the drawings and in the participant’s life. She described having taken ‘ownership’ of her pain, so that rather than being controlled by it, she was controlling it, suggesting a recovered sense of agency. Through the PMP she had developed new understandings and received support for making important life changes. Six months later, the pain was relegated to a background position in the drawing and the participant was leading a quasi-normal life. The pain was present at all three stages, but its position in her drawings changed to reflect its changing effects. The use of drawings within the interview also enabled insight and ownership of progress
Conclusion
Results suggest that learning to self-manage pain can contribute to gaining a sense of control and agency over one’s life. This longitudinal and multimodal application of IPA offers unique insight into how a sufferer’s relationship with their chronic pain can change over time. The drawings, expressive in themselves, facilitated access to the emotional world of the participant and, when reviewed retrospectively, triggered deep reflections and enabled progress to be owned.
Br J Pain. 12(2 Suppl):5–54.
Reviews
65
A Cochrane Review Update Investigating Psychological Interventions for Children and Adolescents with Chronic Pain
Category: Reviews
Emma Fisher - Department for Health University of Bath, Emily Law - Centre for Child Health, Behavior, and Development Seattle Children’s Research Institute, Joanne Dudeney - Centre for Child Health, Behavior, and Development Seattle Children’s Research Institute, Tonya Palermo - Centre for Child Health, Behavior, and Development Seattle Children’s Research Institute, Christopher Eccleston - Department for Health University of Bath
Background
Chronic pain is frequent during childhood and adolescence. Estimates of between 15-30% of children and adolescents report chronic pain, described as pain lasting for longer than three months. Children with chronic pain have impaired physical, social, and emotional functioning. Psychological treatments, namely cognitive behavioural therapy, delivered face-to-face with children have been previously found to be effective at reducing pain and disability across headache and mixed pain chronic pain conditions. These interventions are designed to control pain and modify factors that are integral to the child’s pain experience, namely social, emotional, familial, and behavioural factors.
Aims
We aimed to update a Cochrane review investigating psychological interventions to children and adolescents with chronic pain. We determine the efficacy of interventions on outcomes including pain, disability, anxiety, depression, and adverse events. Finally, we also conducted subgroup analyses to determine efficacy between large (n>20/arm) and small (n<20/arm) trials.
Methods
We searched Medline, Embase, PsycINFO, and the Cochrane Central Database for Systematic Reviews for studies published since 2014, updating the previous search that was conducted through to April 2017. Trials had to deliver psychological therapy face-to-face to children and adolescents between 0-18 years of age. We extracted primary outcomes of pain intensity (mixed pain conditions) or pain frequency (headache conditions). Secondary outcomes included disability, depression, anxiety, and adverse events. We investigated the overall effect of psychological interventions for children with chronic pain and also investigated subgroup analyses by sample size.
Results
We found eight new studies, resulting in a total of 43 randomised controlled trials (N=2617) that deliver psychological treatments to children and adolescents with chronic pain. Most interventions delivered cognitive behavioural therapy, and 22 studies included less than 20 participants/arm and were therefore included as ‘smaller trials’ in the analyses.
We found that psychological therapies reduced headache frequency, and pain intensity in mixed chronic pain conditions post-treatment, however, effects were not maintained between 3-12 months. For the secondary outcomes of disability and anxiety in children with mixed pain conditions, we found an effect at post-treatment for both outcomes but only for disability at follow-up. In contrast, we did not find an effect for children with headache. No effects were found for depression. When conducting subgroup analyses, we found that smaller trials produced larger effect sizes when pooled together compared to larger trials.
Conclusion
Psychological therapies when delivered face-to-face, are beneficial at reducing pain and disability in children with chronic pain conditions. However, smaller trials may be inflating the effect sizes in these analyses. More larger, high quality randomised controlled trials are needed. for example, we could only include two larger trials (n>20/arm) in analyses investigating children with headache. Although up to seven studies could be included in analyses investigating mixed pain conditions, heterogeneity of analyses were moderate to high.
Br J Pain. 12(2 Suppl):5–54.
66
How Do Clinicians’ Beliefs and Attitudes About Chronic Low Back Pain Influence the Orientation of Advice Given to Their Patients?
Category: Reviews
Joao Mineiro - Pain Services Royal Cornwall Hospital & School of Medicine Cardiff University, Dr Ann Moore - School of Medicine Cardiff University
Background
Chronic low back pain (CLBP) is a rising health condition with devastating societal and personal consequences. Despite acknowledgement of its multifactorial impact in clinical guidelines, a discrepancy between scientific evidence and cultural beliefs is found in the general population. The same discrepancy is present among clinicians, creating a ‘know-do gap’ which may be explained by a culture of practice underpinned by biomedical models of health. Moreover, this gap between what clinicians know about guideline recommendations on CLBP and their actual clinical practice has an influence on patients’ beliefs about the condition. In order to minimise this gap, a better understanding of how clinicians’ beliefs about CLBP, biomedical or biopsychosocial, influence their clinical practice is required. Further understanding of such complex constructs as beliefs and attitudes about CLBP benefits from the cooperation of both quantitative and qualitative research and the inclusion of the clinical population involved in the management of this condition.
Aims
This review investigated the influence of clinicians’ attitudes and beliefs on the advice provided to patients with CLBP about physical activity, work and rest by examining both quantitative and qualitative literature. The findings informed recommendations for future practice, specifically the development of an educational leaflet for clinicians managing the condition.
Methods
An online literature search was carried out between May 2017 and September 2017. Only surveys and qualitative studies published between 2002-2017 and with a sample of either students or graduate professionals of Physiotherapy and at least one other professional group linked to the management of LBP were included. Fifteen articles, seven cross-sectional surveys and eight qualitative studies, were subjected to a critical appraisal of their methodological quality and the results interpreted in a segregated method. This strategy allowed for both types of literature to complement each other and produce a deeper understanding of the problem. The findings of this review allowed for the development of a double-sided A4 advisory leaflet. Only basic shapes and colours with short messages were used in the design of the leaflet with the aim to provide a quick but substantiated message; these decisions are in line with the guidance from NICE (2007).
Results
This review found that clinicians’ beliefs about CLBP influenced the orientation of the advice provided to patients. Biomedical beliefs about CLBP were moderately associated with both advice about activity, work and rest of fear-avoidant nature and holding negative expectations about the prognosis of the condition. Biopsychosocial beliefs about CLBP were moderately associated with advice about activity, work and rest of reassuring nature and holding positive expectations about prognosis of the condition. Clinicians’ beliefs about CLBP extend beyond the condition itself to beliefs about patients with CLBP and barriers within professional contexts. Moreover, clinicians often held both biomedical and biopsychosocial beliefs about CLBP. The resultant advice contained mixed messages, both reassuring and fear-avoidant. The influence of clinicians’ biomedical and fear-avoidant beliefs upon those of their patients was stronger whilst explaining the cause and the prognosis of CLBP.
Conclusion
The review provides a deeper understanding of the influence of clinicians’ beliefs about CLBP on the orientation of the advice provided, biomedical or biopsychosocial, about physical activity, work and rest. This deeper understanding in the topic has resulted in recommendations for practice which informed the development of an educational leaflet for clinicians. The educational leaflet raises awareness about the influence of clinicians’ beliefs on those of their patients and how clinical messages can be made more effective. Further research on the understanding of the influence of patient-clinician interaction on the interpretation of advice provided is recommended.
Br J Pain. 12(2 Suppl):5–54.
67
The Effect of Virtual Representation of Body Parts on Pain Perception: A Systematic Review of Clinical and Experimental Studies
Category: Reviews
Priscilla G. Wittkopf - School of Clinical and Applied Sciences Leeds Beckett University, Donna M. Lloyd - School of Psychology University of Leeds, Mark I. Johnson - School of Clinical and Applied Sciences Leeds Beckett University
Background
Virtual reality has been used in rehabilitation settings to provide a virtual representation of missing and/or painful body parts, such as with amputees. Movement of the virtual limb by the patient, by using controllers or motion tracking systems, enables them to interact within the virtual environment and this has been shown to alleviate pain. For example, Osumi et al. (2017) designed a virtual arm positioned at the stump of the amputation whereby movements of the contralateral intact arm produced symmetrical movements of the virtual arm. Participants found that using the virtual arm to touch virtual objects presented in a head-mounted display alleviated pain. To date there is no systematic review investigating the effect of virtual representation of body parts on pain perception.
Aims
The aim of this systematic review was to assess the effect of virtual representation of body parts on pain perception in pain patients and in pain-free participants exposed to experimentally-induced pain.
Methods
Searches of databases (Medline, PsychInfo, CINAHL, and Web of Science) were conducted between 1 and 13 August 2017 using a combination of controlled vocabulary (i.e. medical subject headings) and free-text terms (e.g. ‘virtual reality exposure therapy’, OR ‘augmented reality’ OR ‘virtual reality’ AND ‘pain’) to identify published reports of studies Inclusion criteria were: full study report; investigation of a virtual representation of any body part in a first person perspective; pain as an outcome measure; participants with clinical pain or pain-free individuals exposed to experimental pain. Studies that investigated virtual reality as a distraction, relaxation, gaming or hypnosis were excluded.
Results
Nine clinical studies met the inclusion criteria. There were two randomized controlled trials and both found no significant difference between intervention (i.e. participants watched a virtual body performing movements and mentally imitated) and the control conditions (i.e. participants watched the video without mental imagery or mental imagery alone) for pain intensity. There were seven studies without controls (i.e. pre-post design) and all found that virtual reality alleviated pain (mean = 32-64% relative to baseline). Seven experimental studies were included. They found that pain was alleviated by: observing a virtual arm compared with a virtual object; co-locating a virtual arm with the real arm; moving a virtual arm in synchrony with the real arm; making the virtual arm blue; and covering the virtual arm with iron armour. There were no changes in pain when participants observed virtual legs in difference sizes, nor when the transparency of the virtual arm was manipulated.
Conclusion
The use of virtual reality in rehabilitation settings has become more popular and affordable with lowering of prices and development of new software. Based on primary studies, the use of virtual representation of body parts to reduce pain is promising but evidence of clinical efficacy is inconclusive due to an absence of studies with robust methodological quality. It is expected that the summary of studies provided in this review will help in the design of high quality studies.
Br J Pain. 12(2 Suppl):5–54.
Service Management
68
Patient Safety in Chronic Pain Practice: An Evaluation of Incidents and Complications in a Multidisciplinary Chronic Musculoskeletal Pain Centre
Category: Service Management
John Schutzer-Weissmann - Chronic Pain Centre Royal National Orthopaedic Hospital, Dylan Pritchard - Medical School University College London, Dan Mihaylov - Chronic Pain Centre Royal National Orthopaedic Hospital, Roxaneh Zarnegar - Chronic Pain Centre Royal National Orthopaedic Hospital
Background
The Chronic Pain Centre at the Royal National Orthopaedic Hospital (RNOH) holds monthly multidisciplinary Risk, Incidents and Complex Case Meetings in which clinical and non-clinical incidents, hazards and complex cases are reflectively discussed.
The Centre has a written policy on managing untoward events. In line with this policy all incidents following procedures which necessitate an additional clinical assessment, investigation or intervention, and therefore by definition cause moderate or severe harm (NPSA definitions), should be discussed at the meeting as well as all cases of missed or incorrect diagnosis, actual or attempted patient suicide, prescribing errors and all incidents submitted to the RNOH incident reporting system that are related to chronic pain practice.
The records from these meetings provide quantitative information on complications of interventional procedures and a picture of quality and patient safety issues encountered in a musculoskeletal pain service.
Aims
To determine the rate of incidents after interventional procedures for chronic pain treatment and compare these against published literature, where possible.
To identify commonly occurring patterns in clinical incidents related to chronic pain practice.
To audit responses to incidents against current standards of practice.
Methods
Meeting minutes from March 2016 to July 2017 inclusive were quantitatively and qualitatively reviewed by two investigators for data on the type of incident, severity of harm and follow up actions. Medical records were accessed for additional information where needed. Records of total number of procedures done in the same time frame were accessed from the hospital’s operational data for comparison. Incidents were categorized in broad categories of clinical and non-clinical.
Results
No incidents caused severe harm. Thirty-two events were discussed over the 17 month evaluation period. Twenty were complications of interventional procedures. General procedure complication rates were 0.8% (14/1836) for all non-neuromodulation, 1.87% (9/482) for spinal injections and 3.6% (6/168) for neuromodulation.
The commonest post-procedural complications were transient increased pain (5) and weakness (3) after spinal injection. Neuromodulation-related complications included a drug error (epidural injection of metronidazole instead of saline), antibiotic allergy (2), CSF leak (2) and respiratory depression during conscious sedation (1).
Most (7) non-procedural incidents were related to information governance and information technology issues including incorrect filing, use of e-mail and loss of a dictaphone.
Follow-up and reporting protocols were adhered to and incidents were documented well in the medical notes. Discussions recorded in minutes contained examples of effecting change to improve service provision, reduce documentation errors and refine consent and interventional processes towards reducing variations in practice.
Conclusion
Incident reporting, clinical audit and quality improvement are core standards for UK Pain services. This audit shows that departmental meetings in which incidents are discussed enhance service quality and allow audit and benchmarking.
With the exception of spinal injections, there is limited published data on chronic pain procedure complications. Post-procedure complication rates in this series are, as expected, lower than published case series which include all complications. Arguably reporting rates of moderate-severe complications is more clinically relevant and more suitable for benchmarking. Our data supports existing literature on the rarity of severe complications following procedures
Br J Pain. 12(2 Suppl):5–54.
69
Moving Forwards with Fibromyalgia: an Evidence-Based Clinical Pathway
Category: Service Management
Lyn Margetts - Anaesthetics Torbay and South Devon NHS Foundation Trust, Phillipa Newton-Cross - Physiotherapy Torbay and South Devon NHS Foundation Trust, Rebecca Chasey - Clinical Psychology Torbay and South Devon NHS Foundation Trust, Dee Burrows - Pain Services Torbay and South Devon NHS Foundation Trust, Andrew Howell - Pain Services Torbay and South Devon NHS Foundation Trust
Background
Audit showed that 45% of patients seen in outpatient clinics by Pain Consultants at Torbay and South Devon NHS Foundation Trust between 1st July 2015 and 30th June 2016 had a diagnosis of Fibromyalgia.
The European League Against Rheumatism (EULAR) released new guidance in 2016 for the management of Fibromyalgia strongly recommending the provision of education and exercise early in the course of the condition. (1)
Medication is not recommended as a first line treatment.
Learning self-management has the potential to improve patient activation, quality of life and psychological distress.(2)
Aims
To create a new clinical pathway for patients with Fibromyalgia to enable early access to education about their condition and the role of medication in the management of Fibromyalgia. To facilitate early use of appropriate self-management interventions.
Methods
A multidisciplinary working group comprising a senior doctor, specialist pain physiotherapist, specialist pain psychologist and a chronic pain nurse devised the pathway in collaboration with local commissioners and patient representative group ‘Involve’.
GPs diagnose Fibromyalgia and then provide details of how to access group education in the form of seminars and workshops. Patients opt-in to the initial education sessions. Having attended these, screening tools (Brief Pain Inventory, Psychological Inflexibility in Pain Scale, Patient Activation Measure) are used to guide patients along the pathway to access matched care. Multidisciplinary paper triage is required for patients with longstanding Fibromyalgia or complex presentations for whom group education is not suitable.
Local GPs, physiotherapists and mental health professionals were given guidance on making the diagnosis and accessing the pathway.
The pathway was introduced gradually to allow modification where required, and to incorporate service user feedback. Referral data was collected between March 2017 and December 2017 and feedback was collected after all seminars and workshops.
Results
300 patients were referred onto the new pathway between March 2017 and December 2017.10% of referrals were returned to their GP. 12% were triaged to a consultant or specialist nurse.
72% of patients were diverted from usual medical care.
34% of patients were offered group education, 38% were offered matched care in the form of pain physiotherapy, pain psychology or joint therapies clinics.
Patients were asked to rate seminars and workshops on a scale of 1-10 where 10 was very helpful.
80% rated the “Understanding Fibromyalgia” Seminar 8/10 or higher
80% rated the “Moving Forwards with Fibromyalgia” Workshop 8/10 or higher.
Conclusion
This pathway was designed to provide early access to education and facilitate self-management. 72% of patients with Fibromyalgia were diverted from usual medical care onto this pathway.
Patient feedback was positive.
“Moving Forwards with Fibromyalgia” is now the clinical pathway for patients with Fibromyalgia in South Devon. It represents an evidence-based, patient-centred move away from the traditional medical model of care. It enables prompt, matched care. Patients are empowered to self-manage their condition.
Br J Pain. 12(2 Suppl):5–54.
70
Bundles of Care: Standardisation of Care in An NHS Pain Management Service
Category: Service Management
Cathy Willcocks - Pain Management Solent NHS Trust, Cathy Price - Pain Management Solent NHS Trust, Joanna Harding - Pain Management Solent NHS Trust, Emily Snushall - Pain Management Solent NHS Trust
Background
At present local NHS pain services are working over clinical capacity, with a high volume of referrals and increasing patient complexity. Due to this demand it is essential that services are efficiently coordinated. However, multidisciplinary practice can lead to a lack of standardization and poorly defined management pathways, resulting in variable care throughout the service.
Care bundles are coordinated packages of care formed from individual building blocks (elements of service). These ensure a patient receives consistent high level care throughout their journey. Each care bundle is evidence-based and contains three to four stages, which have been reliably shown to improve patient outcomes.
A care bundles approach was proposed to tackle both variation and efficiency. We were unable to find examples of this in pain management although they are widely used in other clinical areas.
Aims
To create and establish effective care bundles within a pain management service, aiming to increase standardisation of practice and to improve service efficiency.
Methods
The multidisciplinary pain team identified areas of patient care where it was felt the care bundle approach (a package of interventions that must be followed for every patient, every time) could improve service consistency and efficiency. A subsequent prioritisation exercise gave rise to three preliminary bundles; Medication Review, Pain Education and Discharge.
These three areas were examined in further detail to elucidate the core elements deemed most vital to a successful patient care episode. Three or four elements for each bundle were identified.
Following this, baseline data was collected for each of these bundles, examining how current practice compared to the proposed ideal. Twenty patient records were retrospectively reviewed against the new bundle standards, to identify how these elements of service were being delivered and documented.
Results
Twenty records were reviewed from patients who had completed their journey within the pain service, and placed on SOS discharge. There were 6 male and 14 female patients, average age was 55.4 and they had been under the care of the pain team for an average of 9.3 months.
During current practice we complete all elements of the three care bundles 62% of the time.
Analysis of individual bundles showed;
Overall completion rate of the medication review bundle is 70%, ranging from 0% to 100% on individual elements.
Overall completion rate of the pain education bundle is 54%, ranging from 25% to 70% on individual elements.
Overall completion rate of the discharge bundle is 61%, ranging from 45% to 100% on individual elements.
Conclusion
Currently the service is working at a varying level of consistency within patient care, an area which clearly requires improvement.
Findings of the baseline review were presented to the multidisciplinary team. The individual elements of the bundles were examined in detail and suggestions taken as to any practical steps to improve adherence. These included education of all members of the pain team and adjustments to the online patient record system.
Re-audit of further patient records following implementation of these bundles is planned to determine whether standardisation of recording may be improved. Alongside this, further work to improve efficiency is required.
References
- 1. De Conno F, Ripamonti C, Brunelli C. Opioid purchases and expenditure in nine western European countries: ‘Are we killing off morphine?’. Palliative Med. 2005;19(3):179–84. [DOI] [PubMed] [Google Scholar]
- 2. Zin CS, Chen LC, Knaggs RD. Changes in trends and pattern of strong opioid prescribing in primary care. Eur J Pain. 2014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Fischer B, Ialomiteanu A, Boak A, Adlaf E, Rehm J, Mann R. Prevalence and Key covariates of non-medical prescription opioid Use among the general secondary student and adult populations in Ontario, Canada. Drug Alcohol Rev. 2013;32(3):276–87. [DOI] [PubMed] [Google Scholar]
- 4. Gooberman-Hill R, Heathcote C, Reid CM, Horwood J, Beswick AD, Williams S, et al. Professional experience guides opioid prescribing for chronic joint pain in primary care. Family Practice. 2011;28(1):102–9. [DOI] [PubMed] [Google Scholar]
- 5. Blake S, Ruel B, Seamark C, Seamark D. Experiences of patients requiring strong opioid drugs for chronic non-cancer pain: a patient-initiated study. Br J Gen Prac. 2007;57(535):101–8. [PMC free article] [PubMed] [Google Scholar]
- 6. McCrorie C, Closs SJ, House A, Petty D, Ziegler L, Glidewell L, et al. Understanding long-term opioid prescribing for non-cancer pain in primary care: a qualitative study. BMC family practice. 2015;16(1):1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. CASP. Critical Appraisal Skills Programme (Qualitative Checklist) (2017). http://www.casp-uk.net/checklists2017.
- 8. Attride-Stirling J. Thematic networks: an analytic tool for qualitative research. Qualitative Research. 2001;1(3):385–405. [Google Scholar]