BJP ASM Poster Abstracts 2019

The following 6 abstracts will be presented during Plenary Session 7 on Friday 3rd May.

ORAL PRESENTATION – 1

THE IMPORTANCE OF THE CLINICIAN–PATIENT INTERACTION ON OUTCOMES IN MUSCULOSKELETAL PAIN: A SYSTEMATIC REVIEW

Category: Reviews

John Hurley – School of Allied Health, University of Limerick, Mary O’Keeffe – School of Public Health, University of Sydney, Irene Leahy – School of Allied Health, University of Limerick, Helen Purtill – Department of Mathematics and Statistics, University of Limerick, Karen McCreesh – School of Allied Health, University of Limerick, Peter O’Sullivan – School of Physiotherapy and Exercise Science, Curtin University of Technology, Kieran O’Sullivan – Sports Spine Centre, Aspetar Orthopaedic and Sports Medicine Hospital

Background

Many different treatments are used to treat musculoskeletal pain which have been shown to be equally effective at reducing pain. The mechanisms by which these different treatments influence pain and disability are unclear. It is proposed that treatments influence pain through (1) specific treatment-related effects and (2) non-specific effects such as a positive clinician–patient interaction. The clinician–patient interaction incorporates factors such as clinician empathy and listening, clinician–patient communication, shared goals, confidence and trust in clinicians, non-verbal communication and spending enough time with the patient. Emerging evidence suggests that a positive clinician–patient interaction in musculoskeletal settings is linked with reduced pain, reduced disability, as well as enhanced health status and treatment satisfaction. However, there are currently no systematic reviews investigating whether, and how much, clinician–patient interaction influences musculoskeletal pain outcomes.

Aims

To determine the effect of the clinician–patient interaction on outcomes in people with musculoskeletal pain.

Methods

This review was registered prospectively (PROSPERO CRD42015025440). Nine electronic databases were searched independently by two reviewers. The search strategy used keywords relating to (1) interaction, (2) clinicians, (3) patients and (4) pain or disability. Hand searches of the reference lists of included papers and hand searches of the reference lists of the six main systematic reviews related to the area of research were conducted to ensure no relevant papers were missed. Studies were included if they measured clinician–patient interaction and its association with pain and/or disability outcomes for musculoskeletal pain. Two authors independently assessed the individual studies for risk of bias using the relevant (cohort and randomised controlled trial) Critical Appraisal Skills Program (CASP) tool. Data regarding patient characteristics, description of intervention, sample size, data collection methods, study aims and key findings were extracted by two independent authors.

Results

Ten papers (1847 participants) met the inclusion criteria. Studies were not sufficiently homogeneous to conduct a meta-analysis. Nine of the ten papers found a positive association between a positive clinician–patient interaction and decreases in pain intensity in the short term and medium term with four studies reporting a similar positive association for disability outcomes, and one study reported no difference in pain or disability outcomes. Interestingly, two of these ten papers reported an association between certain aspects of clinician–patient interaction leading to increases in pain intensity and disability in the short term and medium term. The review provides preliminary evidence (one study) that the strength of the clinician–patient interaction does not appear to be dependent on changes in pain and disability. Two RCTs, which investigated the effect of a short course aiming to improve clinicians’ interaction skills, showed mixed results.

Conclusion

A positive clinician–patient interaction has a positive effect on pain and disability outcomes for musculoskeletal pain. While the magnitude of the effect was modest, it is similar in size to that typically attributed to ‘specific’ treatments. The range of measures used to assess clinician–patient interaction, many of which have not been well validated, suggests these results should be interpreted cautiously. The content of training courses should be reviewed to determine the most effective aspects for improving pain and disability.

ORAL PRESENTATION – 2

EXPLORING ATTENTIONAL BIASES FOR BODY EXPRESSIONS OF PAIN IN MEN AND WOMEN

Category: Psychology

Edmund Keogh – Department of Psychology, University of Bath, Rachel Francis – Department of Psychology, University of Bath, Janet Bultitude – Department of Psychology, University of Bath

Background

Sex and gender are known to impact on pain. Psychosocial factors are thought to play a role, with suggestions that there might be differences in how men and women express and recognise pain (Keogh, 2014). This study explores the interpersonal gender context of pain by examining whether the attention processes involved in the early detection of pain vary among men and women. It builds on recent work that shows that observers may exhibit a bias in attention away from facial expression of pain when depicted by women and towards such expressions when displayed by men (Keogh et al., 2018). Although there are different channels of nonverbal expression communication, most focus on facial expressions. Therefore, this study sought to explore whether attentional biases exist for bodily expressions of pain.

Aims

The primary aim was to see whether men and women exhibit different attentional biases towards body expressions of pain. We also sought to determine whether this bias varies according to whether the presented expressions were depicted by male or female actors.

Methods

Following ethical committee approval, 50 pain-free adults (25 female; mean age = 20.63) were recruited into the study. They all completed a visual dot probe task. Images were drawn from a standardised set of body expression postures made by male and female actors. Each actor depicted pain, fear and neutral bodily expressions. Pairs of images were created (e.g. pain-neutral; fear-neutral), and presented briefly side-by-side, on a computer monitor. After each image pair, a dot-probe was presented in the location of one of the images. Attention is thought to be biased towards pain if responses are faster when the dot appears in the same location as the pain expression, relative to neutral controls. Images were presented for two different presentation durations, to explore whether biases are more likely at early phases of attention: 150 and 1250 ms. Participants with more than 10% errors were removed (two females; three males).

Results

In dot-probe tasks, a bias index is used to indicate whether attention is drawn towards (vigilance) or away from (avoidance) the location of pain. A mixed-groups analysis of variance (ANOVA) was conducted on the bias index, with participant gender (male vs female) as the between-groups factor, and actor gender (male vs female), index type (pain vs fear) and presentation time (150 vs 1250 ms) as the within-groups factors. A significant interaction was found between index type and actor gender (F(1,43) = 4.09, p < 0.05). There was a general bias towards male body expressions of pain and fear. For female expressions, there was a relative bias towards pain, but away from fear. A significant interaction was also found between index type and presentation time (F(1,43) = 5.04, p < 0.05). Differences only occurred when image pairs were presented for a longer duration, with a relative bias towards pain expressions and away from fear. No other significant effects were found.

Conclusion

A selective attentional bias towards pain expressions was found, particularly when presented for a longer duration. This suggests body expressions of pain capture the attention of observers. While actor gender affected the nature of attentional biases, this was for fear rather than pain. This suggests gender is less relevant to the detection of pain expressions when presented through body postures.

ORAL PRESENTATION – 3

IS THE 2010 ACR FIBROMYALGIA DIAGNOSTIC CRITERIA PREDICTIVE OF OUTCOME FROM DIAGNOSTIC BLOCKS FOR CHRONIC PAIN?

Category: Interventional Pain Management

Joel Perfitt – Chronic Pain Service, Northern General Hospital, Sheffield, Tomasz Bendinger – Chronic Pain Service Northern General Hospital, Sheffield

Background

Diagnostic blocks are a valuable tool in the management of chronic pain and allow for precise diagnosis of pain mechanisms. They inform subsequent treatment including the decision to proceed to definitive therapy, usually in the form of radiofrequency ablation. Fibromyalgia syndrome (FMS) is a clinical syndrome characterised by widespread pain, somatic symptoms, as well as tiredness, waking unrefreshed and cognitive symptoms. The current diagnostic criteria is the 2010 American College of Rheumatology (ACR) diagnostic criteria and takes the form of a scoring matrix based on the above symptoms as well as exclusion of other causes. The mechanism of FMS is poorly understood but is believed to involve central sensitisation, in common with other functional pain disorders including irritable bowel syndrome (IBS), chronic pelvic pain, interstitial cystitis and functional dyspepsia. Diagnostic blocks in pain medicine rely on a mechanistic, pain generator model of pain, and this may be altered in patients with FMS phenotype.

Aims

We aimed to establish whether screening patients using the 2010 ACR diagnostic criteria offered any predictive value when performing diagnostic blocks for chronic pain. If pain mechanisms in patients with FMS phenotype are altered compared to non-FMS, then results from diagnostic blocks may differ between the groups.

Methods

We designed a prospective, observational study for which ethical approval was granted. Inclusion criteria were all English-speaking chronic pain patients listed for first set of diagnostic blocks in tertiary pain clinic in the United Kingdom. Patients were listed for diagnostic block based on consultant clinical assessment, after which they were approached to be included in the study and provide written consent. Consented patients were asked to self-complete the 2010 ACR diagnostic criteria prior to their procedure. Results from diagnostic blocks were collected, assessed and classified as positive or negative according to local guidelines – 70% improvement of pain severity score during duration of action of local anaesthetic. Statistical analysis between group A and B was conducted as follows: categorical data are described as percentages and compared with the χ2 test. Ordinal variables: Widespread pain index and symptom severity score are presented as median and analysed with Mann–Whitney test.

Results

A total of 77 patients were recruited for the study between November 2017 and October 2018 who had diagnostic blocks performed. Two patients were lost to follow-up. Of the 75 patients, 44 received diagnostic lumbar medial branch blocks, 19 genicular nerves of knee blocks, 3 sacroiliac joint block, 1 suprascapular nerve, 6 cervical and 2 thoracic medial branch blocks. Patients were divided into two groups based on defined outcome: 38 patients (group A) had positive diagnostic block and 37 patients (group B) had negative diagnostic block. Of the 38 in group A, 13 (34%) fulfilled the ACR diagnostic criteria, while 25 (66%) did not. Of the 37patients in group B, 13 (35%) fulfilled the ACR diagnostic criteria, while 24 (65%) did not. There was no significant difference between the two groups (p = 0.93). Sub-analysis of medians of widespread pain index (WPI) and symptom severity score (SSS) revealed no statistically significant difference between groups A and B, p = 0.65 and p = 0.3, respectively.

Conclusion

We conclude that the 2010 ACR fibromyalgia diagnostic criteria offer no predictive value when selecting patients for diagnostic blocks for chronic pain. Suspicion of FMS phenotype should not influence the decision to select patients for these blocks, and it is also likely that a diagnosis of FMS should not exclude patients from diagnostic blocks for chronic pain. Further work is needed to establish outcomes from therapeutic procedures on these patients and estimate incidence of false-positive block and match these against controls.

ORAL PRESENTATION – 4

EFFICACY AND SAFETY OF SUBCUTANEOUS TANEZUMAB FOR THE TREATMENT OF OSTEOARTHRITIS OF THE HIP OR KNEE

Category: Other (research)

Thomas J Schnitzer – Physical Medicine & Rehabilitation, Feinberg School of Medicine, Northwestern University, Richard Easton – Orthopaedic Surgery, Michigan Orthopaedic & Spine Surgeons, Shirley Pang – St. Joseph Heritage Healthcare, Dennis J Levinson – Chicago Clinical Research Institute, Glenn Pixton – Clinical Statistics, Pfizer Inc., Lars Viktrup – Lilly Research Laboratories, Eli Lilly and Company, Isabelle Davignon – Clinical Development and Operations Business Unit, Pfizer Inc., Mark T Brown – Clinical Development and Operations Business Unit, Pfizer Inc., Kenneth M Verburg – Global Product Development, Pfizer Inc., Christine R West – Global Product Development–Internal Medicine Therapy Area, Pfizer Inc

Background

Tanezumab is a humanised monoclonal antibody that blocks nerve growth factor (NGF) and is in clinical development for chronic pain treatment. Tanezumab administered intravenously has proven efficacy in previous studies of osteoarthritis (OA) pain.

Aims

A randomised, double-blind, placebo-controlled, multicenter, parallel-group, 40-week study (16-week treatment period; 24-week safety follow-up) was conducted to examine the efficacy and safety of subcutaneous (SC) tanezumab administered in two treatment regimens over 16 weeks.

Methods

This study enrolled OA patients (N = 696) who had not responded to or could not tolerate standard pain treatments. Patients had OA of the hip or knee based on clinical and radiographic ACR criteria, baseline WOMAC Pain and Physical Function scores of ≥5 (11-point numerical rating scale), baseline Patient’s Global Assessment of OA (PGA-OA) of ‘fair’, ‘poor’ or ‘very poor’, and a history of insufficient pain relief or intolerance to acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and either tramadol or opioids (or were unwilling to take opioids). SC tanezumab treatment regimens were fixed dosing (2.5 mg administered at Baseline and Week 8) and step-up dosing (2.5 mg administered at Baseline and 5 mg at Week 8). Co-primary endpoints were changed from Baseline to Week 16 in WOMAC Pain subscale, WOMAC Physical Function subscale and PGA-OA. Safety assessments included adverse event (AE) reporting, physical and neurological examinations, joint x-rays, electrocardiogram and laboratory tests.

Results

At Week 16, patients treated with tanezumab 2.5 mg or 2.5/5 mg experienced statistically significant improvement in WOMAC Pain, WOMAC Physical Function and PGA-OA compared with patients receiving placebo. Both tanezumab dosing regimens met the study co-primary endpoints. The most common AEs (≥3% in any treatment group and more frequent in each tanezumab treatment group than in the placebo treatment group) were nasopharyngitis, pain in extremity and paresthesia. The incidence of serious AEs or withdrawals due to AEs was similar between treatment groups. Adjudicated rapidly progressive OA occurred in 1.3% of tanezumab-treated subjects and none of the placebo-treated subjects during the 40-week study.

Conclusion

Tanezumab 2.5 mg SC provided significant pain relief and improved both function and PGA-OA versus placebo in OA patients. Increasing the dose to 5 mg at Week 8 was associated with modest additional benefit versus continuation on tanezumab 2.5 mg. This study demonstrates that SC tanezumab may be an effective option for patients who have demonstrated intolerance or incomplete response to standard treatments for OA.

ORAL PRESENTATION – 5

QUANTITATIVE SENSORY TESTING (QST) CAN PREDICT PAIN, DISABILITY AND NEGATIVE AFFECT IN MUSCULOSKELETAL CONDITIONS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Category: Reviews

Vasileios Georgopoulos – Academic Rheumatology, University of Nottingham, Kehinde Akin-Akinyosoye – Academic Rheumatology, University of Nottingham, Weiya Zhang – Academic Rheumatology, University of Nottingham, Daniel F McWilliams – Academic Rheumatology, University of Nottingham, Paul Hendrick – Academic Rheumatology, University of Nottingham, David A Walsh – Academic Rheumatology, University of Nottingham

Background

Musculoskeletal pain is a worldwide phenomenon and the most prevalent reason the general population seeks healthcare assistance. Chronic musculoskeletal pain demonstrates huge public health implications and significant impact on patients’ lives. It often leads to loss of employment, isolation, depression, persistent pain and disability. The overall pathophysiology of chronic pain implicates mechanisms in both peripheral and central nervous systems. Neuroplastic changes in the central nervous system can facilitate the development of central sensitisation. Central sensitisation can influence recovery and lead to worse clinical outcomes. Quantitative sensory testing (QST), and index of sensitisation, has been widely used to ascertain and study differences between healthy subjects and patients, to explore pain mechanisms and to predict or monitor the effectiveness of treatment. However, the ability of QST to predict outcomes in chronic musculoskeletal disorders has not been systematically established.

Aims

To determine the ability of QST to predict musculoskeletal outcomes.

Methods

Evidence was systematically reviewed for ability of QST to predict pain, disability and negative affect using searches of CENTRAL, MEDLINE, EMBASE, AMED, CINAHL and PubMed databases up to April 2018. The search strategy was formed with components from previous systematic reviews on QST or musculoskeletal pain. Both randomised controlled trials (RCTs) and prospective cohort studies were included. Title screening, data extraction and methodological quality assessments were performed independently by two reviewers. The Cochrane Collaboration tool and the Quality on Prognosis tool were used to assess risk of bias in included studies. Demographic, QST protocol, modality and musculoskeletal outcome data were extracted. Associations were reported between baseline QST and musculoskeletal-related outcomes using adjusted (β) and unadjusted (r) correlations. Meta-analyses were performed according to statistical association type, musculoskeletal outcome, study design, QST modality and musculoskeletal disorder. The review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Results

Out of the 15,072 identified studies, 37 were considered eligible (n = 3860 participants), of which 32 were prospective cohort studies and 5 randomised controlled trials. Pain was an outcome in 30 studies, disability in 11 and negative affect in 3. Meta-analysis revealed that baseline QST predicted musculoskeletal pain (mean β = 0.18, 95% CI: 0.11–0.25, n = 1991 participants) and disability (mean β = 0.35, 95% CI: 0.21–0.49, n = 1272 participants). Conditioned pain modulation (CPM), a modality quantifying central mechanisms, showed a stronger association with follow-up pain (mean β = 0.35, 95% CI: 0.15–0.54) than did threshold modalities. Subgroup analyses based on study design, specific pathologies, axial or peripheral pain and studies that adjusted for baseline pain yielded similar results to the overall findings presented above.

Conclusion

QST indices of central sensitisation can predict worse musculoskeletal outcomes of pain, disability and negative affect. QST utilisation might help develop targeted interventions aiming to reduce central sensitisation and therefore improve outcomes across a range of musculoskeletal conditions. The findings also suggest that QST might identify those who are most likely to benefit from treatment or those at highest risk of poor outcome associated with sensitisation. QST dynamic modalities such as CPM might have the greatest potential for the prediction of musculoskeletal outcomes.

ORAL PRESENTATION – 6

CHARACTERISTICS AND SERVICE UTILISATION AMONG CHILDREN WITH CHRONIC PAIN IN THE ENGLISH NATIONAL HEALTH SERVICE: FINDINGS FROM A WHOLE-POPULATION ADMINISTRATIVE DATA STUDY

Category: Paediatric

Matthew A Jay – Population, Policy and Practice Programme, UCL GOS Institute of Child Health, Richard F Howard – Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, Ruth Gilbert – Population, Policy and Practice Programme, UCL GOS Institute of Child Health

Background

Chronic pain (CP) in children is a disabling condition that can have wide-ranging impacts on the child’s and family’s quality of life. Although no comprehensive prevalence data are available for the United Kingdom, its prevalence among adolescents has been estimated in a Dutch sample to be 25%. Many of these children are managed satisfactorily in primary care but a minority require input from pain services, often following a long process of investigation and treatment failure. To date, paediatric CP has been poorly described in the literature beyond single-centre studies. Information is lacking to inform service providers and commissioners about the clinical characteristics of children with chronic pain or their service utilisation.

Aims

Using whole of England administrative health data, the objectives of this study were to (a) describe a cohort of children seen by CP services in terms of their demographic and clinical characteristics and (b) describe overall service utilisation before and after their initial CP clinic consultation (labelled CPC1).

Methods

We used the Hospital Episode Statistics – administrative data covering all NHS-funded inpatient admissions, outpatient appointments and A&E attendances in English hospitals. Children aged 10–17 first seen by a CP service between financial years 2007/2008 and 2016/2017 were identified from outpatient data using service speciality codes that identify pain services. We excluded 18 patients with missing gender and 392 who had been inpatients for maternity reasons prior to CPC1 or up to 9 months after as pregnancy would likely confound analysis. Demographic data (age, gender, ethnicity, deprivation) were extracted from inpatient and outpatient data. The presence of comorbid chronic conditions (such as cancer, respiratory diseases, neurological disorder or mental health conditions) in the 5 years prior to CPC1 was identified from inpatient data using a validated ICD-10 code list. Service utilisation was described by counts of outpatient attendances, planned and emergency admissions and A&E attendances.

Results

We identified 11,515 children: 3185 (28%) boys and 8330 (72%) girls. Approximately 87% were white. In boys, 24% lived in the most deprived fifth of neighbourhoods in the country and 17% in the least deprived fifth; in girls, no such gradient was observed with about 20% in all fifths. The prevalence of comorbidity was high: 55% of boys and girls had some other chronic conditions in the 5 years prior to CPC1. Examining service utilisation revealed that there was a rise in outpatient attendances, emergency admissions and A&E attendances in the 2 years prior to CPC1, with rises in emergency admissions and A&E attendances most striking. All abated immediately after CPC1; however, there was a spike of planned admissions after CPC1 with a flat trend beforehand.

Conclusion

Children presenting to pain services in England are a population exhibiting a high prevalence of multi-morbidity including physical and mental health conditions. Our findings underscore the complexity inherent in managing these children, which requires interdisciplinary input at CP services and holistic support elsewhere for the child and family. We also found a pattern of service utilisation indicative of unmet need in the year leading up to CPC1. This suggests that earlier identification, intervention embedded in local services and, where appropriate, referral to specialist services in accordance with published management pathways, and with regard to socioeconomic factors, would benefit this population.

1

COMPARISON OF ANALGESIC EFFICACY OF SUBLINGUAL SUFENTANIL VERSUS OXYCODONE AFTER TOTAL KNEE ARTHROPLASTY

Category: Acute Pain

Mickael Leclercq – Department of Anaesthesiology, CHU Tivoli

Background

Postoperative pain is a major cause limiting recovery. Oxycodone is often used for pain management after fast-track surgery. Recently, a new device has been developed for patient-controlled oral administration of sufentanil. It is conceptually similar to patient-controlled analgesia (PCA) pumps, without IV access requirement; some trials showed a similar pain control with improved patient satisfaction scores. Our aim is to compare the sufentanil sublingual tablet system with oxycodone after total knee arthroplasty (TKA).

Aims

Primary aim is to show a decrease in the visual analogue scale (VAS) of pain of at least 2 points in the sufentanil group in comparison with oxycodone group. Secondary endpoints are the evaluation of patients’ satisfaction and the adverse effects incidence in both groups.

Methods

Between September 2017 and July 2018, 72 American Society of Anesthesiologists (ASA) 1–3 patients scheduled for TKA were randomised in two groups. We applied our standard anaesthetic protocol of fast-track surgery: spinal anaesthesia with hyperbaric bupivacaine; antibiotics, 120 mg methylprednisolone and 1 g tranexamic acid perfusion before incision; periarticular surgical infiltration of 400 mg of ropivacaine with 2.5 µg/mL adrenaline. Postoperatively, every patient received paracetamol QID and celecoxib once a day. Patients in control group O received 10 mg long-acting oral oxycodone BID: in case of VAS pain >3, 5 mg oxycodone was given up to four times a day. Patients in S group received sufentanil sublingual tablet system (SSTS) for auto-administration of a 15 µg tablet with 20 minutes lock-out. Every 6 hours, for the first 48 postoperative hours, we measured static and dynamic VAS and occurrence of nausea, vomiting and pruritus. Patient satisfaction with pain management was recorded at 24 and 48 hours.

Results

In total, 72 patients were enrolled and 66 completed the 48-h follow-up. Twenty-four hours after intervention, no significant difference has been shown between patients treated with oxycodone and those treated with sufentanil, neither for pain at rest or after movement. At 48 hours for VAS scores, we can see a tendency in favour of sufentanil (p-value statistic VAS 0.003, dynamic VAS 0.019) but not statistically significant. In terms of adverse effects, we did not find any significant difference in both study groups. These secondary effects have been uncommon during the 48-hour follow-up. Similarly no significant difference in terms of postoperative mobilisation has been shown. Patient satisfaction with analgesic method has been evaluated: no significant statistical difference has been shown between groups after 24 hours; on the other hand, a difference has been outlined after 48 hours, with a significant proportion of patients treated with sufentanil who rated as ‘excellent’ in comparison with control group.

Conclusion

Oral sufentanil for treating postoperative pain after TKA may be considered an efficient analgesic but with no significant improvement in pain scores in comparison with oxycodone 24 hours after surgery. In terms of adverse effects, no significant difference between the new analgesic method and oxycodone has been shown. As for patient satisfaction, 24 hours after surgery, the two methods are considered globally good, without any significant difference; sufentanil has registered better satisfaction scores at 48 hours.

2

PATIENT SATISFACTION WITH PAIN RELIEF FOLLOWING MAJOR ABDOMINAL SURGERY RELIES UPON GOOD COMMUNICATION, PAIN RELIEF AND EMPATHIC CARING: A QUALITATIVE INTERVIEW STUDY

Category: Acute Pain

Womba Musumadi Mubita – Research and Innovation, Manchester University NHS Foundation Trust, Cliff Richardson – Division of Nursing, Midwifery and Social Work, University of Manchester, Michelle Briggs – Division of Nursing, Midwifery and Social Work, University of Manchester

Background

Monitoring and improving the quality of care is an increasing concern for health care organisations. National Health Service (NHS) organisations in the United Kingdom are required to measure the effectiveness of clinical outcomes in order to identify factors that will improve the quality of care (Raleigh and Foot, 2010). Pain management is one of the markers of high-quality care, but despite the introduction of different pain improvement programmes such as the use of multimodal analgesia through different administration routes, pain management is still suboptimal in many places. Studies in cancer care and emergency departments have revealed that factors such as physician communication, responsiveness to pain severity, improved use of analgesia, empathy and patient’s beliefs and attitudes contribute to patient satisfaction (Martinez et al., 2015; Rosenberg et al., 2016; Savvas and Gibson, 2015). However, literature on the meaning that underlies patient judgements about satisfaction with post-operative pain management is limited.

Aims

(1) To describe patient expectations related to the experience of pain and (2) to explore the meaning that underlies patient judgements about satisfaction with post-operative pain management.

Methods

The study was a qualitative research study using phenomenological approach. Patients undergoing major abdominal surgery were recruited from a Renal Transplant and Urology unit in the North of England, UK. Patient population consisted of patients who have undergone the following procedures: kidney and pancreas transplant, nephrectomy, open radical prostatectomy and cystectomy. A total of 10 participants took part in face-to-face semi-structured interviews. Data collection and analysis ran concurrently to allow for the exploration of the key themes and to judge when data saturation occurred. All interviews were audio recorded and data were analysed using Colaizzi’s approach in order to provide an opportunity to return to the participants for validation of the results. Transcripts were sent to the participants allowing them to read through the data and analyses, providing the researcher with a method of checking for inconsistencies and providing them with an opportunity to re-analyse their data.

Results

Three themes emerged: being informed, managing the pain and empathic caring. The results reported inconsistency in the delivery of information during the pre- and the post-operative period. Some patients reported a lack of information or inability to receive information at the right time which had an effect on their ability to use the patient-controlled analgesia (PCA) effectively. However, some still reported to have received adequate information and were satisfied with the information they received. Information delivery came from various sources. Some patients claimed to have received more detailed information from fellow patients on how to use the PCA effective in order to achieve adequate pain relief. The study also revealed that the administration of analgesia through PCA was effective when patients were able to use it properly and the nurses cared with compassion and empathy, and this contributed to patient’s satisfaction with pain management.

Conclusion

Overall, participants expressed high satisfaction levels because their pain was well controlled and the nurses responded to them with an empathetic and caring attitude. Our study has revealed that in order to achieve satisfaction with the management of post-operative pain, a holistic approach should include timely and adequate information delivery, nurses should have a caring attitude and pain should be well controlled.

3

DOCTORS (NON-ANAESTHETISTS) KNOWLEDGE ON POSTOPERATIVE PAIN: A SURVEY

Category: Acute Pain

Rachel Bloomfield – Anaesthesia and Pain Medicine, North Manchester General Hospital, Northern Care Alliance NHS Group, Manchester, Vinod Gadiyar – Anaesthesia and Pain Medicine, North Manchester General Hospital, Northern Care Alliance NHS Group, Manchester

Background

Acute pain is defined as pain of recent onset, of limited duration and usually related to a pathological process, disease or injury. Of people who undergo surgery, almost 60% experience severe pain in the post-operative period. As well as reducing pain, effective acute post-operative pain control contributes to recovery and rehabilitation and prevents progression from acute to chronic pain (1). Knowledge of how to treat post-operative pain is important for anaesthetists and non-anaesthetists such as surgeons and medical doctors who have to treat these patients in the ward. To our knowledge, there are not many studies looking at this aspect.

Aims

Our goal was to determine the basic knowledge of post-operative pain management among doctors other than anaesthetists.

Methods

We devised a questionnaire with 22 multiple-choice questions which covered various areas of post-operative pain management. These were distributed on an ad hoc basis to 50 doctors of varying grades and specialities. Specialities included general surgery, ENT, maxillofacial surgery, paediatrics and emergency medicine. Doctors grades FY1s up to consultants were included. Questionnaire was filled on the spot. Participants observed completing questionnaire to prevent conferring or cheating.

Results

Out of the 50 doctors, there were 10 FY1, 6 FY2, 11 CT1-2, 8 ST3-7, 6 SAS doctors and 11 consultants. Average score for the whole group was 14.5 out of 22. Maximum score by a consultant was 20 and minimum was 6 by an SAS doctor. Average score for each category was 13.3 for FY1, 12.6 for FY2, 15.2 for CT1-2, 16 for ST3-7, 12.1 for SAS and 15.5 for consultants. Some of the questions and answers included as follows. For morphine has longer half-life than naloxone, 84% answered correctly. For rectal diclofenac does not cause gastric irritation, 66% answered correctly. 92% got the dose of paracetamol right. Only 24% of doctors thought oxygen should be given to patients on patient-controlled analgesia (PCA).

Conclusion

This survey shows that the doctors vary greatly in their knowledge on managing patients with post-operative pain. We found that CT, ST Doctors and consultants scored better than other groups of doctors. This could be due to their experience. We find that there is still a gap in the knowledge on post-operative pain management among doctors, and this can be addressed with education of these doctors.

4

IDENTIFYING PRE-OPERATIVE RISK FACTORS OF DEVELOPING POST-OPERATIVE PAIN IN PATIENTS ATTENDING FOR ELECTIVE JOINT REPLACEMENT

Category: Acute Pain

Martin Galligan – Acute Pain Service, Homerton University Hospital NHS Foundation Trust

Background

Joint replacement is one of the most common operations performed in the United Kingdom (Wylde et al., 2017). It is estimated that 58% of patients following total knee replacement and 47% of patients following total hip replacement will report moderate to severe pain that is poorly controlled (Wylde et al., 2010). This high incidence of pain is the main factor limiting early mobilisation in the immediate post-operative setting (Hovik et al., 2016). In order for us to improve on post-operative pain, control assessment must begin in the pre-operative setting (IASP, 2016). If patients at risk of developing pain in the post-operative setting are identified pre-operatively, this will allow for a robust management plan to be put in place. Predictors of post-operative pain in the pre-operative setting include severe pain and catastrophising (IASP, 2016).

Aims

To identify pre-operative risk factors for developing post-operative pain.

Methods

All patients attending joint school were invited to complete a series of self-administered questionnaires over a period of 2 months. The questionnaire consisted of three validated pain assessment tools: Brief Pain Inventory, The Leeds Neuropathic Pain Assessment Tool and a Pain Catastrophising scale. Basic demographic information including sex and age was also collected. Additional audit tool was used to collect data regarding peri-operative analgesia, post-operative analgesic prescribing in relation to enhanced recovery pathway, adverse effects from analgesia and post-operative pain scores. Total opioid consumption was collected and converted to oral morphine equivalent to allow for easier comparison.

Results

In total, 40/50 questionnaires were completed with the remaining 10 being discarded as data collection had gone over a period of 6 months. In the pre-operative assessment, 20 patients reported a pain score >7/10 indicating severe pain, 17 reported neuropathic symptoms and 15 were identified as catastrophisers. A total of 11 patients scored highly in all three risk groups. Those who had all three risk factors reported pain scores 2 points higher on day 1 post op and 1 point higher on day of discharge when compared with patients who had no risk factors. They also required significantly higher opioid requirements during their admission (172.5 vs 99.28 mg).

Conclusion

There is a clear link between pre-operative risk factors and increased post-operative pain and opioid consumption. Through identification of at-risk patients in the pre-operative environment, additional pain management methods could be identified. This should adopt a biopsychosocial model given the impact of catastrophising has on opioid requirements post-op.

5

ABDOMINAL WALL RECONSTRUCTION: A REVIEW OF ANAESTHETIC TECHNIQUES IN OUR DEPARTMENT AND DEVELOPMENT OF A STANDARD OPERATING PROCEDURE

Category: Acute Pain

Laura McNulty – Anaesthetics, St George’s Hospital, London, Aasifa Tredray – Anaesthetics, St George’s Hospital, London, Jerry Cashman – Anaesthetics and Acute Pain, St George’s Hospital, London, Lenny Ng – Anaesthetics, St George’s Hospital, London, Mehnaz Khan – Anaesthetics, St George’s Hospital, London

Background

Abdominal wall reconstruction is a complex elective surgical procedure, often involving both plastic and general expertise. It is commonly required to restore abdominal wall integrity after previous major surgery. These hernias and defects commonly cause pain and discomfort and not infrequently patients are managed on chronic pain medication. The restorative operative procedure is lengthy, often requires critical care post-operatively and may be associated with significant pain unless it is adequately and multi-modally managed. In our centre, we commonly use either spinal analgesia or a regional anaesthetic technique to ameliorate the patient’s recovery. This patient cohort is managed intensively by a multidisciplinary team including anaesthetists, surgeons and the inpatient pain team, and all members of this team were integral in delivering this quality improvement project.

Aims

Having explored a number of regional techniques in our centre, our aim was to retrospectively assess the effect of intraoperative regional anaesthetic technique on post-operative outcomes, including pain scores, opioid consumption and critical care stay. We hoped to quantitatively support our hypothesis that intrathecal diamorphine is the superior analgesic.

Methods

We developed an anonymised spreadsheet allowing us to collate both retrospective data and to input future patients. In this we collated patient demographics, surgical time, analgesic techniques, critical care stay and number of bed days. Also, importantly, we quantified pain by documenting pain scores and opioid consumption.

Results

We established that the four main intraoperative analgesic modalities were intrathecal diamorphine, erector spinae blocks (ESP), quadrates lumborum blocks (QLB) or IV analgesia alone. In total, 15 sets of notes were available for review. Patients ranged in age from 26 to 85 and surgery averaged at 275 minutes. Analgesic techniques were reviewed and just under 50% had spinal anaesthesia with diamorphine (in combination with a general anaesthetic). Twenty percent had ESP blocks with only one patient having a QLB. The remaining four patients had IV opioids only. Of note, there were a number of cases where spinal analgesia was recommended but declined by the patient. The most striking result noted was that average post-operative opioid consumption was significantly lower in the spinal analgesia group compared to other modalities. However, there was no improvement in post-operative pain scores or reduction in overall hospital length of stay (LOS) in the spinal group when compared to other techniques.

Conclusion

We conclude that intrathecal diamorphine demonstrates a reduction in opioid consumption as evidenced by our data. Even though there is no other strong evidence in our results to support its use, our perioperative experience also causes us to believe that spinal diamorphine is a superior analgesic compared to ESP and QL blocks. Based on this project and our clinical experience, we have written a trust standard operating procedure. In this we advocate spinal diamorphine as a first-line analgesic, but suggest an IV lidocaine infusion where spinal anaesthesia is contraindicated or unachievable.

6

EPIDURAL ANALGESIA, A THING OF THE PAST?

Category: Acute Pain

Katharine Wall – Pain Management Service, The London Clinic

Background

Epidural analgesia is a highly effective technique for controlling acute pain after surgery or trauma. It has the potential to provide pain relief with minimal side effects compared with other methods of analgesia. However, it can also cause serious complications, therefore safe and effective management is vital. Epidural analgesia is on the decline within our organisation by 50% over the last 3 years and subsequently it is challenging to maintain staff knowledge and competencies in order to provide a safe and effective epidural service to patients. In order to assess compliance to policy and efficacy of the epidural infusions being carried out, a 3-month prospective audit was completed, while a health–economics study comparing epidural analgesia with local anaesthetic infiltration/transversus abdominis plane (TAP) block ran consecutively.

Aims

To review the current epidural analgesia service at the organisation, in light of other techniques being introduced. Is the epidural service still robust and effective? Is the practice safe and is adherence to policy 100%? Is the education provided adequate? Do the patients feel satisfied by the service?

Methods

A prospective audit of the epidural service was carried out by the Pain Management Nurse Specialists. The audit looked at compliance to local policy and national standards, rate of complications, quality of record keeping and patient satisfaction. Data were collected over a 3-month period. All patients went to high-dependency unit (HDU)/intensive care unit (ICU) for at least 12 hours initially post-operatively.

Results

Twenty-five patients’ data were collected and none were excluded from the analysis. The most common complication was motor block (32%), followed by pain scores (32%) of more than 4 out of 10. Nine patients (36%) required at least one bolus dose. The average length of infusion was 84 hours. Only 4 patients reported no complications, 10 patients experienced one complication and 11 patients experienced two or more complications. Only one serious complication was noted, a superficial abscess, which resolved with no sensory or motor deficits. All patients had an indwelling urinary catheter in situ prophylactically. Documentation of consent and site of insertion (including cm markings) was 60% and 92%, respectively. Documentation by nursing staff (time discontinued; two signatures for all medication changes; observations) ranged from 84% to 86%. Only four patients were unsatisfied with the service; they all experienced pain or unsatisfactory block.

Conclusion

Overall, a safe and effective epidural analgesia service is provided. There is room for improvement around compliance to policy, regarding documentation and consent; however, 84% of patients were satisfied with this method of pain management. Only 20% of the infusions were discontinued prior to the planned time; one fell out and the others converted to patient-controlled analgesia (PCA) for pain management. Only one serious complication was recorded, and all other complications were escalated and managed appropriately. The action plan in place is to re-audit and aim for 100% compliance in all areas. The mandatory teaching programme has been peer reviewed and continues.

7

SEVERITY OF PAIN, DISABILITY AND DEPRESSION AT THE TIME OF REFERRAL TO UNITED KINGDOM SPECIALIST NATIONAL PAIN SERVICE: HOW MEASURES DIFFER BETWEEN LOCALISED AND NON-LOCALISED CHRONIC PELVIC PAIN

Category: Assessment & Measurement

Terrance Ramrattan – Pain Management, University College London Hospital, Julia Cambitzi – Pain Management, University College London Hospital, Moein Tavakkoli – Pain Management, University College London Hospital, Roman Cregg – Pain Management, University College London Hospital, Andrew Paul Baranowski – Pain Management, University College London Hospital

Background

Abdominopelvic pain (APP) is associated with negative emotional, behavioural, cognitive and sexual consequences. This group shows increased levels of depression, anxiety, catastrophising, reduced functioning and self-efficacy. Patients with APP feel that they are not heard and as a result, they repetitively consult GPs, A + E and other specialities resulting in increased healthcare utilisation and subsequent interventions. A diagnosis is essential in pelvic pain to help patients understand their symptoms and prepare the way for treatment and acceptance of their pain. APP is diagnosed according to the European Association of Urology Guidelines (EUA) on Chronic Pelvic Pain (CPP). Axis One of the EAU classification lists two broad diagnosis: (1) CPP and (2) specific disease-associated pelvic pain or pelvic pain syndrome. As it is documented that people with widespread pain experience higher psychosocial disability than those with localised or regional pain, we aimed to compare the above two groups.

Aims

(1) To determine if self-efficacy, catastrophising, depression, anxiety, positive outlook, pain and pain interference differ between chronic pelvic pain (G1) and specific disease-associated pelvic pain or pelvic pain syndrome (G2); (2) to describe utilisation of healthcare prior to attending a specialised pelvic pain service.

Methods

All patients attending the pain management centre with abdominopelvic pain were asked to complete self-reported questionnaires. Data were collected between December 2013 and December 2018. Patients who did not speak English were offered an interpreter. The questionnaires applied were Pain Self-Efficacy Questionnaire (PSEQ), Pain Catastrophising Scale (PCS), Depression, Anxiety, Positive Outlook Scale (DAPOS) and Brief Pain Inventory (BPI), and data were also collected on healthcare usage. Patients were split into two groups according to axis One of the EAU classification, CPP (Group 1) and specific disease-associated pain or pelvic pain syndromes (Group 2). Using Excel, a two-tailed unpaired t-test was applied between these two groups G1 and G2. Level of significance was p = 0.05.

Results

N = 1873 patients seen. N = 1332 completed questionnaires. Age range 16–89 years (mean 45). N = 424 male (28%), N = 1064 female (72%). N = 1252 (84%) Caucasian. BPI: G1(25.4 ± 0.49 SEM) > G2(22.2 ± 0.33) p < 0.0001. BPI Interference: G1(6.50 ± 0.15 SEM) > G2(4.7 ± 0.09) p < 0.0001. PSEQ: G1(16.9 ± 0.9 SEM) < G2(24.6 ± 0.6) p < 0.0001. PCS: G1(31.6 ± 0.8 SEM) > G2(29.2 ± 0.47) p < 0.0003. DAPOS D: G1(13.7 ± 0.36) > G2(11.9 ± 0.21) p < 0.0001. DAPOS A: G1(8.38 ± 0.27 SEM) > G2(7.33 ± 0.13) p < 0.0001. DAPOS PO: G1(8.56 ± 0.19) < G2(8.94 ± 0.11) p = 0.02. N = 279 GP attendances within last 3 months. 63% (n = 177) > 5 attendances. 36% (n = 102) > . 10 attendances. N = 300 hospital appointments for pain within last 6 months. 62% (n = 187) > 5 consultations. 37% (n = 113) > 10 consultations. N = 69 attended A + E for pain within last 6 months. 66% (n = 46) > 5 attendances. 33% (n = 23) > 10 attendances.

Conclusion

We observed a statistically significant decrease in self-efficacy and positive outlook with increased number of sites where pain is perceived and a statistically significant increase in catastrophising, anxiety, pain perception and pain interference with increased number of sites where pain is perceived. Our data appear to support the current classification system by axis when it comes to collecting and pooling patient-reported outcome measures used in our institution. These data support the mandatory need for multidisciplinary team management for these patients.

8

SURVEY OF PAIN CLINIC ORGANISATION IN LONDON TEACHING HOSPITALS

Category: Audit and Service Evaluation

Nivan Loganathan – Pain Medicine, Barts Health NHS Trust, Ivan Wong – Pain Medicine, Barts Health NHS Trust, Vivek Mehta – Pain Medicine, Barts Health NHS Trust

Background

The organisation of pain clinics, including consultation time for outpatients, and number of scheduled patients for interventional procedures can vary between pain centres. There is very limited published data on actual services provided, although there is guidance from the college (1). The number of patients seen at a clinic session is crucial in determining the quality of medical care output (2). Striking a balance between these two will ensure good medical practice is delivered consistently. The variability of these timings and provision of clinical services has not been benchmarked at regional/national level.

Aims

A survey to gather data on the organisation of pain clinics and benchmark our clinical activity at a national level.

Methods

We developed a simple online questionnaire with tick-boxes and drop-down menus for ease of completion. The online questionnaire was sent to fellow advanced pain trainees at London Teaching Hospitals via an email link. The questionnaire included topics on clinic funding background, consultation times and number of patients seen in a half-day session.

Results

Out of six respondents, only one department was within the anaesthetics directorate. Three hospitals came under the purview of neuroscience departments and two others under the musculoskeletal departments. There was a variation between the clinic consultation times with one centre, Pain-Clinic-B, having the shortest new-patient and follow-up consultation times, which are 20 and 10 minutes, respectively. Five other respondents had an average of 39.2 minutes for new-patient consult time. The follow-up patients at the other centres had a longest consult of 20 minutes, while the shortest consult time and mode time was 15 minutes. Pain-Clinic-B also saw the most number of patients in a half-day session, 10 patients, compared to the other centres which has a mean of 7.4 (i.e. seven patients per session).

Conclusion

This provides a good snapshot of current organisation of pain clinics in the region. We aim to build on this survey at a national level to have a better understanding of the services and benchmark our clinical activity. Pain centres funded by non-anaesthetic departments are given plenty of time by the administrators for all types of consults. This has impact on maximum patients seen at one session, that is, 30% less compared to Pain-Clinic-B. Whether this has any strain on the deliverance of service and longer lead times are questions which should be addressed with further research.

9

AUDIT OF THE EFFECTIVENESS OF TENS IN A MILITARY PAIN SETTING

Category: Audit and Service Evaluation

Jon Norman – Rehabilitation Division, Defence Medical Rehabilitation Centre, Sarah Lewis – Nursing Division, Defence Medical Rehabilitation Centre, Christine Morrison – Nursing Division, Defence Medical Rehabilitation Centre, Meslissa Mabbett – Nursing Division, Defence Medical Rehabilitation Centre

Background

Transcutaneous electrical nerve stimulation or ‘TENS’ is commonly used by chronic pain patients often on the recommendation of clinicians. Evidence for effectiveness or otherwise of TENS in chronic pain conditions is lacking. As a result guidelines such as the NICE Low back pain and sciatica in over 16 years: assessment and management state that clinicians should ‘not offer transcutaneous electrical nerve simulation (TENS) for managing low back pain with or without sciatica’. We work in a tertiary military rehabilitation centre seeing patients who are struggling with functionally limiting pain affecting their ability to perform their designated role. The patients are in the main young males and have failed several treatment modalities prior to referral. We are able to offer TENS treatment to selected patients in this group. We conducted an audit to look at whether TENS is an effective treatment in these patients.

Aims

To measure the response rate for patients self-treating with TENS in a military setting. Secondarily to measure the level of pain relief in those who respond and whether this is associated with improvements with sleep and function.

Methods

A 6-month audit was conducted between January and July 2018. Any patient who had TENS treatment recommended as a treatment option and who went on to a trial of TENS was included. Assessment was by face-to-face interview or by telephone review. The area where TENS was used was recorded as well as whether TENS reduced the target pain and by how much. Frequency of use was recorded as well as any associated improvement of function and sleep.

Results

A total of 37 patients used TENS during the 6-month period. Data were obtained for 35 patients. The area of the body where patients used TENS were low back 27, upper spine and shoulders 5, hip/groin 2 and foot 1. The overall patient response rate of at least 30% pain reduction was 16 patients (46%) with a range of 30–90% for pain relief. Four patients did not respond, and the remaining 15 patients responded but the effect was less than 30%. Eleven patients with low back pain responded (41%). Nine patients reported improvement in function and eight patients reported improvement in sleep although with two exceptions (with increase in function of above 50%) these benefits were modest usually between 10% and 20%. At the end of the audit period, 20 patients were still using TENS daily, 9 were using TENS several times per week and 6 had discontinued TENS treatment.

Conclusion

This audit appears to demonstrate the TENS is a simple, easy therapy that patients are happy to try. TENS provided significant pain relief for nearly half of patients and enough pain relief such that five-sixths of patients chose to continue with TENS beyond this audit period. However, benefit in function and sleep occurs only in around a quarter of patients and the effect size here is generally modest. No patients reported problems or complications while using TENS. We conclude that TENS is a cheap, safe and modestly useful adjuvant in the military population suffering from chronic pain.

10

GABAPENTINOIDS AND HIGH-DOSE OPIOIDS FOR CHRONIC NON-MALIGNANT PAIN: A POTENTIALLY INEFFECTIVE AND DANGEROUS COCKTAIL?

Category: Audit and Service Evaluation

Jennifer Noyes – Pain Management Unit, Royal Victoria Infirmary, Sailesh Mishra – Pain Management Unit, Royal Victoria Infirmary

Background

Gabapentinoids are a mainstay of treatment for neuropathic pain within chronic non-cancer pain. However, in 2016 the IASP changed its definition of neuropathic pain, and therefore, its use for conditions such as back pain is now questioned. There is additional concern regarding the increased rate of prescription of gabapentinoids potentially mirroring the opioid crisis. The prescription use of gabapentin has increased by 350% and that of pregabalin by 150% in the last 5 years. Furthermore, there is new evidence which suggests co-prescription of moderate or high-dose gabapentin with opioids is associated with an increased risk of opioid-related deaths. Gabapentinoids should therefore be used with caution when co-prescribed with opioids and discontinued when found ineffective at medication review.

Aims

This review was conducted to evaluate indications for patients taking gabapentinoids when they are referred to our Pain Management Unit. Secondarily, to assess the cohort of patients who were co-prescribed high-dose opioids along with gabapentinoids as this poses a much greater risk of opioid-related death.

Methods

We analysed clinic letters from pain consultants over a 16-week period, from 30 July to 16 November 2018. Patients who had previously been seen in any pain unit were excluded from the review. We examined the medications of all the new referrals to ascertain how many of them were already prescribed gabapentinoids with their dosing schedule at the time of the referral. Patients, who were co-prescribed opioid medications, also had their dosing regimen documented. Oral morphine equivalent (OME) was calculated using the Royal College of Anaesthetists Faculty of Pain Medicine conversion table. High-dose OME was defined as >120 mg. Total daily gabapentin dose of <900 mg was recorded as low, 900–1800 mg was moderate and >1800 mg was high. Similarly, total daily pregabalin dose of <200 mg was recorded as low, 200–300 mg was moderate and >300 mg was high for the purpose of this review.

Results

There were 83 new patients seen in the pain clinic during this period who were taking a gabapentinoid prior to referral. One patient with malignant cancer pain was excluded from analysis. Another 10 patients were excluded due to non-record of the dose of gabapentinoid. Finally, prescription patterns of the remaining 72 patients were analysed in further detail. Only 18 of the 72 patients (25.0%) were prescribed gabapentinoids for a robust neuropathic pain indication. The rest, 75.0%, were prescribed gabapentinoids for non-evidenced diagnoses, the majority being back pain with or without radiculopathy. Alarmingly, 8 of the 72 patients (11.1%) were co-prescribed an intermediate (4/72) to high-dose (4/72) gabapentinoid with a high dose of opioid, which carries an increased risk of death. Only one of these eight patients had an appropriate neuropathic pain diagnosis for the prescription of a gabapentinoid. The highest OME was 470 mg co-prescribed with 2700 mg gabapentin.

Conclusion

There is a concerning pattern of complex pain patients being co-prescribed potentially life-threatening combinations of high-dose opioids and gabapentinoids within primary care. Early referral of these complex patients to pain management units is strongly recommended prior to escalation of dose of the medications. There is a need for clearer guidance to be available regarding the initiation, escalation and if not clinically effective, subsequent discontinuation of gabapentinoids for primary care physicians.

11

IS PATIENT AGE A PREDICTIVE FACTOR OF LIKELY OUTCOME FOLLOWING LUMBAR FACET DENERVATION PROCEDURE, IN THE MANAGEMENT OF CHRONIC LOW BACK PAIN (CLBP)?

Category: Audit and Service Evaluation

Nicola Bailey – Chronic Pain Management Service, NHS Highland, John Macleod – Chronic Pain Management Service, NHS Highland

Background

Lumbar radiofrequency denervation procedure of the lumbar facet joints is a treatment that is used in management of chronic low back pain (CLBP) in various Chronic Pain Management services across Scotland as part of the holistic management of chronic mechanical back pain, in well-selected patients. It is unclear if there are specific predictive factors that may help identify which patients groups will most likely have excellent/moderate or poor outcome following this procedure. Across NHS Highland (NHSH), there is a large population of CLBP patients referred to our Chronic Pain service, which are assessed to determine if they may benefit from lumbar facet joint radiofrequency denervation, as part of their management. However, there is very limited research available to suggest which patient factors, including age, are most predictive of excellent, good or poor outcome, following lumbar facet joint denervation procedure, in group of well-selected chronic back pain patients.

Aims

This clinical audit aimed to explore patient outcome (including % pain improvement, number of month’s improvement, sleep, and medication use and activity levels and function) up to 6 months, following lumbar radio frequency denervation procedure, and whether age could be predictive of outcome, for CLBP patients managed within NHSH.

Methods

A total of 77 current CLBP patients, deemed suitable for lumbar denervation, being managed under NHSH Chronic pain management service, following radiofrequency lumbar denervation procedure carried out by a Pain Consultant in NHSH, between dates 2017 and 2018, were purposively selected. Each patient selected was chosen for procedure based on clinical decision making that mechanical facet joint disease may be a factor in the CLBP, by either pain Consultant or Lead physiotherapists based on clinical history, examination and imaging. All patients selected first had positive medial branch blocks, history of chronic back pain >6 months. Each patient was telephoned by a physiotherapist, 6 months post lumbar denervation procedure and demographic data for each patient was recorded on an excel spread sheet including their age, sex, pain pattern, % improvement pain, number of months benefit, improvement in sleep yes/no, medication reduction (yes/ no), function and activity.

Results

77 patients, age range, 33–87; mean average age of group, 53.5; excellent outcome (54.5%), moderate outcome (21%) and poor outcome (24.6%); 30 males; 47 females; and no predictive pattern with age identified. Excellent outcome: 42 patients (54.5%) had an excellent outcome following denervation procedure, with 70% or more reduction in CLBP for 6 months or more, had improved sleep, function/activity and reduction in medication use, during this time. Mean age of patients within excellent outcome, 56.36; Median, 54–55; actual ages: range (36–87). Moderate outcome: 16 patients (21%) had moderate outcome following procedure of 50–100% reduction of CLBP or 2–5 months or 50–69% reduction of pain >6 months. Mean age, 54.62; median age, 48–53; actual ages (range, 33-85). Poor outcome: 19 patients (24.6%) had poor outcome following procedure with 0–100% reduction of pain, for 0–2 months. Mean age, 49.57; median age, 44; ages (range, 32–84).

Conclusion

Lumbar radiofrequency denervation procedure is a treatment that has an excellent outcome for approximately 54.5% of CLBP patients for 6 months or more, in a group of 77 patients audited. However, 24.6% of these patients had poor outcome. The data did not clearly establish if patient age is a predictive factor of outcome; all age groups were found in excellent, moderate and poor categories and patient selection for this procedure should be based on in-depth clinical reasoning/selection.

12

EVALUATING OPIOID PRESCRIBING PRACTICE WITHIN A PRIMARY CARE CHRONIC PAIN SERVICE

Category: Audit and Service Evaluation

Kristiina Vassilevskaja – Pain Service, Homerton University Hospital NHS Foundation Trust, Martin Galligan – Acute Pain, Homerton University Hospital NHS Foundation Trust, Melanie Rendall – Pain Service, Homerton University Hospital NHS Foundation Trust

Background

Opioids have been used widely in patients with chronic non-cancer pain with prescribing trends suggesting a continuous increase in opioid utilisation, despite the concerns over their long-term use and effectiveness. Prolonged use of strong opioid analgesia is associated with dependence, opioid-induced hyperalgesia and opioid-related mortality. As a result, there has been a shift towards reversing this trend on both national and local levels although variations in opioid prescribing patterns still exist across the United Kingdom. As a community psychosocial led pain management service, our main aim is to support patients with getting back to their valued activities through either group based or individual interventions as provided by the multidisciplinary team. For a proportion of patients, this involves medication review. Until recently, there has not been any data examining prescribing trends within the service; given recent trends in opioid prescribing nationwide, there was a need to evaluate current practice within our service.

Aims

The aim of this study was to review prescribing patterns among the pain consultants and non-medical prescribers among the patients seen within the 3-month period between September and November 2018.

Methods

A prospective analysis of patients attending pain consultant clinic and non-medical prescriber’s medication review clinic was performed over a 3-month period. Information regarding analgesia at time of review and alterations to doses was collected and analysed. The non-medical prescribers included an extended scope physiotherapist, specialist pain nurse and a senior pharmacist. All opioids were grouped into the Step 2 and Step 3 opioids in accordance with the analgesic ladder as outlined by the World Health Organization (WHO). Only controlled drug analgesia doses were reviewed in this audit including tramadol, buprenorphine, fentanyl, oxycodone and morphine preparations. All new and follow-up patients were included. During each consultation, baseline information on the patient’s current medication was recorded on the Excel spreadsheet along with any details of the medication change.

Results

A total of 217 patients attended for a medication review over the 3-month period, the majority were new patients with the remainder follow-ups. A total of 100 patients were reviewed by a pain consultant and the remaining 117 were reviewed by a non-medical prescriber; 131 patients were already receiving step 2 and 3 analgesia at the time of review; step 1 analgesia was discounted and neuropathic agents were reviewed as part of a separate audit. Further analysis revealed that 50 patients were already receiving a controlled drug prior to first appointment. Following a review of their controlled drug analgesia, six patients had a dose reduction with an additional two patients having their analgesia discontinued. A further three patients had a dose increase; however, this was only patients receiving tramadol. Only two patients had new analgesia started, in the form of buprenorphine patch with the remaining patients having no changes made.

Conclusion

While only a small proportion of patients had a reduction in opioid analgesia, the majority of patients captured were first appointments and the length of time of data collection would not allow for a meaningful reduction in analgesia. Overall, the results demonstrate a shift away from opioid dose escalation and closer monitoring of opioid use. As the service is underpinned by the biopsychosocial model, the focus remains on multidisciplinary management. The complex nature of chronic pain and difficulties of implementing a dose reduction regime are recognised and ongoing auditing will be used alongside consideration of multidisciplinary interventions for opioid reduction.

13

NURSE-LED POST PAIN INTERVENTION CLINIC OUTCOME DATA

Category: Audit and Service Evaluation

Athina Karavasopoulou – Pain Clinic, Barts Health NHS Trust, Charlotte Guest – Pain Clinic, Barts Health NHS Trust, Kirstie Emmerson – Pain Clinic, Barts Health NHS Trust, Helen Bonar – Pain Clinic, Barts Health NHS Trust, Mirja Shaw – Pain Clinic, Barts Health NHS Trust, Lorena Warde – Pain Clinic, Barts Health NHS Trust, Hanna Kotas – Pain Clinic, Barts Health NHS Trust, Charis Napier – Pain Clinic, Barts Health NHS Trust, Kristin Ullrich – Anaesthetics and Pain Management, Barts Health NHS Trust

Background

Clinical nurse specialists (CNS) working in pain management at a Central London teaching hospital perform regular nurse-led outpatient clinics. These outpatient clinics involve assessing chronic pain patients following their pain intervention either face-to-face or on the telephone. The default appointment is telephone-based; however, patients suffering communication difficulties are scheduled a face-to-face appointment instead. The interventions frequently performed in our day surgery unit include facet joint injections (FJI), caudal epidurals, transforaminal epidural injections (TFE), sacroiliac joint injections (SIJ), trigger point injections (TPI), lidocaine infusions, and pulsed radiofrequency (PRF) and denervation (RF) procedures. The benefits of CNS conducting follow-up clinics is well known which includes improved patient satisfaction (1), cost-effectiveness and reduced waiting times (2,3); however, the effectiveness of the different pain interventions including repeat interventions in our Trust has not been systematically reviewed.

Aims

To review current patient outcomes of commonly performed pain interventions at a Central London teaching hospital.

Methods

After gaining Trust approval, prospective data collection took place for a year (August 2017–August 2018) at one central London hospital. The sample included adult patients suffering persistent pain who had undergone a pain intervention treatment and were subsequently scheduled a nurse-led outpatient follow-up appointment (either face-to-face or by telephone). Data collection was performed by the CNS during the routine outpatient follow-up appointment. Data included patient demographics, presenting pain complaint, date and type of pain intervention, waiting times from pain intervention to nurse-led follow-up appointment, date of follow-up appointment, outcome of pain intervention (0% = no pain reduction and 100% = complete pain reduction), and duration of benefit (if applicable). The data were subsequently analysed by the CNS.

Results

The CNS reviewed 600 patients during this time period of which 72% (n = 431) were telephone versus 28% (n = 169) face-to-face. These took place 1 month up to 1 year following their procedure. Interventions performed included FJI (51%), caudal (28%), TFE (12%), SIJ (6%), lidocaine infusions (5.5%), RF (7%) and TPI (8.5%). Thirty-five percent (n = 211) underwent more than one procedure and more than half (58%) were repeat interventions. The majority of patients were treated for low back (± lower limb) pain (65%), 15% for neck/shoulder pain and 6% for widespread pain/fibromyalgia. Seventy percent of the patients experienced a decrease in their pain following their intervention with 50% stating more than 50% reduction in their pain. Furthermore, 20% stated their pain remained the same and 5.8% experienced an increase in their pain. For FJI, SIJ, caudal epidurals and TFE, approximately 50% of patients experienced up to 3 months pain relief.

Conclusion

Surprisingly, the waiting times for a nurse-led follow-up appointment following a pain intervention varied widely, from 1 month up to 1 year. The reasons for these waiting times may be patient cancellations and scheduling errors. Current practice shows the most common pain intervention performed is FJI which is in line with the most reported pain presentation being low back (± lower limb) pain. A multimodal pain management approach is always required when treating chronic pain. Following analysis of the results, the outpatient pain service will review the number of interventions performed.

14

REVIEW OF THE CURRENT ANALGESIC PRACTICE FOLLOWING EXTENDED/RADICAL PLEURECTOMY AND DECORTICATION FOR THE TREATMENT OF MALIGNANT MESOTHELIOMA IN A CENTRAL LONDON CARDIOTHORACIC HOSPITAL

Category: Audit and Service Evaluation

Athina Karavasopoulou – Pain Clinic, Barts Health NHS Trust, Charlotte Guest – Pain Clinic, Barts Health NHS Trust, Kirstie Emmerson – Pain Clinic, Barts Health NHS Trust, Helen Bonar – Pain Clinic, Barts Health NHS Trust, Mirja Shaw – Pain Clinic, Barts Health NHS Trust, Lorena Warde – Pain Clinic, Barts Health NHS Trust, Hanna Kotas – Pain Clinic, Barts Health NHS Trust, Charis Napier – Pain Clinic, Barts Health NHS Trust, Sibtain Anwar – Anaesthetics, Barts Health NHS Trust

Background

The incidence of malignant mesothelioma has been increasing since recording of this began in 1968. Post-surgical pain following diagnostic, palliative and curative radical/extended pleurectomy surgery (thoracotomy incision) remains an issue. Many factors can affect the analgesic outcome including surgical technique, choice of analgesic, post-operative level of care, ongoing input from the inpatient pain management service (IPS) and compliance with post-operative physiotherapy. Important patient factors include patient education and psychological preparation. Adequate pain relief following this particular surgery is essential to promote early mobilisation and improve recovery time. Various analgesic techniques have been documented to provide superior pain relief with minimal side effects. The decision as to which analgesic technique to use for a particular patient is usually the anaesthetist’s and/or surgeon’s preference and what services are available.

Aims

The aim of this service evaluation was to review the efficacy of current pain management regimen of patients diagnosed with malignant mesothelioma following radical/extended pleurectomy and decortication surgery (thoracotomy incision). The results will be used to provide recommendations and improve the quality of care provided.

Methods

With trust approval, the IPS reviewed patients in a Central London cardiothoracic hospital who underwent extended/radical pleurectomy and decortication for the treatment of mesothelioma. The IPS collected retrospective data from January 2018 until August 2018. The following data were collected at 24, 48 and 72 post-operative hours and included patient demographics, pain scores using the 11-point numerical rating scale (NRS; 0 = no pain, 10 = worse pain imaginable) at rest and on movement, analgesic treatment as well as treatment-related side effects. The current pain management plan includes the insertion of an epidural catheter with an epidural infusion and step down to a standardised oral regimen. The types of analgesics were recorded including epidural analgesia data such as level of insertion, epidural type and rate of infusion. Comparison was also made between post-operative analgesic regimens and pain scores. Finally, length of stay in critical care and overall hospital stay was recorded.

Results

Twenty patients were included; 80% male and 20% female; age ranged between 29 and 79 years. All patients had post-operative epidural analgesia. Additional medications included regular simple analgesics, opioids and as required strong opioids. One patient required systemic opioids. Sixty percent of the epidural catheters were removed by day 3. Twelve patients reported moderate pain at rest up to day 3 post-op and all had bupivacaine epidural and/or oral analgesics prescribed. Twenty-two patients reported moderate pain on movement up to day 3 post-op of which n = 17 had bupivacaine epidural and/or oral analgesics prescribed. One patient experienced severe pain at rest on day 3 post-op and was prescribed oral analgesics. Fifteen patients reported severe pain on movement up to day 3 post-op of which n = 14 had bupivacaine epidural and/or oral analgesics prescribed. Finally, patients who had bupivacaine/fentanyl epidural and infusion rate between 5 and 10 mL/h reported lower pain scores on day 1 and 2 post-op.

Conclusion

Patients undergoing radical/extended pleurectomy surgery for the treatment of malignant mesothelioma would benefit from having a bupivacaine/fentanyl epidural infusion for 3 days or more post-op. The results showed that patients whose epidural catheter was removed prior to day 3 post-op reported higher pain scores including severe pain at rest and/or on movement. Furthermore, 5–10 mL/h bupivacaine/fentanyl epidural rate appears to adequately manage the patient’s post-op pain. As expected, oral analgesics alone does not appear to effectively manage the post-operative pain. Our current pain management practice needs reviewing based on these results.

15

THE USE OF MINDFULNESS IN SCOTTISH PAIN SERVICES – A SNAPSHOT AUDIT

Category: Audit and Service Evaluation

Lars Williams – Pain Management, NHS Greater Glasgow & Clyde, Vidyamala Burch – Breathworks CIC, David Craig – Pain Management, NHS Greater Glasgow & Clyde, Alessio Agostinis – Pain Management Centre, Overdale Hospital Jersey

Background

Mindfulness came originally from Buddhist contemplative practice, but is now commonly used in Western society in a secularised form, including as a therapeutic technique in different healthcare settings. Mindfulness practice cultivates present-moment awareness, an ability to have a non-reactive perspective on thoughts and emotions, and acceptance; all of which are thought to be helpful attitudes in the psychological management of chronic pain. Although there is limited evidence at present to support the use of mindfulness as a stand-alone intervention for chronic pain (1,2), mindfulness techniques are often incorporated into wider self-management programmes for this difficult condition. We are aware, anecdotally, of increasing use of mindfulness by healthcare professionals working in chronic pain management, but there is no published systematic survey describing how mindfulness is used in UK pain services, or how healthcare practitioners delivering mindfulness interventions are trained. This survey is an attempt to fill that gap.

Aims

To build up a map of mindfulness use in Scottish pain services, including details of the mindfulness interventions that services currently provide, and signposting towards third-party mindfulness resources. We were also interested in staff beliefs and attitudes around mindfulness in chronic pain management, including their personal use of mindfulness.

Methods

An online survey (created in Webprolol 3.0) was distributed by e-mail to all staff known to be working in Scottish secondary care pain services in December 2018, with one reminder e-mail sent 3 weeks later. Approximately 160 staff were sent an e-mail containing a link to the survey. Twenty-five e-mails were returned as undeliverable, and these addresses were not followed up. Prior to this mail out, the survey had been publicised at a national pain meeting in late November 2018. The survey ran for 1 month, till January 2019. Results were analysed using tools in Webprolol 3.0. Of the 135 e-mails assumed to have been delivered, we received 68 responses, a response rate of just over 50%. Importantly, all 14 Scottish health boards and all professional groups working in chronic pain management services in Scotland were represented in the responses.

Results

Thirty-two percent of respondents indicated that their pain service offered formal mindfulness courses (e.g. 8-week MBSR, MBCT or MBPM courses). Almost all (97%) respondents stated that their pain service directed patients to third-party mindfulness resources, mainly apps, online resources and books. Familiarity with the evidence base was rated at a mean of 5.5/10 (median 6), and the extent to which the evidence base supports the use of mindfulness in pain management at a mean of 6.9/10 (median 7). Most felt developing mindfulness provision in their pain service to be worthwhile (mean rating 7.7/10, median 8). Forty-nine percent of the respondents indicated they had a personal practice in mindfulness, practicing on average 3.9 times a week for an average of 17 minutes. Thirty-four percent had had formal training in mindfulness. Free text comments emphasised the importance of mindfulness as part of a wider therapeutic framework rather than a stand-alone intervention in chronic pain management.

Conclusion

The response rate (50%) was surprisingly high for this type of survey, with all Scottish pain services and professional groups represented. Mindfulness provision, and support for mindfulness as an intervention by pain services, seems very high. A high proportion of staff report a personal mindfulness practice, even taking into account potential bias among respondents. It would have been interesting to correlate personal practice and training with attitudes and beliefs, but low numbers precluded this analysis. We plan to roll the survey out to England and Wales and then review implications for mindfulness delivery and staff training in UK pain services.

16

EXPECTATIONS OF PATIENTS IN A SECONDARY CARE PAIN CLINIC: A SURVEY

Category: Audit and Service Evaluation

Hannah Shereef – Anaesthesia and Pain Medicine, North Manchester General Hospital, Northern Health Science Alliance NHS Group, Manchester, Vinod Gadiyar – Anaesthesia and Pain Medicine, North Manchester General Hospital, Northern Health Science Alliance NHS Group, Manchester

Background

The incidence of chronic pain varies from 11% to 40% in the literature (1). In the United Kingdom, most patients are referred by general practitioners to secondary care pain clinics, though this is changing. There are not many studies which look at what the patient is expecting when they attend a pain clinic. One study showed that patients expect a firm diagnosis and cure (1). It also found that patients without a diagnosis thought that others will not believe their pain and medications were a way of ‘fobbing them off’. Another study (2) showed that patients preferred biomedical interventions. A further study (3) found that in addition to pain relief, improved sleep and increased ability to function were perceived as important goals. We sought to ascertain the understanding, thoughts and expectations of a new patient to the pain clinic at an NHS Trust in North Manchester.

Aims

To explore the reasons for new patients attending pain clinic and to ascertain their expectations with regard to further management of their chronic pain.

Methods

A standardised anonymised questionnaire comprising eight questions was given to all new patients attending pain clinic over a 6-month period. Questions asked included whether patients would like a better understanding of what is causing their pain, are looking for their pain to be further investigated, are seeking medication advice, are looking for new procedures to reduce pain, are looking for alternative or non-medical treatments to reduce pain, are looking for psychological therapies to reduce pain, are looking for advice with managing or coping with pain, and whether they are looking for their pain to be recognised as a health problem that is affecting their day-to-day life. Possible responses were strongly agreed, agreed, neutral, disagreed or strongly disagreed. These responses were analysed.

Results

There were 78 complete responses. The majority of respondents (93%) strongly agreed/agreed that they wanted recognition that their chronic pain was a health problem that is affecting their day-to-day life. While 78% of respondents wanted a better understanding of what was causing their pain, 64% of respondents wanted their pain to be further investigated; 80% of respondents were seeking medication changes; and 87% wanted to explore the possibility of procedural intervention. Only 30% of respondents agreed that they were looking for psychological therapies, for example, CBT to reduce pain. In contrast, 52% of respondents wanted to explore alternative or non-medical therapies. Only 37% wanted help coping with their pain, for example, referral to support groups.

Conclusion

The findings suggest that the patients are keen that their pain is recognised as a health problem affecting their life. A high proportion of patients are seeking medication changes or procedural interventions rather than psychological therapies and support; a significant number would like their pain to be further investigated. There is also an interest in exploring alternative therapies. This suggests that some patients are referred before they have reached the endpoint in their medical/surgical investigations or interventions, or that they are finding it hard to accept the nature of chronic pain.

17

ANALGESIA AFTER DAY CASE BREAST SURGERY

Category: Audit and Service Evaluation

Freyia Mahon-Daly – Anaesthetics, Imperial College Healthcare NHS Trust, Amy Fass – Anaesthetics, Imperial College Healthcare NHS Trust, Edward Costar – Anaesthetics, Imperial College Healthcare NHS Trust

Background

Adequate post-operative pain relief is an important aspect of day case breast surgery patient care, in order to prevent patient suffering and to prevent re-attendance for analgesia following discharge, and the resulting inconvenience and cost incurred. High post-operative pain scores have also been shown to reduce patient mobility, which in turn is a known risk factor for the development of deep vein thrombosis.

Aims

(1) To determine the proportion of patients discharged with written and oral instructions explaining post-operative analgesia. (2) To determine whether pain is adequately controlled in patients following discharge, and to understand whether patients with high pain scores take analgesia as prescribed.

Methods

Patients were contacted to provide a pain score using the verbal rating scale (VRS) on post-operative days 1–3 (0 = no pain, 10 = severe pain) and to provide details of their analgesia use. Patient records were accessed to establish if there was discrepancy between the analgesia prescribed and that taken by the patient. The audit standards used were from The Royal Collage of Anaesthetists audit recipe book: (1) 100% patients discharged with written and oral instructions regarding pain relief; (2) <5% reporting ‘severe’ pain on verbal pain score in the first 48 hours after discharge; and (3) >85% reporting ‘none’ or ‘mild’ pain in the first 48 hours after discharge.

Results

All patients (n = 37) were discharged home with written instructions explaining analgesia, and 68% (n = 25) were also given oral instructions prior to discharge. Severe pain (7–10) was experienced by 21% (n = 8) of patients surveyed, 75% of whom (n = 5) failed to take the provided analgesia regularly as prescribed. No pain or mild pain (0–3) was reported by 78% (n = 29) of respondents.

Conclusion

There is a need to educate patients about the importance of regular analgesia. Opportunities have been identified for breast care specialist nurses to discuss the importance of taking regular analgesia following surgery and to elicit any concerns in their consultation prior to surgery. In addition, a lay document clearly explaining when each medication should be taken and advising regular pain relief has been developed to give to patients in addition to their discharge letter. Re-audit following the implementation of these measures is planned.

18

REDUCING ANALGESIC PAIN MEDICATION PROGRAMME (RAMP) IN NHS BORDERS – A PILOT

Category: Audit and Service Evaluation

Neil Clark – Chronic Pain Service NHS Borders, Clare Scott – Chronic Pain Service NHS Borders, Rob Forbes – Chronic Pain Service NHS Borders

Background

Medication in the treatment of chronic pain has had a high profile in recent times. The Quality Prescribing for Chronic Pain – A Guide for improvement 2018–2021 called for optimisation of prescribing and reducing harm and wasteful unwarranted variation. In the NHS Borders Chronic Pain Service Pain Management Programme (PMP), it was recognised that many patients were keen to reduce their medication with support, though this is not the focus of the PMP. The RAMP programme was piloted to support patients reducing their medication while attending an exercise and education programme after completing a PMP.

Aims

Establish a supported medication reduction programme; develop content and delivery by physiotherapist, nurse and consultant anaesthetist; delivery of 2 × 6-week RAMP programmes in January/February 2018 and August/September 2018; evaluation of outcomes including numerical rating scale (NRS), morphine equivalent dosage (MED) and qualitative feedback.

Methods

Patients were recruited post pain management programme, where the focus is on the acquisition and development of self-management skills for chronic pain. Before starting the programme, a questionnaire was used to collect demographic data (age, gender, pain diagnosis/location), current medication and NRS. This was collected at the end as well as a post RAMP feedback questionnaire.

RAMP consisted of 6 × 1¼ hour sessions consisting of check in, education on reducing pain medication, effects on long-term use of medication, withdrawal symptoms, how to reduce, self-management strategies to support reduction and withdrawal symptoms by ‘surfing the urge’, exercise including Qi Gong, aerobic and strengthening exercise and relaxation, inspiring stories of those who have reduced medication.

Results

14 patients recruited post PMP

Mean NRS pre 7.13/10 (Range 8/10–5/10);

Mean NRS post 5.63 (Range 8/10–1/10);

Mean MED Pre 28 mg (Range 80–15);

Mean MED post 20 mg (Range 80–0).

9/14 had tried reducing their medication by the end of the programme

Most helpful factors in medication reduction:

N = 3/9 relaxation methods including Qi Gong;

N = 2/9 support and encouragement;

N = 1/9 education on appropriate use of medication.

Obstacles to reduction:

N = 4/4 fear.

Method of reducing:

6/8 graded reduction of medication;

2/8 stopped medication all at once.

Other changes noticed by reducing medication:

4/8 reported improved cognitive function;

7/8 reported improvements in other well-being.

Changes in pain NRS in those who had reduced:

5/8 less pain intensity, reduced spread of pain, less headaches;

2/8 no change in pain;

1/8 more pain.

Conclusion

The majority of patients reduced their medication in a graded way over the course of the programme. The main obstacle to reducing medication was fear. However, of those that reduced their medication, the majority found a reduction in their pain NRS and improvements in cognitive and other aspects of well-being. A 6-week supported exercise and self-management programme with a focus on education about medication and medication reduction was effective in helping patients reduce their medication.

19

MANAGEMENT OF PATIENTS ON STRONG OPIOIDS FOR CHRONIC NON-CANCER PAIN AT INITIAL ASSESSMENT IN PAIN CLINIC

Category: Audit and Service Evaluation

Simon Braude – Pain Medicine, Royal Free Hospital, Arif Ghazi – Pain Medicine, Royal Free Hospital

Background

The Opioid Aware campaign suggests there is ‘little evidence that (opioids) are helpful for long term pain’, the risk of harm increases substantially at doses above oral morphine equivalent 120 mg/day and that if a severe pain remains despite opioids they should be stopped. Side effects from long-term opioids include tolerance, dependence, endocrine dysfunction, constipation and opioid-induced hyperalgesia. This campaign occurs in the context of an increase in opioid-related deaths in the United States. Patients on strong opioids for chronic non-cancer pain are a complex and heterogeneous group of patients. They may require intensive multidisciplinary input and would benefit from education regarding potential side effects of long-term opioid use.

Aims

The aim was to retrospectively review new patients within our clinic with chronic non-cancer pain on strong opioids at the time of their initial clinic visit. We looked at patient demographics, opioids used and reviewed our management of these new patients referred to our clinic.

Methods

During the 12-month period of 2018, all new patients at our Royal Free Hospital pain management clinic had their electronic case notes and clinic letters reviewed retrospectively. Within this cohort, we identified patients with chronic non-cancer pain and those on strong opioids at the time of referral. We reviewed the medication management at this initial visit by the clinician and looked for documentation of opioid education as well as collecting demographic data. We identified 27 such patients during this time period. The age range was 22–85 and 6 of the 27 patients were male.

Results

There were five patients using fentanyl, eight using morphine, four using oxycodone, eight using buprenorphine and two using tapentadol. The most common indications were lower back pain (12/27) and chronic widespread pain/fibromyalgia (5/27). Other indications included renal loin pain haematuria, ischaemic limb pain, porphyria, chronic pancreatitis, joint pain and chronic post-surgical pain. Within the patient cohort, an opioid reduction was suggested by the clinician in 7 of the 27 patients and an opioid increase was suggested in 2 of 27 patients (both on buprenorphine). One patient had a recommended change of formulation to slow release morphine, but no patients were recommended to rotate opioid. In 4 of the 27 patients, there was documentation by the clinician of opioid education, for example, to the side effects of opioids or opioid tolerance. Nine of the 27 patients were on greater than 120 mg oral morphine equivalent daily dose.

Conclusion

In the majority of patients, there was no immediate suggested changes to their existing opioid regime, which reflects their complexity and requirement of ongoing multidisciplinary team (MDT) input. However, of those in whom changes were made, in most cases there was a recommended reduction in opioid consumption. This demonstrates that in many cases, opioids may be causing more harm than benefit. It is of concern that 9 of 27 patients were at a dose above 120 mg oral morphine equivalent, and this reflects the challenges these patients present in primary care. Our data suggest the need for more intensive multidisciplinary management including providing patients with education regarding long-term opioid use.

20

EVALUATING COMPLIANCE IN DOCUMENTING PAIN ASSESSMENT AFTER MAKING PAIN THE FIFTH VITAL SIGN

Category: Audit and Service Evaluation

Betty Enriquez – Acute Pain Service, Homerton University Hospital NHS Foundation Trust

Background

There is a high prevalence of acute and chronic pain in hospitals in the United Kingdom and worldwide. The reasons for this high prevalence are multiple; however, failure to assess pain has been identified as one of the main causes. Pain assessment is a cornerstone of pain management because it enables adequate prescription of analgesics and is essential to evaluate the effectiveness of the pain management planned. The introduction of Electronic Patient Record (EPR) system in the Trust in 2015 resulted in a dramatic reduction in compliance of pain assessment documentation: from 92% to 12% on the new electronic system in 2016. The pain assessment section on EPR was located on a different section to the vital signs; following this decline in pain score documentation, pain assessment was added alongside vital sign observations making pain the fifth vital sign.

Aims

The Trust standard is that 100% of patients have their pain assessment documented along with the other vital signs, and a minimum of once a day. The aim of this audit was to identify compliance in documentation of pain assessment and evaluate the effectiveness of changes made to EPR.

Methods

A snap shot audit was performed of a randomly selected 24-hour period. A request was made to the CIS Information Team to retrieve data from EPR. Data were obtained from all adult in-patients electronic records. Accident and Emergency, Intensive Care Unit, Surgical Centre (Day Case Surgery) and Labour ward were excluded because these departments are audited individually (some of these departments still use paper records for documentation of pain and vital signs). Comparison was made with previous years’ pain assessment documentation audit.

Results

A total of 241 patients were identified during the 24-hour period; 84% had their pain assessment documented at least once during that period, only one patient had a pain assessment on movement documented. The ward with the highest documentation of pain scores was Haematology ward with 100% of patients having their pain score documented. This was also the ward with patients reporting the highest pain scores. The ward with the lowest number of pain scores documented was Elective Orthopaedic Ward with only 50% of its patients having a pain score documented.

Conclusion

Comparison with previous year’s data shows a 72% increase in pain score documentation demonstrating that introducing Pain as the fifth Vital Sign has been effective; however, it still does not achieve the standard. The results have highlighted that medical wards have the highest pain scores and some of these patients have not had their pain reassessed or had a referral to the Acute Pain Service. This may be due to healthcare professionals’ lack of skills and knowledge in pain assessment and management; consequently, educational programmes targeting the educational needs of staff in different clinical areas have been programmed.

21

TRANSDISCIPLINARY APPROACHES IN PAIN MANAGEMENT: SERVICE EVALUATION OF JOINT MDT CLINICS

Category: Audit and Service Evaluation

Katie Herron – Pain Medicine Department, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Ruth Wheelhouse – Pain Medicine Department, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Priscilla Robinson – Pain Medicine Department, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Laura Groom – Pain Medicine Department, Royal Liverpool and Broadgreen University Hospitals NHS Trust, HooKee Tsang – Pain Medicine Department, Royal Liverpool and Broadgreen University Hospitals NHS Trust

Background

It is well established that multidisciplinary team (MDT) pain management programmes (PMPs) are often efficacious over unidisciplinary treatments for people with complex chronic pain. MDT-led PMPs are a good example of ‘Transdisciplinary’ working where all clinicians hold holistic responsibility and deliver treatment advice for a shared goal within a ‘flexible exchange of discipline-specific roles’. Research has shown that transdisciplinary working has significant benefits for patients, improves team communication and increases expertise (Gordon et al., 2014). Where PMPs are not possible, alternative unidisciplinary approaches or MDTs working in isolation can potentially limit care compared to the transdisciplinary nature of a PMP as well as contradictory treatment plans, expectations and inappropriate referrals. Patients experience long waiting times which are often extended further when referred to another discipline. To address this, our service piloted transdisciplinary clinics in outpatients. This involved joint MDT appointments with a psychologist and physiotherapist or specialist nurse or consultant.

Aims

We aim to continue our service evaluation on patient experience and staff perspectives on joint MDT clinics and review the potential service efficiency improvement in UK secondary care from June 2018. We anticipate using the Team Decision Making Questionnaire (TDMQ) in a total of eight staff and 40 patients by April 2019.

Methods

Patients referred for a joint MDT appointment all had chronic pain >6 months and at least one of the following difficulties: (1) reducing medication, (2) psychosocial needs, (3) fear-avoidance and (4) poor progress. Patients completed an in-house designed Satisfaction Survey (MDT-S) that comprised five items for rating appointment satisfaction (0 = not satisfied; 10 = very satisfied), verbatim responses for most helpful or needs improvement as well as a family and friends test. Clinicians completed the 19-item TDMQ (Batorowicz and Tracy, 2008). Answers rated from 6 (to a vast extent) to 0 (not at all) on the degree to which transdisciplinary clinics enabled them to achieve potential benefits. Service efficiency improvement was determined through number of appointments needed to treat and waiting time compared to standard treatment of six psychology, four physiotherapy, and three nursing/consultants on average.

Results

Twenty patients attended a joint clinic (5 MDT-S collected). One patient was discharged and eight were discharged from one discipline. Four continued treatment with two separate disciplines. Three patients were offered one to two joint reviews. Four patient outcomes are undetermined. Compared to standard treatment, joint clinics reduced appointments by 38%. Six patients showed a ?50% appointment reduction. Six patients were discharged sooner due to fewer appointments. Seven patients achieved satisfactory benefit from psychology within three joint appointments which saved such patients a further 8-month wait for psychology. Fifty percent of patients’ plans were changed after joint MDT. Mean satisfaction scores on MDT-S were 10/10, 9.61/10 for helpfulness of information and 6.6/10 for helpfulness in making changes at home. Several patients commented on the benefits of having ‘two perspectives’. TDMQ (4 collected) showed ‘share innovative ideas’, ‘ensure quality of services’ and ‘generate new ideas with colleagues’ were the highest rated benefits.

Conclusion

In line with ‘person centred care’ as a national driver for NHS England’s 5-year forward view, this approach shows service improvement through transdisciplinary approaches that allows for tailored patient plans and skill sharing for overall role enrichment in pain clinics. It is evident that this approach supports clinicians who are ‘stuck’ with moving patients forward. Not only does this clinic offer better quality care similar to transdisciplinary approaches on PMPs, it reduces burden of multiple appointments for patients, it potentially increases efficiency of services and reduces growing waiting times in secondary care.

22

EXPLORING PATIENTS’ UNDERSTANDING OF PAIN MANAGEMENT PROCEDURES AS THEY GIVE THEIR CONSENT

Category: Audit and Service Evaluation

Lewis Hendon-John – Anaesthetics, Frimley Health NHS Foundation Trust, Rajesh Gupta – Anaesthetics, Frimley Health NHS Foundation Trust, Karin Cannons – Pain Management, Frimley Health NHS Foundation Trust, Mohjir Baloch – Anaesthetics, Frimley Health NHS Foundation Trust

Background

Interventional procedures are frequently used as a treatment option for chronic pain, with many patients undergoing several procedures over the course of the lifetime. British Pain Society guidelines state that informed consent for these procedures involves a process of joint decision-making after a discussion of treatment options. This includes discussion of the potential risks and benefits, as well as the potential outcome from not having the procedure. In our chronic pain service, this discussion happens at the initial consultation with the pain specialist. After this consultation, a Faculty of Pain Medicine patient information leaflet should be provided to enable them to be as fully informed as possible, share in the decision-making process and provide informed consent. It had been noted that when arriving for pre-assessment or the procedure some patient’s stated they did not have an information leaflet and/or struggled to recall the risks and benefits.

Aims

To access the level of understanding that patients have with regard to the risks and benefits of procedures for the management of pain. To determine the proportion of patients provided with written information and the extent to which they found this beneficial.

Methods

A patient survey was designed to assess elements of the patient’s understanding of risks and benefits, whether they received an information leaflet and how useful they found it. All patients undergoing a procedure specifically for the management of pain over a 4-week period were requested to complete this survey which was distributed by staff on the day of the procedure. No patients were excluded from the survey; however, they all had the option to refuse to take part. All responses received were compiled and analysed, with free-text answers being grouped into themes to aid analysis.

Results

A total of 110 patients responded to the questionnaire. Three respondents indicated that they did not recall having the risks and benefits explained to them during initial consultation. A total of 76 respondents were able to recall some benefits and 57 could recall some risks. These patients provided 86 responses for both risks and benefits, falling into 10 themes for benefits and 16 themes for risks. Seventy percent of patients received an information leaflet, with 77% of those stating that there was sufficient information in the leaflet; 3% indicated there was insufficient information; 5% did not understand the information in the leaflet; and 7% did not read it. Of all respondents, 68% had no other source of information other than the information leaflet. Nineteen percent used the Internet, 6% discussed with their GP and 5% used their own previous experience of the procedure.

Conclusion

Effective pain management requires informed consent for procedures. This means providing maximum possible information to the patient and then giving them the opportunity to consider that information, ask questions and decide; principles reinforced under the recent Montgomery ruling on informed consent (2). A report by Irish patient client council (2014) (2) mentioned that 38% of patients were given adequate information regarding their pain management which is less when compared to our cohort of patients. This audit demonstrated provision of satisfactory information about procedures to our patients. Better results might be achieved with more diligent provision of information leaflets and discussion with patients.

23

PREVALENCE OF DEPRESSION AND ANXIETY IN NEW PATIENTS SEEN IN PAIN CLINICS IN THE UNIVERSITY HOSPITALS OF NORTH MIDLANDS (UHNM)

Category: Audit and Service Evaluation

Mohamed Rabie – Anaesthetics and Chronic Pain, University Hospitals of North Midlands NHS Trust, Harnarine Murally – Anaesthetics and Chronic Pain, University Hospitals of North Midlands NHS Trust

Background

Living with a chronic painful condition often has a significant physical, psychological and economic impact on the patients and society. A recent research endorsed by the British Pain Society found that chronic pain affects more than 40% of the UK population with up to 14.3% of the patients having moderate to severe disability secondary to their chronic pain. The comorbidity between a chronic painful condition and any mood and anxiety disorders adds to the complexity of the pain management and also leads to a less favourable long-term prognosis. It was found that the prevalence of mood and anxiety disorders in chronic pain patients is variable between studies and also according to the population being studied with an overall prevalence of 4.7–72% and 7–28.8% for depression and anxiety, respectively. Therefore, it is national standard that the pain, psychology and psychiatry and other teams work jointly.

Aims

The main aim of the audit was to assess the prevalence of depression and anxiety in new patients attending pain clinics in UHNM. We also wanted to assess the average pain intensities and the impact on normal daily activities.

Methods

We planned a prospective service evaluation project. In our chronic pain service, we ask the new patients to complete two validated pain questionnaires, the Hospital Anxiety and Depression Scale (HADS) and Brief Pain Inventory (BPI), before they are seen in the clinic. Approval was obtained from the audit department in UHNM. From March to June 2017, we collected the following information for each new patient seen in the chronic pain clinics: HADS, BPI, patients’ demographics, sites of pain and pain pharmacological treatment. We then looked at the patient clinic letters from current and previous visits. The data were then analysed with help from the audit department. Analysis included descriptive statistics from the patient information. We also tried to look at the relationship between different parameters and scores from the above questionnaires.

Results

A total of 114 patients were included in the study. Females n = 79 (69.3%), males n = 35 (30.7%). Average age was comparable, 54 years. The most common area of pain, for both sexes, is lower back, accounting for almost half of all primary areas of pain reported. Pain of musculoskeletal origin was found in 60.5% of patients. 51.7% of patients had experienced pain for over 5 years. Average anxiety and depression scores from HADS were 10.7 (SD, 4.6) and 10 (SD, 4.3), respectively. In total, 72% of the total sample had a HADS anxiety and depression score greater than or equal to 8. The mean combined pain severity score (worst, least, average and current pain scores) from BPI was 6.9 (SD, 1.5). The mean pain interference score (with normal functional activities) from BPI was 7.4 (SD, 1.57). Scores were normally distributed, with no evident difference between males and females.

Conclusion

Our study showed that based on scores from HADS, the majority of the new patients seen in outpatient pain clinic had potentially comorbid anxiety and/or depression (a score of 8). Therefore, multidisciplinary management involving psychology/psychiatry services will improve their outcome. The pain intensity and interference scores were in the moderate to severe range. There was moderate statistic correlation between scores of anxiety and depression, but its clinical significance cannot be inferred from this study. Larger and more robust studies will be needed to confirm this finding.

24

SECONDARY FAILURE FOLLOWING EPIDURAL CATHETER INSERTION AFTER MAJOR SURGERY AND TRAUMA – A DESCRIPTIVE SURVEY

Category: Audit and Service Evaluation

Nick Haslam – Department of Anaesthetics, Royal London Hospital, Barts Health NHS Trust, Ivan Wong – Department of Anaesthetics, Royal London Hospital, Barts Health NHS Trust, Charlotte Guest – Surgery and Anaesthetics, Royal London Hospital, Barts Health NHS Trust, Kristin Ullrich – Department of Anaesthetics, Royal London Hospital, Barts Health NHS Trust, Shankar Ramaswamy – Department of Anaesthetics, Royal London Hospital, Barts Health NHS Trust, Helen Bonar – Pain Management and Acute Pain, Royal London Hospital, Barts Health NHS Trust, Mima Shaw – Pain Management and Acute Pain, Royal London Hospital, Barts Health NHS Trust, Kirstie Emmerson – Pain Management and Acute Pain, Royal London Hospital, Barts Health NHS Trust, Athina Karavasopoulou – Pain Management and Acute Pain, Royal London Hospital, Barts Health NHS Trust, Lorena Warde – Pain Management and Acute Pain, Royal London Hospital, Barts Health NHS Trust, Hanna Kotas – Pain Management and Acute Pain, Royal London Hospital, Barts Health NHS Trust, Charis Napier – Pain Management and Acute Pain, Royal London Hospital, Barts Health NHS Trust

Background

Epidural analgesia for acute post-operative pain management after major surgery is successful in approximately 70% cases and commonly used to manage pain following trauma (e.g. rib fractures). Reasons for inadequate epidural analgesia include primary failure (e.g. incorrect placement of the epidural catheter) and secondary failure (e.g. catheter migration, suboptimal dosing of local anaesthetic agents). A multidisciplinary approach is essential to maximise the success of epidural analgesia. This involves pre-operative patient assessment and selection, enhanced recovery pathways, technical skills of epidural catheter insertion, troubleshooting of epidural analgesia issues post-op and appropriate termination of epidural infusion and conversion to alternative analgesia. The reasons for the secondary failure of epidural analgesia in our hospital have not been systematically reviewed.

Aims

A descriptive survey examining secondary failure following epidural catheter insertion in adult non-obstetric patients following major surgery and trauma.

Methods

Following Trust approval, a prospective data collection took place over a 1-month period (September to October 2018) at a large NHS teaching hospital in London, UK. Adult patients, who had had major surgery or suffered traumatic injuries who then received epidural analgesia, were included in this descriptive survey. Data collection was performed by the inpatient pain management team during routine daily ward rounds. Data points included patient demographics, type of surgery, level of epidural catheter, type of drug used during epidural drug infusion, post-operative destination, description of epidural problem (if applicable), description of troubleshooting action (if applicable), duration of epidural catheter remained in situ and decision to stop epidural infusion.

Results

Twenty-seven patients received epidural analgesia after major surgery across six specialities and trauma. The majority (22/27) were thoracic epidural catheters. Most (24/27) used a mixed bupivacaine and fentanyl infusion. Mean catheter duration was 3.1 days and ranged from 0 to 5 days. Fifty-nine percent (16/27) of epidural catheters worked well without adverse effects or failure. Of the remaining 11, 22% (6/27) required significant intervention, 7% (2/27) were removed due to sepsis and 11% (3/27) were inadvertently displaced. Two epidural catheters were removed prematurely (less than 3 days) by the admitting teams at first intervention for other clinical reasons. No serious complications were reported. The decision to stop and subsequently remove the epidural catheter and convert to alternative analgesics was made by nurses and doctors of variable experience and grades from different teams (Pain, Intensive Care, Anaesthetics, Surgery) but not always in collaboration with the pain team.

Conclusion

This survey demonstrates that management of epidural analgesia takes place in heterogeneous clinical areas with variable staff skill mix and resources. The decision to stop epidural analgesia prematurely was made by various members of different teams. There was a relatively high incidence (41%; 11/27) of secondary failure and of these 22% continued to provide analgesia following significant intervention. The survey showed very few patients’ epidural catheters were removed prematurely (7%). Access to specialists with expertise in epidural management is important to continue to maximise benefit from epidural analgesia. Focused education programmes for admitting teams may prevent premature removal of epidural catheters.

25

RETROSPECTIVE AUDIT OF PATIENT REPORTS OF EFFECTIVENESS OF INTRAVENOUS LIDOCAINE INFUSION FOR CHRONIC PAIN

Category: Audit and Service Evaluation

Mohamed Rabie – Chronic Pain, Royal National Orthopaedic Hospital, Rebecca Berman – Chronic Pain, Royal National Orthopaedic Hospital, Dan Mihaylov – Royal National Orthopaedic Hospital, Nicolas Varela – Royal National Orthopaedic Hospital, Roxaneh Zarnegar – Royal National Orthopaedic Hospital, Tacson Fernandez – Royal National Orthopaedic Hospital

Background

In the Royal National Orthopaedic Hospital (RNOH), intravenous lidocaine infusions (IVLI) are used to manage a variety of pain conditions such as chronic post-surgical pain (CPSP), complex regional pain syndrome (CRPS), phantom pain, spinal cord injury and peripheral nerve injury with variable success. However, there is no good quality evidence for its effectiveness. The underlying mechanisms of action lidocaine in chronic pain are not fully confirmed, but it appears to modulate sodium channel expression, reduce peripheral and central sensitisation and has an anti-inflammatory action by reducing circulating inflammatory cytokines. The side effects of IVLI are generally mild and temporary and include sedative and imbalance effects in addition to the more serious but reversible effects as arrhythmias and convulsions. There is no consensus on the optimal dose. In the RNOH, we use a maximum dose of 4 mg/kg over 1 hour per session. The frequency and time interval between sessions is determined on individual basis.

Aims

The proximate aim of this audit was to determine how many patients reported benefit and if this could be related to aetiology. The secondary aims were both to determine whether it was reasonable to continue this practice and also to help power and plan a planned double-blind randomised controlled trial (RCT).

Methods

The aim of the study was discussed and approved in a Chronic Pain Department Meeting and Research and Development Department in RNOH. The study aimed to retrospectively evaluate the demographics and characteristics of chronic pain patients in RNOH who received IVLI from August 2017 to August 2018. The information was retrieved from the Chronic Pain Department electronic database. We collected information on age, sex, ethnicity and date(s) of infusions and entered it on a spreadsheet. Subsequently, we looked at the patient clinic letters and day case discharge summaries to collect information on current diagnosis, type and aetiology of pain and pain location, and if infusions resulted in improvement in the patient’s pain complaint. We decided to indicate the benefit in a dichotomous (yes/no) manner rather than a percentage of pain improvement as this was not possible to ascertain on some pain clinic follow-up letters.

Results

A total of 442 IVLI sessions were carried out in RNOH between August 2017 and August 2018 for 154 patients (64 M, 90 F), 2.8 mean (± 2.9 SD) infusions per patient. The average age was 50.9 years. Main pain locations were in lower limb; 32.4% (15 M/35 F), the lower back; 24.6% (18 M/20 F), and upper limb; 14.8% (13 M/10 F). The main pain mechanisms were chronic post-surgical pain; 33% (19 M/33 F), back pain (mechanical with or without radicular features); 19% (13 M/14 F), brachial plexus injury pain; 10% (14 M/2 F), widespread musculoskeletal pain; 9% (0 M/14 F), CRPS; 6% (6 M/8 F). Fifty-six percent of the patients reported benefit from IVLI (33 M/53 F). Effectiveness of IVLI ranged from 42.9% for post-amputation pain to 83% for central neuropathic pain conditions, for example, spinal cord injury.

Conclusion

The effectiveness of IVLI in managing refractory chronic pain conditions is variable and appears to be more effective in central neuropathic and widespread musculoskeletal pain than in CRPS. An audit of this kind cannot give any information about the specificity of the treatment response. It is very likely that there is a large placebo effect. The next step is to carry out a small study of whether patients and observers can be truly blinded to IVLI compared to a normal saline infusion with the final step being a double-blind RCT with either an active or inert control limb.

26

THE EXPERIENCE OF CHRONIC PAIN IN ADULT CANCER SURVIVORS: A QUALITATIVE EVIDENCE SYNTHESIS

Category: Cancer Pain

Julie Armoogum – Department of Nursing and Midwifery, University of the West of England, Candy McCabe – Nursing and Midwifery, University of the West of England and Royal United Hospitals Bath NHS Foundation Trust, Diana Harcourt – Health and Social Sciences, University of the West of England, Claire Foster – Health Sciences, University of Southampton, Alison Llewellyn – Nursing and Midwifery, University of the West of England and Royal United Hospitals Bath NHS Foundation Trust

Background

There have been significant improvements in cancer survival in recent decades and it is predicted that by 2030, there will be 4 million people living with and beyond cancer in the United Kingdom (1). However, a recent systematic review found that almost 40% of people diagnosed with cancer experience pain after treatment (2) and almost a fifth of women living beyond a diagnosis of early stage breast cancer in the United Kingdom expressed an unmet need relating to pain (3). There is recognition for the need of research in this area and persistent pain is a National Cancer Research Institute top 10 research priority (4). To date, there is a paucity of research into the experiences and needs of adult cancer survivors with chronic pain.

Aims

To identify, review and synthesise qualitative literature surrounding the experience of chronic pain in adult cancer survivors.

Methods

A systematic qualitative evidence synthesis was conducted between October 2017 and February 2018. Studies were included if they explored cancer survivors’ experience of chronic pain, adopted a qualitative methodology and passed a quality assessment. Data synthesis followed Thomas and Harden’s (5) method of thematic synthesis of qualitative research.

Results

Four studies were identified that generated findings from 52 female breast cancer survivors. Sample sizes ranged from 8 to 21. No studies included people whose completion of cancer treatment dated further than 30 months. The studies found the experience of chronic pain and the experience of a diagnosis and treatment of cancer were interwoven and intricately related to each other. Chronic pain had a physical impact on daily lives and was also an emotional experience. Cancer survivors reported that the chronic pain was an unexpected consequence of their treatment. Furthermore, they felt they were left to manage their pain by themselves and they needed to adopt a variety of methods to help with managing it. There was also a temporal nature to chronic pain and cancer survivors’ experience of it. How women experienced pain, conceptualised it and adapted to it changed over time.

Conclusion

Chronic pain in cancer survivorship has physical and emotional consequences that are unique to this population. There is limited qualitative research into this area, and what is available is exclusively in the breast cancer population. More research is needed to understand the experience of survivors from different tumour types at various stages of survivorship.

27

NEUROLYTIC SADDLE BLOCK IN PATIENTS RECEIVING PALLIATIVE CARE WITH INTRACTABLE CANCER PAIN

Category: Cancer Pain

Shelley Barnes – Anaesthesia and Pain, Bristol Royal Infirmary, Nilesh Chauchan – Anaesthesia and Pain Medicine, Bristol Royal Infirmary, Kate Davies – Palliative Medicine, St Peter’s Hospice

Background

Intractable perineal cancer pain is difficult to manage. Traditional analgesia with opioids and adjuvants can cause intolerable side effects leading to poor quality of life without adequate pain control. Simple single interventional techniques can transform such patients’ remaining life. Limited published data on these techniques exists. We present a series of neurolytic saddle blocks performed over 28 months for 11 patients with palliative perineal pain secondary to rectal, gynaecological or urological cancers. Median age 61 (range, 43–80 years), female:male ratio 7:3 and median length of survival: 43 days post-procedure (range, 14–176 days, one survivor). Average volume of 6% aqueous phenol used was 1.52 mL (range, 0.8–2.5 mL). The primary outcomes were post-procedure percentage changes in 24-hour oral morphine dose equivalent at days 1, 3 and 5 and 1 month and percentage change in Australia-modified Karnofsky Performance scale (AKPS). Secondary outcomes were change in adjuvant analgesia, qualitative statements and adverse effects.

Aims

The aim was to assess effectiveness and complications of neurolytic saddle blocks in patients with intractable pain and high opioid requirements. Specifically to assess any opioid reduction, improvement in quality of life, long-term neurological complications post-procedure and also to ascertain any correlation with phenol dose used.

Methods

The technique for the neurolytic saddle block was as per a sitting spinal. The saddle block was performed aseptically in theatre by a consultant anaesthetist at the level of L3/4 or L4/5 using a 25 g Whitacre needle. Six percent aqueous phenol was injected in 0.2-mL increments until the patient described tingling or numbness in their feet. Patients were then kept in a bolt upright sitting position with legs raised for about 40 minutes. Temporary motor weakness was expected which largely resolved in a few hours. Data were collected retrospectively from paper and electronic patient notes and included patient demographics. Twenty-four-hour morphine dose equivalent pre-procedure, day 1, 3, 5 and 1 month post-procedure were calculated and used to calculate percentage change. AKPS score pre- and post-procedure were calculated. Changes in adjuvant analgesia were identified. Qualitative statements in the patient records were collated and adverse effects identified.

Results

Primary outcome: 24-hour morphine dose equivalent post-procedure compared with pre-procedure: Day 1: 9/11 had decreased requirements (average 61.8%), 2/11 had no change. One month: 3/11 patients had died, 5/11 had decreased requirements and 3/11 had increased requirements. Percentage change in AKPS score on day 3 compared to pre-procedure: 7/11 no change, 2/11 decreased score and 2/11 increased score. Secondary outcomes: Adjuvant Medication: 3/11 increased use, 5/11 decreased use, 2/11 no change and 1/11 changed agents. Qualitative Statements: eight statements of improved perineal pain, two reports of disappointment in procedure effectiveness and one comment on psychological distress with loss of lower limb function. Adverse effects: 7/11 patients experienced neurological adverse effects in the lower limbs, 3/7 resolved the same day or within a few days, 2/7 had mild residual weakness and were bed bound pre-procedure, 1/11 had long term weakness, and had required a Zimmer frame pre-procedure. 1/11 had a self-limiting headache.

Conclusion

Patients with intractable perineal cancer pain have limited pain management options. Quality of life can be poor, both from pain and medication side effects. Neurolytic saddle blocks can provide relief for patients with a short prognosis. Our experience has shown reduction in opioid requirement and improvement in perineal pain. Neurological sequelae can occur temporarily with some risk of long-term effects. Careful patient selection is paramount, balancing benefits versus risks. Larger dose of neurolytic agent may correlate with better pain relief but worse neurological outcome. Further large studies are required to determine patient selection criteria and optimum dose of agent.

28

EVALUATION OF PERCUTANEOUS CORDOTOMY SERVICE IN PORTSMOUTH

Category: Cancer Pain

Joanna Harding – Pain Medicine, Queen Alexandra Hospital, Portsmouth, Nicholas Campkin – Pain Medicine, Queen Alexandra Hospital, Portsmouth, Michael Williams – Pain Medicine, Queen Alexandra Hospital, Portsmouth

Background

Percutaneous cervical cordotomy (PCC) is a procedure that lesions selected pain-conducting tracts in the spinal cord, in order to achieve loss of pain. It is commonly used for patients experiencing severe uncontrollable unilateral pain, below the dermatomal level of C4 due to cancer. The service in Portsmouth was originally set up because of the high incidence of malignant mesothelioma in the local area due to asbestos exposure in the local dockyards. Currently approximately 50 cases per year are undertaken at Portsmouth. Since 2013 information on patients undergoing PCC is collected on the national online neurodestructive procedures in cancer pain (Dendrite) database, collating pre- and post-procedural information.

Aims

To establish efficacy of percutaneous cervical cordotomy and quantify the risk of side effects following the procedure.

Methods

Cases in Portsmouth entered into the Dendrite database since 2013 were examined. All cases had their pain scoring (numeric rating scale 0–10) pre-procedure and at 1 week post-procedure assessed. The presence of dysesthesia, mirror pain and motor weakness at 1 week post-procedure alongside descriptors of severity (mild/moderate/severe) were recorded. The presence of urinary retention was also recorded.

Results

A total of 147 patient records (male 114, female 33) since 2013 were examined, and 110 records had follow-up data available. Average age was 66.4 years and most common diagnosis was mesothelioma. PCC achieved significant reduction in pain scores. The mean pain score pre-procedure was 9.1 for breakthrough and 5.7 for background. 86.5% had improvements in both breakthrough and background scores, giving mean pain scores 1 week post-procedure of 2.1 for breakthrough and 1.3 for background. A further 8% had improvement in one of their scores. Side effects are prevalent, with nearly a third of all patients experiencing dysesthesia or mirror pain, predominantly these are mild with some resolving completely. Motor weakness post-procedure had a prevalence of 34%; however, only 14% of this was on the contralateral side to the pain site, which represents the motor tracts exposed during the procedure. There was a 4% risk of urinary retention, all of which resolved.

Conclusion

PCC achieves high-quality analgesia in patients that otherwise have difficult to manage symptoms. More than 85% can expect to have significant improvements in their pain scores. Side effects are prevalent but predominantly mild and well tolerated. The patients who went on to have motor weakness documented afterwards, only 10 had a documented neurological deficit before the procedure. However, some patients who had lower limb weakness post-procedure had descriptors in their data such as difficulties walking, or pain sites in the pelvis/lower limb. This implies that we are poor at fully establishing and documenting pre-existing limb weakness pre-procedure.

29

A SYSTEMATIC REVIEW OF THE USE OF QUANTITATIVE SENSORY TESTING (QST) IN CANCER PAIN ASSESSMENT

Category: Cancer Pain

Maisie Martland – Academic Unit of Palliative Care, University of Leeds, Arhmed Seyar Rashidi – Department of Biochemistry and Molecular Biology, University of Southern Denmark, Roman Rolke – Department of Palliative Medicine, Aachen University, Chris Jones – Leeds Institute of Health Sciences, University of Leeds, Michael Bennett – Academic Unit of Palliative Care, University of Leeds, Matthew Mulvey – Academic Unit of Palliative Care, University of Leeds

Background

Pain is prevalent in cancer patients and is the most feared symptom. Approximately 80% of cancer pain is tumour-related, while 10–20% is related to anti-cancer therapies. A recent systematic review highlighted that 40% of cancer patients will experience neuropathic pain. The presence of neuropathic pain is associated with poorer quality of life and lower performance status than patients without neuropathic pain. Cancer pain is associated with mixed aetiology mechanisms. Therefore, rigorous assessment is needed to identify the mechanisms present. Accurately diagnosing these mechanisms is essential to providing effective and targeted treatment for patients. Quantitative sensory testing (QST) is a set of non-invasive tests that can support the diagnosis of neuropathic pain by quantifying the functionality of the peripheral nerve fibres. Currently, it is unclear if QST is being widely used to aid the diagnosis of neuropathic pain and if so, which tests within the QST protocol are being used.

Aims

The aim of this systematic review is to describe QST parameters commonly used in the assessment of cancer pain (tumour-related or treatment-related pain) and identify which ones consistently demonstrate abnormal sensory processing in this patient population.

Methods

Electronic databases Ovid, Medline, EMBASE, AMED, CINAHL, SCOPUS and CENTRAL were searched from inception to March 2018. Two reviewers independently applied the eligibility criteria to the search results by examining titles and abstracts. Studies that included patients with cancer pain, reported standardised QST assessment and written in English were included. Studies were excluded if they combined QST data from cancer and non-cancer patients, were case reports or only reported post-intervention outcome data. Full texts were reviewed of the papers which met the inclusion criteria and could not be excluded based on abstract or title. Disagreement on included studies was discussed with a third reviewer and consensus was reached. Data were collected on study characteristics, participants (age, gender, cancer diagnosis, pain aetiology), setting, outcome measures and results (QST modalities, patient reported outcome measures). The data were synthesised narratively around the different QST modalities. Narrative descriptions were grouped into tumour-related and treatment-related cancer pain.

Results

Searches identified 286 records of which 41 full texts were examined in detail. Of these, 18 studies met the eligibility criteria and were included in the systematic review. Three studies included patients with tumour-related pain, while 15 studies included patients with pain from chemotherapy-induced peripheral neuropathy (CIPN). Across all studies, 50% (9/18) reported sensory abnormities using thermal detection thresholds (cold and warm), 44% (8/18) reported abnormal mechanical detection thresholds using von-Frey filaments and 39% (7/18) found abnormal pin-prick thresholds. Abnormal vibration and thermal pain (heat/cold) thresholds were reported in a third of included studies, respectively. Studies varied in terms of the different procedures used to evaluate the same or similar QST parameters. Few studies made direct links between commonly reported symptoms in tumour-related or treatment-related cancer pain, the underlying pathophysiological mechanism and the selection of appropriate QST parameters.

Conclusion

The key finding from this systematic review was that there is a lack of published data characterising the phenotype of tumour-related pain using QST. However, there is an increase in QST studies of CIPN. Overall, there was a lack of justification for the choice of QST parameters. Consequently, it remains unclear whether the data represent sensory abnormalities common to cancer pain, or are a reflection of the QST parameters selected by the researchers. As such it remains unclear which sensory tests might prove most useful in the assessment and detection of neuropathic pain in patients with cancer pain.

30

THE INTRODUCTION OF ESSENTIAL PAIN MANAGEMENT UK, TRAIN THE TRAINER TO INTERMEDIATE ANAESTHETIC TRAINEES

Category: Education

Sailesh Mishra – Pain Management Unit, Royal Victoria Infirmary, Jennifer Noyes – Pain Management Unit, Royal Victoria Infirmary

Background

Essential Pain Management (EPM) UK is a growing pain education initiative endorsed by the Faculty of Pain Medicine. It has been embraced in the Tyne Base Unit of the Newcastle University where it is included in the fifth-year MBBS curriculum since 2015. Beyond MBBS students, EPM sessions have also been delivered to nursing students, nurses and other allied healthcare professionals. The expanding interest and use of EPM UK requires an increase in the number of trainers who can deliver this programme. We have piloted an EPM Train the Trainer (TTT) workshop, specifically aimed at intermediate (ST3 and ST4) anaesthetic trainees in the Northern School of Anaesthesia, to increase our local EPM UK trainers’ cohort and to deliver pain education in an innovative platform to our trainees.

Aims

The aims of this pilot were (1) to increase the number of EPM UK trainers in the North East of England, (2) to increase the confidence of intermediate trainees to deliver teaching and training and (3) to increase intermediate trainees’ knowledge of pain management.

Methods

We delivered a 2-hour EPM TTT workshop during the trainees Intermediate Pain Study Day. Trainees anonymously completed a pre- and post-workshop questionnaire. We asked the following questions, on a 0 to 5 point confidence scale:

How confident are you that you can adequately describe the pain pathway?

How confident are you that you could adequately teach the pain pathway to novices?

How confident are you that you could teach the RAT model of pain management?

How confident are you that you can adequately describe the site of action of common pain management drugs?

How confident are you that you can teach the site of action of common pain management drugs to novices?

How confident are you that you could deliver an EPM UK Lecture?

How confident are you that you could lead an EPM UK Discussion group?

How confident are you that you could run a Full EPM UK Workshop?

Results

A total of 16 intermediate anaesthetic trainees took part in the workshop. Pre-workshop, trainees were on average 3.1/5 confident that they could describe the pain pathway and 2.9/5 confident that they knew the location of action of pain management drugs. This increased to 4.5/5 and 4.3/5, respectively, after the workshop. Trainees’ confidence that they could teach EPM UK also increased across all the questions. In particular, the trainees’ confidence that they could deliver an EPM lecture increased from 1.2 to 4.0; lead a discussion group increased from 1.2 to 4.1 and run a full EPM programme from 1.1 to 3.6. The TTT workshop also received excellent feedback with 13/15 trainees rating it as excellent, 2 rating it as good while one trainee did not complete the feedback.

Conclusion

Delivering EPM UK TTT to intermediate anaesthetic trainees increases their own knowledge pain management. In addition, it increases trainees’ confidence to be able to train other healthcare professionals. After the workshop, trainees were in the range of ‘somewhat confident’ to run a full EPM workshop. It would be expected that after completing an EPM TTT workshop, trainees could co-deliver EPM UK with experienced faculty members, to improve their confidence to run a course independently on subsequent occasions. We suggest the introduction of EPM UK TTT in all deaneries as part of intermediate pain training.

31

PRACTICE-BASED EDUCATION TO IMPROVE PAIN MANAGEMENT: A SYSTEMATIC REVIEW

Category: Education

Amelia Swift – Institute of Clinical Sciences, University of Birmingham, Roses Parker – School of Health and Social Care, London South Bank University, Alison Twycross – School of Health and Social Care, London South Bank University

Background

Pain management in acute settings remains sub-optimal despite efforts to improve it. Improved attitudes, skills and knowledge achieved through workforce education is the most frequently cited solution.

Aims

To describe the methods used in and efficacy of practice-based pain education for post-registration/licensed health professionals.

Methods

A systematic review of the literature was conducted following the PRISMA guidelines using a range of synonyms for pain, education and clinical practice. Papers were excluded if there was no intentional educational intervention included (e.g. the focus was improvement in practice by protocol implementation without additional educational support). The quality of the studies was appraised using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Papers were reviewed by AS and RP, and graded before data extraction and synthesis.

Results

Fifty-seven papers were selected; most biased in participant selection, sampling, lack of attention to confounders and non-blinding of outcome assessors. Most were pre- and post-test quasi-experimental studies using convenience samples. Participants were nurses (n = 51), medics (n = 14), AHPs (n = 3) and pharmacists (n = 1). Interventions were usually brief (range, 15 minutes to 18 months) with a modal value of 3 hours. Approaches included didactic knowledge transfer (n = 43), group discussion (n = 25), case studies (n = 13), coaching (n = 13) and feedback about patient outcomes (n = 4). Content focused on pain theory including physiology, assessment, pharmacological and non-pharmacological management of pain. Some explored misconceptions, beliefs and attitudes towards pain management and few explored change management. Outcome measures included change in knowledge (n = 38), attitudes (n = 24) behaviours (n = 36) and confidence or self-efficacy (n = 5). Modal follow-up was 3 months with a range between immediately to 25 months. All but one study demonstrated improvements in outcome measures.

Conclusion

Educational interventions to improve pain management outcomes tend to use teaching and learning strategies that are known to be the least effective but are the most cost and time-efficient. Outcomes of these interventions are modest and there is limited evidence of sustained improvements. Improvements in workforce knowledge are not necessarily related to improvements in patient experience or outcomes. There is a need to agree core outcome measures to evaluate the efficacy of education and to design cost-effective teaching and learning strategies that can be tested in terms of improvements in patient outcomes.

32

CONFIDENCE IN PAIN MANAGEMENT AMONGST FOUNDATION YEAR 2 DOCTORS – CAN WE IMPROVE THE UNDERSTANDING OF THIS COMMON PROBLEM?

Category: Education

Milena Vannahme – Anaesthetics, Bradford Royal Infirmary, Ibrahim Mohamed – Anaesthetics, Bradford Royal Infirmary, Sanjeeva Gupta – Anaesthetics, Bradford Royal Infirmary

Background

While pain remains a frequently encountered problem in both primary and secondary care by all grades of doctors, it has been recognised that teaching of pain remains poorly represented in undergraduate medical school curricula. Foundation doctors are frequently expected to deal with pain issues, both acute and chronic, in various settings despite this lack of preparation. Teaching resources are available via both the e-learning website by BMJ Education and the Royal College of Anaesthetists. Pain management is also part of the Foundation Programme Curriculum and resources are available via the e-learning for Healthcare website.

Aims

We aimed to establish confidence in pain management among Foundation Year 2 (FY2) doctors and assess the impact of focused teaching sessions delivered by advanced pain trainees.

Methods

We organised a teaching session for FY2 doctors as part of their regional teaching programme at a teaching hospital. This was delivered by an advanced pain trainee, focusing on pain assessment and management, covering simple and more advanced therapeutic options, including issues surrounding chronic pain. Attending juniors were asked to complete a questionnaire before and after the session. This aimed to assess their understanding of their own ability to manage the above situations. A simple Likert-type scale (ranging from strongly disagree to strongly agree) was used for each of the six questions. Free text feedback was also used for feedback. Pre- and post-intervention questionnaires were compared using Microsoft Excel 2016.

Results

Out of the 26 who attended 17 pre- and 18 post-intervention questionnaires were returned. Analysis revealed that teaching resulted in a greater confidence in all six categories: pain assessment, pain management, precautions when using analgesia, knowledge surrounding patient-controlled analgesia, epidural analgesia and neuropathic pain. Free text feedback particularly highlighted the use of Parecoxib and understanding surrounding epidural analgesia as valuable learning points.

Conclusion

As can be expected based on the lack of pain teaching in undergraduate curricula, Foundation Doctors require further education on pain management. While numerous e-learning resources are available for self-directed learning we found a teaching session delivered by advanced pain trainees to be valuable in raising juniors’ confidence in managing pain issues.

33

MEDICATION CHOICES FOR PATIENTS WITH DIETARY RESTRICTIONS IN PAIN MEDICINE

Category: Education

Ivan Wong – Anaesthesia and Pain Medicine, Barts Health NHS Trust, Lorena Ward – Pain Medicine, Barts Health NHS Trust, Shehryar Khan – Pharmacy, Barts Health NHS Trust, Saz Snidvongs – Anaesthesia and Pain Medicine, Barts Health NHS Trust

Background

Patients may choose not to take medications that contain certain ingredients due to previous adverse response, allergy, food intolerance, dietary restriction, personal and cultural factors. Many analgesics are presented as liquid, capsule and tablet, which are made of complex chemical formulations. There is currently no easily accessible and reliable source of information for patients and clinicians to make informed decisions on different drug preparations for dietary restrictions. 8.7% of the UK population belongs to one of the following groups including vegetarian, vegan, halal and kosher. In our clinical practice, we often come across patients with different dietary restrictions, but there is currently no reliable system to identify preparations suitable for different dietary restrictions. Prescribing medication without considering dietary restrictions may lead to intolerance of medication and therefore loss of treatment opportunity as the patient may have adverse response to excipients rather than the active ingredient.

Aims

To identify dietary ingredients in commonly prescribed analgesic medications. Information collected is then included in a database that can be easily accessible by healthcare professionals. This provides clinicians with reliable and easily accessible information when making an informed decision with patients who have dietary restrictions.

Methods

Manufacturers of medications are contacted to obtain a list of available preparations for each class of commonly prescribed analgesics. Important ingredients for each drug preparation including plant products, animal products and additives are identified. Information is obtained from hospital pharmacy, manufacturer, Summary of Product Characteristics (SmPC), patient information leaflet and the electronic Medicines Compendium (eMC). The following categories of medications are included in the search, gabapentinoids – pregabalin and gabapentin; antidepressants – amitriptyline, nortriptyline, duloxetine; opioids – codeine, tramadol, tapentadol, morphine, oxycodone, fentanyl, buprenorphine; topical analgesics – lidocaine, capsaicin; non-steroidal anti-inflammatory drugs – ibuprofen and paracetamol. For each of the drug preparation, the following information is collected; animal products (gelatin, pork, beef, poultry, fish, shellfish, egg, dairy products); plant products (gluten, soy, nuts, latex) and any known cultural or religious factors (Halal, Kosher, Vegetarian, Vegan, alcohol).

Results

The following preparations used in our hospital Trust were identified; the number of preparations for each medication is in brackets. Gabapentinoids – pregabalin (12) and gabapentin (12); antidepressants – amitriptyline (5), nortriptyline (3), duloxetine (10); opioids – codeine (22), tramadol (12), tapentadol (3), morphine (11), oxycodone (16), fentanyl (10), buprenorphine (24); topical analgesics – lidocaine (2), capsaicin (3); non-steroidal anti-inflammatory drugs – ibuprofen (>100) and paracetamol (>100). A number of important animal, plant and chemical products are used commonly as excipients. Animal products identified include lactose and gelatin. Plant products identified include starch, gluten, sucrose and citric acid. Chemical products identified include talc, E products, alcohol, titanium dioxide, silica, food colourings and propylene glycol.

Conclusion

A systematic review of commonly prescribed analgesics in the United Kingdom was performed to identify the important food and chemical ingredients. The database can assist healthcare professionals when making prescribing decisions for patients with dietary restrictions.

34

EVALUATING THE IMPACT OF EDUCATION PROGRAMME ON IMPROVING NURSING KNOWLEDGE AND ATTITUDES TOWARDS PAIN WITHIN A DISTRICT GENERAL HOSPITAL

Category: Education

Martin Galligan – Acute Pain, Homerton University Hospital NHS Foundation Trust

Background

Pain after surgery is arguably one of the most common symptoms reported by patients. Acute pain management continues to be a challenge faced by healthcare professionals. Following a seminal report by Royal College of Surgeons and Royal College of Anaesthetists (1990) which estimated the incidents of severe pain in the post-operative setting ranged from 31% to 75%. Moving forward to modern-day practice, the incidence of pain has remained largely unchanged with 75% of patients continuing to report moderate to severe pain. A lack of knowledge and awareness of pain by health care professions continues to be a major contributing factor to the under treatment of pain. It is well documented throughout the literature that a lack of pain education is a major contributing factor to the under treatment of pain. Despite this there continues to be a significant lack of pain education in both pre-registration nursing and medical students.

Aims

To assess the impact of education programme on nursing knowledge and attitudes towards pain assessment and management.

Methods

A survey was designed to evaluate nursing staff’s current level of knowledge and attitudes towards pain assessment and management. The survey was based on the widely used and validated Ferrell and McCaffery (2014) knowledge and attitudes survey. This was reduced from 38 to 16 questions based on feedback from senior nursing team in order to improve compliance in completing. The survey consisted of 11 true or false questions, 3 multiple-choice questions and two vignettes. Surveys were distributed over a 4-week period in December 2017. Based on the results from this survey, an extension education programme was then developed and delivered trust wide. Those in attendance at the study day days were then invited to complete the survey in October 2018. An audit standard of 80% pass mark as a bench mark of adequate level of knowledge as recommended by Ferrell and McCaffery (2014).

Results

A total of 58 surveys were completed in the base line audit and a further 65 were completed following educational interventions. The mean score increased from 73% to 76% following educational interventions. There was also an increase in participants achieving a score of greater than 80% from 41% to 48%. Individual question analysis also revealed a significant improvement across the majority of questions following educational intervention. Knowledge surrounding pharmacology, pain assessment and belief in patient’s report of pain improved.

Conclusion

The results of this audit have identified gaps in knowledge surrounding pain assessment and management which is consistent with the literature. Through implementation of a targeted education programme, there has been an improvement in overall knowledge of registered nurses.

35

EVALUATING THE EFFECTIVENESS OF ESSENTIAL PAIN MANAGEMENT PROGRAMME IN IMPROVING HEALTHCARE PROFESSIONALS KNOWLEDGE OF PAIN MANAGEMENT

Category: Education

Martin Galligan – Acute Pain, Homerton University Hospital NHS Foundation Trust, Roshinah Shookhye – Acute Pain, Homerton University Hospital NHS Foundation Trust

Background

The assessment and management of pain in today’s healthcare setting continues to be challenging. The main cause of this is thought to be related to a lack of knowledge from health care professionals. Although it is well documented in the literature that lack of pain education is a major contributing cause, there continues to be a significant lack of pain education in pre-registration nursing and medical undergraduate programmes. The Essential Pain Management (EPM) programme was developed by Australia and New Zealand Faculty of Pain Medicine. The aim of the course was to address the growing knowledge gaps of professionals in relation to pain in a simple and easy format. EPM has now been adopted worldwide with courses being held internationally. The course is a half-day workshop that aims to cover the principles of pain physiology, assessment and management. It also introduces learners to a systematic method for the assessment.

Aims

To evaluate the efficacy of the EPM programme as a method of improving knowledge of pain in health care professionals.

Methods

Participants at EPM course were asked to complete the pre- and post-course questionnaire as designed by EPM Lite UK. The pre-course consisted of 25 true or false questions and the post-course then had an additional 25 questions making it 50 questions in total. For the purpose of data analysis, only the first 25 questions in the post-course questionnaire were compared with pre-course test to allow for meaningful comparison in scores.

Results

A total of 51 participants attended over 4 study days, 42 participants completed the pre-course questionnaire with 4 being discounted as incomplete and 5 not returned. In total, 46 participants completed the post-course questionnaire with 4 being discounted as incomplete and 1 not returned. The results found that mean score pre-course was 69.04% following educational intervention of EPM Lite study day this increased to 73.82% in post-course questionnaire. Further informal questioning of the candidates identified that 80% did not have any formal pain education during undergraduate study and 98% felt that current pain education in the undergraduate setting is not adequate.

Conclusion

The results demonstrate the EPM teaching resulted in an increase in post-course test scores which would indicate that it is an effective method of improving pain knowledge. The EPM programme will now be incorporated into all pain teaching across the trust with the aim of standardising the RAT model as a method of assessing and managing pain.

36

THE EFFECT OF DIFFERENT STAGES OF THE MENSTRUAL CYCLE ON PAIN SENSITIVITY: RESPONSES OF HEALTHY ARABS AND WHITE BRITISH WOMEN

Category: Experimental (Basic) Science

Aseel Ibrahim Alyahyawi – School of Clinical and Applied Sciences, Leeds Beckett University, Ghazala Tabasam – School of Clinical and Applied Sciences, Leeds Beckett University, Ian Hurley – School of Clinical and Applied Sciences, Leeds Beckett University, Sabri Garoushi – MENA Research Group, School of Clinical and Applied Sciences, Leeds Beckett University, Osama A Tashani – MENA Research Group, School of Clinical and Applied Sciences, Leeds Beckett University

Background

Response to pain can be affected by individual socio-cultural aspects (e.g. ethnicity) and in women can also be affected by the stage of menstrual cycle and/or the different hormone levels.

Aims

In this study, the aim was to investigate whether the stage of menstrual cycle as measured by progesterone level in the saliva is a predictor of experimental pain sensitivity in two different ethnic groups.

Methods

A total of 30 female participants (15 Arabs and 15 White British) were recruited to take part in this study and their average age was 22.7 years. All participants went through two cycles of cold pressor task in which their pain threshold, the first expression of pain and tolerance (how long they could tolerate pain) were recorded in seconds after putting their hands up to the wrist in a bucket of ice slurry (temperate 1°C–2°C). All participants then had to rate their pain intensity and level of unpleasantness on an analogue visual scale anchored between 0 mm = no pain/not unpleasant at all to 100 mm = the worst pain/most unpleasant imaginable. Participants’ mechanical pain threshold was also measured in kilopascal (kPa) after applying pressure on the thenar eminence using a Somedic hand-held digital algometer. Saliva samples were collected to measure the progesterone levels using Abcam’s Progesterone ELISA.

Results

The pain sensitivity response of the women participants as per their self-declared ethnicity showed that Arab women had a slightly higher cold pressor threshold (mean ± SD = 28.1 ± 5.5 seconds) compared with White British women (18.1 ± 4.0 seconds) (t = 2.4, p = 0.03). There were no significant differences between the two groups in all other pain responses. Forward regression analysis of the effect of independent factors (age, concentration of salivary progesterone, being in follicular or luteal phase of the menstrual cycle, ethnicity and use of contraception) on pain responses revealed that ethnicity was the predictor for cold pressor threshold (standardised coefficient beta =–0.41, t =–2.4, p = 0.025) while stage of the menstrual cycle was the predictor of the mechanical pain threshold (standardised coefficient beta = 0.36, t = 2.07, p = 0.048). Regardless of ethnicity, women in the follicular phase were more likely to be more sensitive to pressure pain than women in the luteal phase (558.3 ± 123.4 kPa vs 659.9 ± 104.2 kPa, respectively).

Conclusion

The overall findings from this study suggest that the stage of menstrual cycle as measured by progesterone level in the saliva can influence mechanical pain sensitivity, and ethnicity may affect cold pressor task pain threshold. However, these two factors, menstrual stage and ethnicity, had little effect on pain tolerance and the evaluative aspects of pain responses (i.e. ratings of pain intensity and unpleasantness).

37

PARTICIPANT-CHOSEN MUSIC IS MORE EFFECTIVE THAN OBSERVER-ASSIGNED MUSIC OR NO MUSIC IN REDUCING EXPERIMENTAL PAIN THRESHOLD AND TOLERANCE

Category: Experimental (Basic) Science

Reece Dean – School of Clinical and Applied Sciences, Leeds Beckett University, Osama Tashani – School of Clinical and Applied Sciences, Leeds Beckett University

Background

There is evidence that using music in association with other mainstream interventions could improve pain relief of post-surgical pain. However, there is little research on what type of music is more influential in reducing pain.

Aims

The aim of this research is to compare the effectiveness of observer-assigned music and participant-chosen music in reducing experimentally induced pain.

Methods

In total, 15 participants (7 females), aged between 18 and 35 years, undertook 3 cold pressor task cycles while listening to no music, observer-assigned music and their own chosen music in a randomised order. Pain threshold, when they first feel pain, and tolerance, when they longer cannot tolerate pain, were measured in seconds. Participants’ pain intensity ratings score was marked on a 100 mm visual analogue scale from no pain at all (0 mm) to the worst pain imaginable (100 mm). A one-way repeated-measures analysis of variance (ANOVA) was conducted to compare the effect of experimental conditions on the average of the three cycles of cold pressor task’s pain sensitivity responses.

Results

There was a significant effect of the music type on pain threshold, Wilks’ Lambda = 0.28, F (2, 3) = 15.14, p = 0.002, and pain tolerance, Wilks’ Lambda = 0.29, F (2, 3) = 14.44, p = 0.001, but not on pain intensity ratings; Wilks’ Lambda = 0.72, F (2, 3) = 2.23, p = 0.150. Pairwise comparisons showed that participant-chosen music improved the cold pressor pain threshold (mean ± SD, 24.1 ± 13.7 seconds) and pain tolerance (43.6 ± 19.1 seconds) when compared to observer-assigned music (threshold = 19.5 ± 7.8 seconds, tolerance = 35.2 ± 10.6 seconds) and no music at all (threshold = 12.8 ± 5.6 seconds, tolerance = 28.3 ± 10.1 seconds), all tests were significant at p < 0.05. However, there is no real difference between the experimental conditions on the intensity ratings. Males had significantly higher pain threshold scores than females.

Conclusion

The use of participant-chosen music is a useful method of managing experimentally induced cold pressor pain. It may be beneficial for music therapists to specifically cater the music selection to the individual as opposed to the use of more traditionally ‘relaxing’ music.

38

OCCIPITAL NERVE BLOCK FOR CHRONIC MIGRAINE

Category: Interventional Pain Management

Magdy Aglan – Chronic Pain Service, Burnley General Teaching Hospital

Background

Chronic migraine headache is common, affecting 7.6% of males and 18.3% of females in the United Kingdom. World Health Organization (WHO) classifies severe migraine among the most disabling illnesses comparable to quadriplegia. The personal, social and economic burden of headache is substantial. Migraine is estimated to cost the NHS £3.42 billion a year considering healthcare cost and loss of productivity (absenteeism and presenteeism). Headache accounts for 33% of new referrals to neurology and is the most common neurological reason for Emergency Room (ER) attendance. Our Pain Management service receives migraine and headache patients’ referrals from the Neurology Department after failure to respond to multiple medication trials. We assess the patient in a multidisciplinary approach and offer clinical psychology and injections including trigger points injections, Botox and occipital nerve blocks (ONB). ONB have been shown to relieve headache pain. A small study suggested greater ONB is effective for migraine patients presenting to the ER.

Aims

The aim was to evaluate the effectiveness of ONB for chronic migraine patients who presented to our chronic pain service over the last 2 years. The main outcome measure was the number of headache days/month. Other outcome measures were parameters of the brief pain inventory (daily activity, sleep and mood).

Methods

Retrospective study: Pain lists from the previous 2 years (May 2016–April 2018) were reviewed to identify patients who had ONB. Patient notes were reviewed to identify patients who had the diagnosis of migraine (by the Neurology department) with complete records (headache diary and Brief Pain Inventory before ONB and after the treatment in a follow-up appointment 3–6 months after treatment). The general term ONB was used since the most tender occipital point injection (unilateral/bilateral) may cover the greater, lesser or third occipital nerves. Injected drugs were recorded. Personal data were collected (age, sex and duration of pain). Headache parameters collected were frequency of attacks (number of headache days/month), average duration of headache attack, severity of pain (VAS) and level of background pain. Effects of migraine on daily activity, sleep and mood as recorded on the BPI (score out of 10). Any side effects after ONB were reported.

Results

Of 51 patients who had ONB, 31 patients had migraine with complete records (22 females, 9 males). Five patients had no benefit (<30% improvement) and 26 patients (83%) had >30% improvement. The mean number of headache days (HD) per patient was 21 HD/month before and 9 HD/month after ONB (57% improvement). In total, 16 patients (52%) had >50% improvement and 7 patients (23%) had >75% improvement. The mean value for migraine attacks’ duration was 3.5 hours before and 1 hour after ONB (63% improvement). Baseline VAS of headache attack was 9.5 and 3 after ONB (72% improvement). The mean score of migraine effects on daily activity, sleep and mood was 8, 9 and 9.5 before and 4, 3 and 4 after ONB representing 50%, 66% and 61% improvement, respectively. One patient developed occipital haematoma, another had dizziness and two more had a temporary increase in local pain and tenderness.

Conclusion

Chronic migraine is a common and disabling condition. Migraine has serious effects on patients and the NHS. Occipital tenderness is a common finding in migraine patients and should be looked for. Our results showed that ONB reduced mean headache days/month by 83% and improved migraine attack’s duration and severity by >63%. Effects on daily activity, sleep and mood improved by >50%. Our results suggest that ONB is an effective, simple and safe procedure. It could be valuable for chronic migraine treatment. The impact of our results is limited because of small number of patients and retrospective nature of the study.

39

GENICULAR NERVE ABLATION – ANALYSIS OF OUTCOMES USING OXFORD KNEE SCORE

Category: Interventional Pain Management

Joel Perfitt – Chronic Pain Service, Northern General Hospital, Sheffield, Tom Bendinger – Chronic Pain Service, Northern General Hospital, Sheffield

Background

Knee pain is a common health problem associated with significant disability. The commonest cause of significant knee pain is osteoarthritis (OA). Multiple therapeutic options exist including: physiotherapy, analgesics and total knee arthroplasty (TKA). TKA is an effective treatment for many patients with knee OA and is commonly performed but has a high cost. Despite good results in many patients, approximately 20% continue to suffer from pain and disability after TKA. TKA is not an appropriate treatment for young patients, or patients for whom anaesthesia and surgery may be hazardous. Pharmacological analgesic strategies are helpful in some patients but their effect is often limited and side effects are common. Intra-articular steroid injections only provide short-term benefit. Ablation of the genicular nerves is an emerging treatment for knee pain. This offers an inexpensive, minimally invasive, non-surgical and non-pharmacological option for managing knee pain.

Aims

We aimed to assess the effectiveness of genicular nerve ablation procedures, using the Oxford Knee Score. We analysed both pain and functional change from baseline using this tool. Secondary aims were comparison between radiofrequency and alcohol ablation and assessment of risk factors for failure to respond.

Methods

This was a prospective observational study of existing practice within our pain service. Patients were listed for genicular nerve ablation on the basis of clinical assessment and positive response to diagnostic genicular block with local anaesthetic (70% pain reduction). Patients were then asked to self-complete an Oxford Knee Score (OKS) assessment prior to ablation. Ablation of genicular nerves was performed using either bipolar radiofrequency needle technique or alcohol ablation using 75% absolute alcohol. Post-procedure OKS were collected from the patient during routine clinic follow-up between 10 and 16 weeks post-procedure. Patients reporting no improvement were recorded with the same OKS pre and post. Data were collected on OKS (pre- and post-procedure), demographics, complications and previous surgery. Mean change in score was calculated as well as numbers of responders and non-responders. OKS was further analysed as a pain sub score (OKS-P), and functional score (OKS-F). Lower scores represent more significant pain/disability.

Results

So far, 14 patients have been included with complete data available. At least a further 12 patients are awaiting follow up and are expected to be added to the data prior to completion of this work. Of the 14 patients, three received alcohol ablation and 11 radiofrequency. No procedure-related complications were reported. Mean scoring prior to procedure; OKS = 16.6/48, OKS-F = 7.9/20, OKS-P = 8.7/28. Mean scores post-procedure improved in comparison to baseline; OKS 24.5 (increase of 7.9/48) p = 0.05, OKS-F = 9.8 (increase of 1.9/20) p = 0.199, OKS-P = 14.7 (increase of 6.0/28) p = 0.032. Further data are awaited for analysis of risk factors and comparison between alcohol and RF ablation but the preliminary data favour alcohol ablation improving OKS-P from 4.6 to 17.6 versus RF ablation OKS-P from 9.8 to 13.9.

Conclusion

Knee pain is associated with significant disability as demonstrated by our data. Nine of 14 (64%) patients had OKS <20 which is an indicator of severe disease. Treatment that reduces pain with minimal side effects or risk is likely to be of great benefit. These preliminary data indicate that genicular nerve ablation reduces pain and improves function in the medium term for these patients, without significant complications. Greatest improvements were seen in the pain-severity portion of the OKS, indicating greater effectiveness in reducing pain than improving function after treatment. Further data are awaited and must be analysed prior to making definite conclusions.

40

DORSAL ROOT GANGLION STIMULATION – ANALYSIS OF REVISION RATES

Category: Interventional Pain Management

Joel Perfitt – Chronic Pain Service, Northern General Hospital, Sheffield, Nick Plunkett – Chronic Pain Service, Northern General Hospital, Sheffield

Background

Dorsal root ganglion stimulation (DRGS) is a form of implantable neuromodulation using electrical stimulation of dorsal root ganglion. It is a recognised treatment for severe, chronic peripheral neuropathic pain. It has several advantages over conventional spinal cord stimulator (SCS) therapy, including the ability to provide more targeted therapy to the painful area. DRG stimulation has been available in the United Kingdom since 2011 and is a much newer therapy than conventional SCS. Despite its similarities, there are some significant differences and with any new technique or therapy there is expected to be a learning curve as knowledge and skills are developed. Our institution is a tertiary pain service in the United Kingdom and has been implanting DRG stimulators since 2014 alongside our established practice in conventional SCS.

Aims

The aim of this project was to establish the incidence of complications or technical problems requiring revision in patients receiving DRG stimulation therapy. We wanted to establish the rate of revision procedures over time and identify any trends.

Methods

Inclusion criteria were all patients who had full second-stage DRG stimulator inserted at our institution from March 2014 to July 2018. This was a total of 52 months. We performed a paper notes review of all patients, supported by electronic records. Data were collected for demographics, date of DRG insertion, number of leads and site of insertion, indication and number of revision procedures. Numbers of revisions were cross-referenced against electronic theatre records to ensure accuracy. Total days of DRG stimulation and mean revision rate over the 54 months were calculated for the entire cohort. Revision rates were expressed as number of revisions per 100 days, and revisions per 100 lead-days (Lead-days = number of leads × days). We then divided the data by year of insertion and calculated the revision rate for each year of insertion to identify any trends.

Results

A total of 22 patients fulfilled the inclusion criteria and were included for analysis. Mean age at implantation was 48 years. Two patients received two DRG leads, making total number of leads inserted 24. Five patients received cervical leads, five thoracic leads and twelve received lumbar leads. Total number of days DRG stimulation was 20,072 days (22,851 lead-days). There were a total of 26 revision procedures. Nine revision procedures related to the battery/IPG portion and 17 to the lead system (non-IPG related). One stimulator system was removed without re-implantation. The rate of revision across the cohort was 0.13 revisions/100 days of stimulation, or 0.114/100 lead-days of stimulation. This equates to one revision every 769 days per patient. When analysed by insertion year, revision rate decreased over time. The rate of revision in the 2014 cohort was 0.235/100 days decreasing to 0.054 in the 2017 cohort. This represents a 435% decrease over 3 years.

Conclusion

We have established that the revision rate at our institution over the last 4 years is one revision every 769 days per patient. This allows us to inform our patients when considering this therapy. We have demonstrated a clear learning curve during the introduction of this new treatment. It is reassuring that our practice has improved over time. Therefore, for prospective patients, the revision rate is highly likely to be lower than one per 769 days. The information from this study may inform institutions implementing this treatment. A significant learning curve can be expected based on this data.

41

SACROILIAC JOINT DENERVATION – SINGLE-CENTRE EXPERIENCE

Category: Interventional Pain Management

Ravi Kare – Anaesthetics and Pain Management, Norfolk and Norwich University Hospitals NHS Foundation Trust, Amit Gadre – Anaesthetics and Pain Management, Norfolk and Norwich University Hospitals NHS Foundation Trust

Background

Sacroiliac joint (SIJ) syndrome is diagnosed in 10–25% of cases of lower back pain. The response to traditional radiofrequency (RF) denervation of the SIJ has being inconsistent. A study examining pain referral patterns resulting from SIJ pathology has reported findings of 94% buttock pain, 72% lumbar pain, 50% with pain in the lower extremity, 28% pain below the knee and 14% to the groin. There is great variability of pain referral patterns from SIJ dysfunction, and thus limits their use for diagnostic purposes. The SI joint was first implicated as a source of pain as early as 1905. The SI joint is a true synovial joint and the largest axial joint in the body. It is supported by a complex series of both muscles and ligaments. The superior two-thirds of the joint space is filled with fibrous cartilage. Because nociceptors are present in the joint capsule and surrounding ligaments, pain can be provoked by both distention of the joint capsule and stimulation of the ligaments. SI joint innervation is complex and arises from both the ventral and dorsal rami of the spinal nerve roots. Both the anterior and posterior limbs of the joint are innervated, hence achieving proper denervation can be challenging.

Aims

A service evaluation study to review the outcomes in terms of pain intensity and functional improvement in patients who had undergone RF ablation at our hospital over the last 18 months, using either multiple lateral branch ablation or the Simplicity IIIR Probe. The period of follow up the side of the block as well as outcome of relief obtained was reviewed.

Methods

Retrospective review of follow-ups case note review, using electronic templateR as well as Synapse PACSR Images was done for all the SI joint denervation procedures carried out over 18-month period (2016–2018), of the benefit as well as the date of follow-up along with the side of block and the method used was seen.

Results

A total of 22 patient episodes were identified during this period. Out of these 14 were with non-simplicity probes using while 8 were with simplicity probes. The period of follow-up varied from 3 to 6 months. Seven of 22 had a follow up at 3 months while 4/22 at 6 months. For the rest, the follow-up period was between 2 and 5 months, 10/22 had a left SI joint denervation, 1/22 had bilateral and 9/22 had on the right. Nine (64%) patients in the non-simplicity group had good pain relief at the time of follow-up. Two had minimal benefit while three did not have any benefit. Three (33%) patients in the simplicity group had good pain relief (>50% relief for >6 months) while in one patient had moderate short-lived benefit (<6 months). Three patients (33%) did not have benefit at follow-up, while two are awaiting follow-up.

Conclusion

This re-emphasises the variable outcomes with SI Joint denervation procedures. The review also highlights whether more suitable selection with lateral branch blocks using local anaesthetic only may be a better screening method. The limitations of the study are that a small number of procedures are done, and also the methods used for denervation, that is, the needles as well as approaches, are different. The non-simplicity methods were using palisade lesioning. The use of Simplicity III in our institution is relatively new and may improve with experience of the operating surgeon. Outcome evaluation would also be better when using IMMPACT (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials) recommendations.

42

A REAL-WORLD FOLLOW-UP OF PAIN, DEPRESSION AND QUALITY OF LIFE OUTCOMES IN A UK NEUROMODULATION CENTRE

Category: Interventional Pain Management

Angie Alamgir – Barts Neuromodulation Centre, Barts Health NHS Trust, Richard Van Groningen – Barts Neuromodulation Centre, Barts Health NHS Trust, Habib Ellamushi – Barts Neuromodulation Centre, Barts Health NHS Trust, Joanne Lascelles – Barts Neuromodulation Centre, Barts Health NHS Trust, Vivek Mehta – Barts Neuromodulation Centre, Barts Health NHS Trust, Serge Nikolic – Barts Neuromodulation Centre, Barts Health NHS Trust

Background

Barts Neuromodulation Centre is a centre of excellence for research and innovation. In the United Kingdom, the NICE 159 guidelines have highlighted the importance of psychological and multidisciplinary assessment to ascertain the suitability of patients for neuromodulation.

Aims

To evaluate the impact of neuromodulation on pain, psychological and quality-of-life parameters over a 2-year period.

Methods

Over 2 years, measures including the Brief Pain Inventory (BPI), Hospital Anxiety and Depression Scale (HADS), Pain Self-Efficacy Questionnaire (PSEQ) and EuroQol-5D (EQ-5D) were given to patients attending the Bart’s Health NHS Neuromodulation Centre at baseline, 1-month, 3-month, 6-month and 1-year intervals. Patients were assessed by a specialist MDT consisting of a Consultant in Pain Management, Consultant Neurosurgeons, Consultant Psychologist with nursing support. Demographic data and medical history were recorded at baselines. Patients were provided with the questionnaires during face-to-face interviews. All the data were collected by an independent investigator for analysis.

Results

A total of 239 patients were treated, mean age was 53 and 57% were female. Results indicated promising improvements across various indicators. Please refer to graphs for full breakdown of results. BPI – Pain Severity (score 0–10); at baseline, the mean pain severity was 7.3 and at 6 months 3.2 (a decrease of 56.2% vs baseline); HADS – Anxiety & Depression (score 0–21); at baseline, the mean anxiety score was 11.4 and at 6 months 5.9 (a decrease of 48.3% vs baseline); at baseline, the mean depression score was 11.1 and at 6 months 4.8 (a decrease of 56.7% vs baseline); PSEQ Pain-Self Efficacy (0–60); at baseline, the mean pain self-efficacy score was 20.1 and at 6 months 42 (an increase of 109% vs baseline); EQ5D VAS Score – Quality of Life (0–100); at baseline, the mean pain QOL score was 45.6 and at 6 months 66.4 (an increase of 46% vs baseline).

Conclusion

The prospective follow up of this cohort of patients demonstrates marked improvements in pain severity, depression, anxiety, self-efficacy and quality-of-life parameters in patients with intractable neuropathic pain and improvements were maintained at >12 months.

43

PATIENT-REPORTED OUTCOME MEASURES FOLLOWING INTERVENTIONAL PROCEDURES

Category: Interventional Pain Management

Sanjay Bhandari – Pain Services, Calderdale and Huddersfield NHS Foundation Trust, Pravin Dandegaonkar – Pain Services, Calderdale and Huddersfield NHS Foundation Trust

Background

Almost 10 million Britons suffer pain almost daily resulting in a major impact on their quality of life and more days off work. The costs of back pain alone account for 20% of the UK’s total health expenditure. An increasing number of patients are undergoing interventional pain procedures, though the evidence for some of these procedures is limited. In order to evaluate the effectiveness and safety of interventional pain procedures, we performed a retrospective study looking at various simple patient-reported outcomes after such procedures.

Aims

The aim of this study was to identify whether interventional pain procedures are effective in the management of chronic pain and to know if patients would like to undergo this modality of treatment in future as well.

Methods

We conducted a retrospective service evaluation study involving patients with chronic pain who underwent image guided interventional pain procedures over 3 months at our District General Hospital. A pre-designed questionnaire was used to enquire about the degree of pain relief and its duration, effects on sleep, mobility and pain medications, change in the quality of life and any side effects secondary to the procedure. They were also asked if they would like to have such procedure in future if clinically indicated. The data were collected over the phone and entered into an excel sheet directly. The patients who did not answer the first time were given two further calls (3 in total). The data were analysed once all the information was collected.

Results

Seventy-two percent (93 out of 129) patients responded to the questionnaire with male:female ratio of 3:1 and age range of 26–88 years. Most common procedures performed were epidurals (Caudal, Lumbar), suprascapular nerve blocks, sacroiliac joint injections and facet interventions. In total, 71 patients (about 77%) found improvement in pain symptoms, of which 51% of the patients reported over >60% pain relief, 20% reported 30–60% benefit. Duration of pain relief was variable with 48% saying it lasted for more than 8 weeks. About 50% of the patients were able to reduce the amount of analgesics taken and showed improvement in sleep while 61% stated that the quality of life had improved after interventions. Only one patient had transient numbness around injection site but none of the patients experienced any complications. Ninety-two percent (86 out of 93) patients said that they will have the procedure again if necessary in the future.

Conclusion

Interventional pain procedures in carefully selected patients prove to have benefit not only in terms of pain but other patient-reported outcomes. The simple outcome tool can be effectively used as a substitute for expensive commercially available outcome databases. Local individual clinician data and data for the services can be used for informing patients as well as serves as an evidence to showcase value of interventions to the commissioners.

44

DIFFERENCES BETWEEN CLINICIAN-LED AND PATIENT-LED MANAGEMENT OF FIBROMYALGIA: RESULTS FROM A WORLDWIDE SURVEY

Category: Interventional Pain Management

Pamela Andrews – School of Health and Life Sciences, Glasgow Caledonian University, Martijn Steultjens – School of Health and Life Sciences, Glasgow Caledonian University

Background

Fibromyalgia is a unique condition that affects an estimated 2% of the global population. Fibromyalgia patients often present with multiple symptoms and the condition often coexists with other chronic diseases, which makes management even more complex. Clinicians often use their experience and evidence to guide clinical decision-making whereas patients may be more likely to explore other options based on their symptoms, recommendations from other patients with less emphasis on evidence-based medicine.

Aims

To understand the differences in clinician-led management versus patient-led management strategies in fibromyalgia.

Methods

Participants with self-reported fibromyalgia were recruited via social media (e.g. Facebook and Twitter) and charity websites (e.g. NFA and FMAUK) to participate in this web-based anonymous survey. Data were collected and managed using REDCap and were approved by Glasgow Caledonian University Ethics Committee. The survey was developed for the purposes of the study and was part of a wider project to collect information surrounding the diagnosis and management of FM. The survey was available online between February 2016 and August 2016.

Results

A total of 1296 individuals from 26 countries agreed to participate. 95.4% were female with a mean age of 45.1 ± 11.4 years. Individuals presented with multiple symptoms (5.4 ± 4.4) and pain in multiple locations (11.0 ± 5.3). Individuals were most likely managed by their general practitioner. Only 46.4% of individuals were provided with a clinician-led treatment plan, and of those only 52.4% were satisfied with the plan provided. Individuals were prescribed on average 7.2 ± 4.4 different types of medication with opioid analgesics and antidepressants being the most common. Individuals were also prescribed on average 3.1 ± 4.1 non-pharmacological strategies with physical exercise and psychosocial treatments being the most common. 51.7% of individuals took medications not prescribed to them with herbal medications and vitamin supplementation being the most common. When self-selecting non-pharmacological strategies, individuals tried on average 3.9 ± 4.6 treatments with manual therapies and complementary and alternative medicines being the most common strategies selected.

Conclusion

The results presented here indicate that there may be differences between what patients are being prescribed versus what they would choose themselves. The results indicate that patients are more likely to try more alternative options over more traditional methods to manage their symptoms. Future management guidelines where the patient needs are incorporated to allow a more personalised approach to their long-term care are warranted.

45

INTRADISCAL OZONE FOR BACKACHE, A PAKISTANI EXPERIENCE

Category: Interventional Pain Management

Shahzad Bhatti – Department of Interventional Radiology, Sir Ganga Ram Hospital

Background

Ozone is an upcoming remedy for most of musculoskeletal-related pains specially for backache. Directly injecting oxygen ozone into the discs has proved to be the effective alternative for surgery in patients with disc herniation.

Aims

Experience is shared with patient undergoing ozonucleolysis affected by lower backache and sciatica due to disc herniation including post-operative recurrence. The aim is to find a non-surgical method to treat disc herniation with minimal morbidity.

Methods

A total of 38,000 patients were treated with single to multiple sessions of Oxygen Ozone therapy from January 2008 to June 2018. All the patients had MRI evidence of annulus tear/disc prolapse with clinical signs of nerve root compression. All the patients received intradiscal injection of Oxygen Ozone mixture under angiofloro with 22/23 G cheeba needle at an ozone concentration 27 µg/mL with peri ganglionic infiltration with depomedrol and 1% xylocaine. Males were 24,790 and 13,210 females between the ages of 18 and 80 years. Therapeutic outcome was assessed 5 months after treatment using modified MacNab method.

Results

A satisfactory therapeutic outcome was obtained. Seventy-five percent showed signs of recovery. Among them 55% of the patients showed complete recovery with resolution of symptoms. Twenty percent of the patients complained of occasional episodic pain and with no limitation of occupational activity. Fifteen percent of cases showed insufficient improvement. Five percent of cases had insufficient improvement and went for surgery. Five percent of cases never turned up after the first visit.

Conclusion

Intradiscal injection of Ozone for herniated discs has revolutionised percutaneous approach to nerve root diseases making it safer, cheaper and easier to repeat than treatments currently used in Pakistan.

46

OUTCOMES USING AN SCS DEVICE CAPABLE OF DELIVERING COMBINATION THERAPY (SIMULTANEOUS OR SEQUENTIAL) AND ADVANCED WAVEFORMS/FIELD SHAPES

Category: Interventional Pain Management

Clark Metzger – Spinal Surgery, NeuroMicroSpine, Blake Hammond – Spinal Surgery, NeuroMicroSpine, Stephen T Pyles – Pain Management, Pain Treatment Centers, Anthony Berg – Pain Management, Spine Team Texas, Romanth Waghmarae – Pain Management, Advanced Pain and Wellness Institute, James North – Pain Management, Carolinas Pain Institute, Yu Pei – Clinical Research, Boston Scientific, Roshini Jain – Clinical Research, Boston Scientific

Background

Developing ‘all in one’ spinal cord stimulation (SCS) systems with capability for multiple types of neurostimulation paradigms will likely empower patients to identify the best treatment approach suitable for their own needs. As these SCS systems continue to come ‘online’, it will be important to track and evaluate how patients use these devices and associated clinical outcomes.

Aims

We report real-world outcomes in patients using an SCS system designed to combine multiple waveform availability, both sequentially and simultaneously, with an algorithm designed to enable highly manipulatable control of stimulation field shape.

Methods

This is a consecutive, multi-centre case-series of patients based on retrospective chart review (Clinicaltrials.gov identifier: NCT01550575). Patients were implanted with an SCS system (Precision Spectra WaveWriter, Boston Scientific) capable of combination therapy (either sequential or simultaneous), multiple waveforms and advanced field shapes, and waveform automation for treatment of low back and/or leg pain. Data collection includes (1) baseline characteristics, (2) procedural information and (3) pre- and post-implant numerical rating scale pain intensities (0–10 NRS).

Results

To date, 217 patients have been analysed. A statistically significant improvement in overall targeted pain scores (NRS) at last follow-up was reported (baseline NRS: 7.5; at last follow-up (96.6 ± 80.9 days) NRS: 2.4; p < 0.0001). Thirty-nine percent of all patients indicated >80% pain relief at their last follow-up. Twenty-two percent (48 of 217) reported being pain free (NRS = 0) at last follow-up. Updated data will be presented.

Conclusion

Given the overall diversity of etiologies and experiences associated with chronic pain, the SCS-implanted patient population may particularly benefit from devices with considerable adaptability providing for individualised treatment customisation. This study provides initial clinical experience regarding use of an SCS system capable of offering combination therapy and waveform automation.

47

CASE-SERIES ASSESSMENT IN EUROPE OF A NEW PERCUTANEOUS SCS LEAD FOR MULTI-SITE AND/OR EVOLUTIVE PAIN PATTERNS

Category: Interventional Pain Management

Sarah Love-Jones – Anaesthetics, Southmead Hospital, Adam Williams – Neurosurgery, Southmead Hospital, Jose Francisco Paz-Solis – Department of Neurosurgery, University Hospital La Paz, Yu Pei – Clinical Research, Boston Scientific, Roshini Jain -–Clinical Research, Boston Scientific

Background

Advancements in spinal cord stimulation (SCS) lead designs, when used in combination with new neural targeting technologies, are thought to facilitate improved outcomes with SCS, including in patients with multi-site and/or evolutive (or changing) pain patterns over time.

Aims

In this study, SCS clinical outcomes are assessed in chronic pain patients using a newly available lead with increased span and minimal spacing between electrodes (vs other traditional linear designs).

Methods

This is a multi-centre, observational clinical study utilising retrospective chart reviews at selected sites in Europe. We examined a series of chronic pain patients using a 16-contact lead designed for coverage of up to 3 vertebral levels with a 67 mm active span and 1 mm electrode spacing (Infinion CX, Boston Scientific). All patients were treated per standard of care and implanted with SCS devices (Boston Scientific) using neural targeting algorithms and capable of multiple stimulation waveforms.

Results

To date, data analysed in 15 patients demonstrate a 68% improvement (change in NRS from baseline = 5.7 ± 1.7) in overall pain as reported at last follow up (mean 4.2 ± 5.7 months; p < 0.0001). In addition, a high responder rate (50% improvement in overall pain scores) was reported post-trial and at last follow-up. Eighty-seven percent of all patients (13 of 15) reported a pain score of 3 or less at last follow-up (baseline mean NRS = 8.3). Additional data will be reported.

Conclusion

New lead designs offering greater adaptability may be important in reducing treatment failures and enhancing more personalised SCS treatment approaches. A 16-electrode lead with minimal contact spacing and longer vertebral span coverage represents another potential tool in the drive to achieve better and sustained SCS patient outcomes.

48

TARGETED NEUROSTIMULATION IN PATIENTS REPORTING CHRONIC FOCAL PAIN IMPLANTED WITH A SPINAL CORD STIMULATION SYSTEM CAPABLE OF MULTIPLE WAVEFORM PROGRAMMING OPTIONS

Category: Interventional Pain Management

Ashish Gulve – Pain Management, The James Cook University Hospital, Lilly Chen – Clinical Research, Boston Scientific, Roshini Jain – Clinical Research, Boston Scientific

Background

Recent studies evaluating dorsal root ganglion (DRG) stimulation for focal pain report encouraging results (1); however, a high incidence of associated adverse events has been documented (2). Spinal cord stimulation (SCS) is thought to be a viable alternative as programming SCS to deliver stimulation to dorsal nerve roots has been reported to successfully treat focal pain (3).

Aims

In this preliminary investigation, we report initial experience using SCS with precise neural targeting technology and sub-perception modalities to treat patients with focal pain.

Methods

This is an ongoing multicenter, consecutive, observational, case-series examination of patients reporting chronic focal pain implanted with a multiple waveform SCS system (Precision, Montage and Novi, Boston Scientific) with the following capabilities: Multiple Independent Current Control (MICC), Anatomically-Guided (3D) Neural Targeting (3DNT, Precision Spectra only) and multiple available stimulation waveforms (including sub-perception programming). Pain relief outcomes (NRS) are being collected and analysed at baseline and follow-up.

Results

To date, 10 patients diagnosed with Complex Regional Pain Syndrome or other types of focal pain (e.g. hernia, neuropathy, DPN, other) who were implanted with a multiple waveform SCS system for ankle, foot and/or upper limb pain have been assessed. Mean baseline NRS score was 8.5 (SD = 1.2) and mean last follow-up duration was 10 months (SD = 5.3). A statistically significant improvement in mean overall pain was reported at last follow-up as indicated by a 47% reduction in NRS score (NRS = 4.5; p < 0.001) versus baseline. Additional data will be reported.

Conclusion

This preliminary work will help support the study of Spinal Cord Stimulation using multiple programming options and neural targeting in patients suffering with chronic focal pain. Further follow-up and analysis is planned.

References

1. Deer TR, Levy RM, Kramer J, et al. Dorsal root ganglion stimulation yielded higher treatment success rate for complex regional pain syndrome and causalgia at 3 and 12 months: a randomized comparative trial. Pain 2017; 158(4): 669–681.

2. Liem L, et al. Long term complications and failures in dorsal root ganglion stimulation. INS World Congress, 2017.

3. Levine AB, Parrent AG and MacDougall KW. Stimulation of the spinal cord and dorsal nerve roots for chronic groin, pelvic, and abdominal pain. Pain Phys 2016; 19(6): 405–412.

49

NEUROPATHIC PAIN MEDICATIONS: SHOULD WE WORRY?

Category: Neuropathic Pain

Donald Irvine – Anaesthetics, Aberdeen Royal Infirmary

Background

Neuropathic pain is commonly seen in the NHS and a variety of national guidelines are available for treatment. A Cochrane review in 2012 said 45% of patients were on two or more neuropathic agents. Medications should be started on a trial basis and stopped if not effective. If continued, the patients are at risk of side effects, dependence and poly pharmacy. Drug dependence has been an issue especially with opioid medications but is increasingly recognised with other analgesic agents. Owing to this possible harm, we have audited our local practice to establish if this is an issue.

Aims

Assess our prescription of neuropathic agents to ensure patients are being treated appropriately and safely.

Methods

A quality improvement project to review current prescribing practices. We reviewed electronic case notes, over a 2-week period for all patients who had attended the chronic pain clinic. All prescribed neuropathic medications, their doses and indication for use were documented and compared to our local guideline.

Results

In the 2-week period, 69 patients were seen by the chronic pain service in Aberdeen. The prevalence of patients on neuropathic agents was 64%; 42 patients being on neuropathic agents and 27 not. Of the 42 patients on neuropathic medications, 36 were prescribed as per the local guideline and 8 patients were not. Further information was collected on the number of agents: with 26 patients being on 1 agent, 13 patients being on 2 agents and 3 patients on 3 agents. No patients were on more than three agents. The reasons for the patient taking the agents were peripheral neuropathy 15 patients, radicular pain 13 patients, not neuropathic reason 8 patients, fibromyalgia 6 patients, phantom limb pain 1 patient and herpetic neuralgia 1 patient.

Conclusion

The majority of prescribed neuropathic medications are following our local guideline. With regard to the number of medications, 38% of patients were on two or more agents, which is reassuring and lower than national statistics. Eight patients, however, were not. With the new descriptor of nociceptive pain being adopted by the IASP, these patients may fit into this type of pain. We look forward to further advice on how to manage this. We will continue to monitor our prescription of neuropathic medications and update our local guideline as more evidence and consensus about nociplastic pain becomes available.

50

THE USE OF BOTULINUM TOXIN FOR THE TREATMENT OF REFRACTORY PERIPHERAL NEUROPATHIC PAIN IN A TERTIARY SPECIALIST CENTRE

Category: Neuropathic Pain

Tommy Brown – School of Medicine, University of Liverpool, Bernhard Frank – Pain Medicine, The Walton Centre NHS Foundation Trust

Background

Neuropathic pain is notoriously difficult to treat effectively, particularly in tertiary centres where first- and second-line pharmacological interventions have usually been tried elsewhere. Systemically administered treatments are often poorly tolerated due to dose-limiting side effects. There is emerging evidence that botulinum toxin A (BoNT-A) has an analgesic effect independent of its paralytic effect on the neuromuscular endplate. Subcutaneous BoNT-A injections are therefore recommended as third-line treatments for peripheral neuropathic pain in the most recent international guidelines with weak positive evidence for its use. Patients with facial neuropathic pain such as trigeminal neuropathy and post herpetic neuralgia have been excluded from many studies due to fear of unmasking. Several published trials have found BoNT-A interventions to be effective, safe and lacking systemic side effects. It also appears to have a cumulative effect with repeated applications producing a greater sustained analgesic response.

Aims

This study aimed to explore the effectiveness and tolerability of repeated BoNT-A injections in peripheral neuropathic pain, including facial pain patients, focusing on a refractory neuropathic pain population in a tertiary setting. These data will be used to argue for the provision of BoNT-A in this population.

Methods

This was a prospective study design collecting data from refractory neuropathic pain patients treated by the specialist neuropathic service with BoNT-A injections at the Walton Centre in Liverpool, England. Data were collected from July 2016 to October 2018. Each patient was assessed in clinic prior to their referral for BoNT-A injections using the four criteria of the updated grading system for neuropathic pain in research and clinical practice. They then received at least two BoNT-A injections, unless indicated otherwise, over 12-week intervals. Patients received 100–300 U of BoNT-A according to clinical judgement and response on follow-up. Data were collected as a self-completed questionnaire booklet before the first intervention and after each subsequent session. Due to poor compliance of the mostly elderly patients with the detailed data collection, the primary outcome was a global impression of change. Tolerability was assessed clinically.

Results

A total of 27 participants were referred and diagnosed with probable or definite neuropathic pain from post-herpetic neuralgia (14 patients – 52%), trigeminal neuropathy (8 patients – 30%) and post-surgical/radiotherapy pain (5 patients – 19%). At the time of data analysis, 21 patients had received BoNT-A injections and been followed up. For various reasons, only 16 patients had received more than one intervention. Ten patients (48%) were found to have improved following BoNT-A treatment, with all of these receiving at least two separate BoNT-A interventions. Of the remaining 11 patients, two reported their symptoms to be worse following intervention; however, they both did not receive a second intervention. Nine patients were found to have no change following BoNT-A, but only six of these patients received the planned two sets of injections. Of the 16 patients who received more than one intervention, 63% were found to have improved outcomes clinically.

Conclusion

An improvement in the global impression of change was noted in almost half the patients who received a single BoNT-A intervention and this was sustained or further improved after a second injection, suggesting the observed analgesic effect requires more than a single intervention. This case series adds support for the use of BoNT-A in refractory neuropathic pain patients, including pain in the trigeminal nerve territory not suitable for high-dose capsaicin patches. Side effects were common particularly increased pain and weakness. Long-term outcomes and more detailed psychophysical data could help to select patients most likely to benefit.

51

EXPLORING PRESCRIBING PATTERNS OF MEDICINES USED TO MANAGE NEUROPATHIC PAIN IN PRIMARY CARE SETTINGS: A SCOPING REVIEW

Category: Neuropathic Pain

Comfort Mshelia – School of Healthcare, University of Leeds, Mary-Claire Kennedy – School of Healthcare, University of Leeds, Gretl McHugh – School of Healthcare, University of Leeds, Theo Raynor – School of Healthcare, University of Leeds

Background

Neuropathic pain (NP) which is pain arising due to injury to the nerves affects about 8% (1) of people in the United Kingdom. Symptoms of NP are serious and can have significant effects on patients’ quality of life. Prescribing guidance is provided by the National Institute for Health and Care Excellence (NICE) on how NP should be managed in primary care settings in the United Kingdom. However, it is unclear how prescribers choose medicines to prescribe to individuals with NP. Many patients do not experience complete relief from pain even when the highest possible effective dose is used or they cannot tolerate the side effects associated with their medication. It is therefore important that prescribing to this group of patients is rational and in line with prescribing recommendations. This review will highlight areas where prescribing practice can be improved and provide evidence which can be used when prescribing guidelines are updated.

Aims

The aim of the scoping review is to provide an overview of patterns in the prescribing of medicines used to manage neuropathic pain in primary care settings. The objectives are (1) to identify which medicines are most and least commonly prescribed and (2) to explore variations in the prescribing of medicines.

Methods

We undertook a scoping literature review using the Joanna Briggs Institute guidance (2). Five bibliographic databases (MEDLINE, Embase, CINAHL, International Pharmaceuticals Abstracts and the Cochrane Central Register of Controlled Trials) were searched for relevant published literature until November 2018. The search strategies were developed in collaboration with an information specialist and did not contain any methodological search filters that would limit results to specific study designs. The search of bibliographic databases returned a total of 6105 titles. Retrieved titles were imported into Covidence. After removing duplicates, 4931 citations remained to be screened for inclusion. Inclusion criteria were applied as these titles were screened for relevance. A total of 59 titles were retained. The full texts of these 59 papers were independently screened by two reviewers and any disagreements were resolved by discussion.

Results

A total of 19 studies were included in the review. Nine were from the United Kingdom and two from the United States of America. The Netherlands, Italy, Germany, Norway, Spain and Sweden each had one paper. Two papers compared data from six European countries – France, Germany, Italy, the Netherlands, Spain and the United Kingdom. Most (n = 13) of the studies included in this review adopted a retrospective cohort study design. Patients with NP were often prescribed lower doses of medicines than recommended for the management of NP (3–5). They were also prescribed more items than patients who did not have NP (6,7). Despite this, the majority of initial prescriptions for NP were for one item (8–11). Amitriptyline was the most frequently prescribed medicine (12–14). The most commonly prescribed classes of medicines were antiepileptic agents followed by non-opioid analgesics and third nonsteroidal anti-inflammatory drugs (NSAIDs) (6,7,15–20).

Conclusion

To our knowledge, this is the first literature review focused on examining the prescribing patterns of medicines used to manage neuropathic pain in primary care settings. The review found that existing studies have a narrow focus in terms of NP conditions or they focus on prescribing patterns of specific medicines. There is an obvious need for more recent studies examining prescribing patterns of medicines used to manage a broad range of NP conditions.

52

COMPLEX REGIONAL PAIN SYNDROME OF THE DOMINANT HAND IN A PATIENT WITH PROFOUND HEARING LOSS

Category: Non-Pharmacological Pain Management

Hannah Dawe – Anaesthetics/Pain, St George’s University Hospitals NHS Foundation Trust, Andy King – Pain Management, Ashford and St. Peter’s Hospitals NHS Foundation Trust

Background

Complex regional pain syndrome (CRPS) usually occurs as a result of trauma or injury, but in some cases no cause is elucidated. It is a clinical diagnosis which is reached after other causes are excluded. Symptoms of severe pain, swelling and reduction of motor function in the affected limb can be debilitating for affected patients. We present the case of a 32-year-old profoundly deaf female, reliant on British Sign Language (BSL) for communication, whose dominant hand was rendered useless following a trivial injury. For her, CRPS had an extremely detrimental effect due to the challenges and barriers she faced communicating effectively with the healthcare professionals involved in her care.

Aims

History: Our patient developed CRPS following a very minor precipitating event. While opening a glass jar, she developed a sudden severe pain in her right hand and wrist which worsened over the next 24 hours, extending proximally beyond her elbow. This made it impossible for her to use her hand for any activities of daily living or for communication.

Methods

Management plan: (1) Patient reassured and information given regarding diagnosis and treatment aims; (2) pregabalin dosing optimised to try to alleviate side effects of daytime drowsiness; (3) urgent referral to physiotherapist, psychologist and occupational therapist, ensuring BSL translator would be present; (4) review in Consultant Pain Clinic in 2 months with BSL translator; and (5) consideration to be given to stellate ganglion block at this time if symptoms not improving.

Results

Discussion: Our patient had attended her GP surgery and local Emergency department multiple times prior to diagnosis. She had been referred to hand therapy and physiotherapy, then the pain clinic at our hospital. This process had taken over a year and our patient expressed her frustration at this and had concerns regarding the difficulty she had had accessing the correct treatment. She had also attended appointments without a BSL interpreter which had been useless.

Conclusion

Access to healthcare is a legal right. However, recent publications highlight the difficulties that deaf people have accessing healthcare. These include lack of access to services due to problems booking appointments, difficulty communicating with healthcare professionals due to poor provision of BSL interpreters, misunderstandings regarding diagnosis and management and loss of confidentiality if relying on family and friends to interpret. Accessing health information can be difficult and it should not be assumed that written information is necessarily understood. Recommendations which have been made in order to provide a better service, involve improved training for healthcare providers, use of appropriate technology and ensuring the patient is provided with their preferred method of communication.

53

MESH-RELATED PAIN AND SELF-MANAGEMENT INTERVENTIONS: PATIENT ISSUES AND CLINICAL EXPERIENCES

Category: Non-Pharmacological Pain Management

Sarah Edwards – Pain Management, National Hospital of Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Katrine Petersen – Pain Management, National Hospital of Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Katie Herron – Pain Management, Royal Liverpool and Broadgreen University Hospitals NHS Trust

Background

The issues around vaginal mesh procedures for women with stress urinary incontinence have garnered increasing attention and concern in recent years (Gornall, 2018), and the negative outcomes for thousands of women following this procedure have led to a prominent campaign, ‘Sling the Mesh’. Complication rates are estimated at 9.8%, with women reporting symptoms including infection, bladder and bowel issues, and persistent pain (Keltie et al., 2017). Care pathways for women with mesh-related pelvic pain are being developed and may include a referral to pain management. Our specialist multidisciplinary abdominopelvic pain management team at University College London Hospitals (UCLH) works with these patients in close partnership with the UCLH Urogynaecology department. Many of the women are referred by a pain consultant or clinical nurse specialist to pain management Psychology and Physiotherapy for self-management input.

Aims

We aimed to identify themes in patient presentation and treatment goals, using case studies of women with mesh-related pain attending pain management Psychology and Physiotherapy sessions at our Centre. We also aimed to identify specific clinical challenges which this patient group presents for our team, to develop our service.

Methods

Women with mesh-related pain were offered either individual Psychology and Physiotherapy sessions, or a session on our abdominopelvic pain management programme, ‘Link’, which aimed to build up self-management strategies using cognitive-behavioural therapy and acceptance and commitment therapy. We reviewed the treatment files for eight women, with whom we had worked more recently and had detailed notes. Due to the exploratory nature of the work, this was a qualitative analysis. We drew out the most common cognitive, behavioural and affective themes, and treatment goals, for these women. The process involved reflecting on patient notes, drawing out and amalgamating formulations, and discussing with colleagues. From these processes, the most common themes were identified, and further discussion clarified which themes were most frequent and most challenging. In addition, we identified particular clinical challenges which arose when working with these patients, through supervision and multidisciplinary meetings.

Results

Cognitively, vivid images about the mesh itself, such as ‘it’s like a cheese grater’ and ‘it’s stuck to my insides’, were common. Thoughts of being let down by healthcare systems, and not being listened to, were frequently reported. Women struggled with the wide-reaching impact of symptoms, with thoughts such as ‘everything has changed since this was done to me’. Behaviourally, recurrent themes were lower sitting tolerance, difficulties with sex, and reduced socialising, and these were goals for treatment. Emotionally, distress, anger and anxiety, which are common in persistent pain, were often noted, alongside shame and embarrassment. Patients hoped to reduce pain, and bladder and bowel symptoms. A challenging issue was the possibility of further surgery to remove some or all of the mesh, and the decision-making process around risks and benefits. Clinicians noted that this pre-occupied women and could make transition to self-management more difficult.

Conclusion

We found common themes for women with mesh-related pain, which were specific to this patient group. Our analysis highlighted the importance of close interdisciplinary working and joint approaches, in particular with Urogynaecology, due to the complicating issues of possible mesh removal and ongoing medical management. As women with these symptoms increasingly come forward for help and support, with high-profile media campaigns from groups such as ‘Sling the Mesh’, we anticipate carrying out self-management interventions with more women. We hope to be able to carry out quantitative research into outcomes for this patient group in the near future.

54

NON-PHARMACOLOGICAL TREATMENT FOR CERVICAL OSTEOARTHRITIS: A HEAD-TO-HEAD COMPARISON BETWEEN NSAID THERAPY AND NEUROMODULATION USING PULSED SHORTWAVE THERAPY (PSWT)

Category: Non-Pharmacological Pain Management

Ian Rawe – Clinical Research, BioElectronics Corp

Background

Cervical osteoarthritis is a degeneration of the joints, vertebrae and discs in the cervical region of the spine which can lead to pain, inflammation and decreased quality of life. Standard analgesic therapy includes non-steroidal anti-inflammatory drugs (NSAIDs) as well as paracetamol to reduce pain. The limited effectiveness of these standard therapies for osteoarthritis, along with the risks of long-term usage, have led clinicians to recommend non-pharmacological approaches. ActiPatch® (BioElectronics Corporation, Frederick, MD, USA) is a wearable, non-prescription, non-invasive neuromodulation therapy that relies on tissue absorption of high-frequency, non-thermal electromagnetic energy (pulsed shortwave therapy) to relieve pain and improve physical functioning. This therapy has already been shown to relieve pain from osteoarthritis of the knee, improve physical functioning, enhance overall quality of life and decrease the need for pharmacotherapy.

Aims

The goal of this study was to investigate the effectiveness of pulsed shortwave therapy in reducing pain related to cervical osteoarthritis, when compared to the effectiveness of a NSAID-based (Cox-2 inhibitor) therapy.

Methods

Forty-six subjects, who were diagnosed with cervical osteoarthritis by radiological imaging and reported pain lasting 2 months or more, were evenly randomised into one of two therapy groups: (1) group 1 received standard NSAID-based (Cox-2 inhibitor) therapy: Etoricoxib 60 mg, used once daily for 4 weeks and (2) group 2 received a PSWT therapy: ActiPatch® device, worn 24 hours/day for 4 weeks. The primary outcome measure was change in the Neck Disability Index (NDI): a patient-completed, condition-specific, functional status questionnaire with 10 items (pain, personal care, lifting, reading, headaches, concentration, work, driving, sleeping and recreation). The secondary outcome measure was that change in pain levels is recorded on a 0–100 visual analogue scale (VAS), while at rest and performing physical activity. In addition, data were collected on the use of rescue pain medication (paracetamol), patient satisfaction and adverse side effects. All outcome measures were collected at baseline and at 4 weeks, following study completion.

Results

In the NSAID therapy group, the mean baseline values for NDI, VAS rest and VAS activity were 47.5 ± 0.7, 69.7 ± 1.9 and 76.7 ± 1.7, respectively. In the PSWT group, the mean baseline values for NDI, VAS rest and VAS activity were 48.8 ± 4.1, 66.9 ± 2.4 and 75.7 ± 1.7, respectively. After 4 weeks of respective therapies, both groups showed statistically and clinically significant improvements in outcome measures when compared to baseline. For instance, mean NDI scores decreased by 17.4 ± 1.6 and 26.9 ± 2.4 points in the NSAID and PSWT groups, respectively, and the difference was statistically significant (p = 0.04). VAS at rest and activity decreased by 33.9 ± 3.7 and 35.2 ± 4.0 points, respectively, in the NSAID group, compared to 45.8 ± 3.1 and 48.5 ± 4.1 points, respectively, in the PSWT group. The differences in improvements of VAS at rest and activity were statistically significantly different between the two groups (p = 0.01 and p = 0.03).

Conclusion

Both NSAID therapy and neuromodulation therapy using PSWT resulted in statistically and clinically meaningful changes in pain level (VAS) and functionality (NDI) associated with cervical osteoarthritis, when used for 4 weeks. However, the group using PSWT demonstrated superior improvements in all outcome measures when compared to the NSAID therapy group, including patient satisfaction rating. These results indicate that as a non-prescription intervention, neuromodulation therapy using PSWT is superior to NSAID-based (Cox-2 inhibitor) therapy as an analgesic modality for cervical osteoarthritis.

55

THE USE OF EXTERNAL NEUROMODULATION IN A COMMUNITY CHRONIC PAIN SERVICE

Category: Non-Pharmacological Pain Management

Johanna Theron – Community Chronic Pain, Kent Community Health NHS Foundation Trust

Background

External neuromodulation (ENM) is a non-invasive modality that could be utilised for patients with localised neuropathic pain. An external nerve mapping probe connected to an impulse generator, of the type commonly used in operating theatre for nerve blocks, is used to apply electrical stimulation to the nerves covering distribution of the painful area, or targeting the epicentre of the painful area directly. The amplitude is adjusted to achieve acceptable paraesthesia in the painful area. Three to four treatments are considered a trial. If helpful, then onwards referral for percutaneous or implanted stimulation could be considered. Those with medium term relief may choose to have repeated treatments instead. Self-treatment is an option but few patients can afford the cost of the machines. Repeated treatment sessions cost clinician time and running self-treatment clinics in-house is a logistical burden for a multisite service. Neither option leads to long-term self-management or discharge.

Aims

To assess whether ENM offers demonstrable and unique benefit for patients with difficult to treat neurological conditions, in order to inform the decision whether to continue offering the modality to such patients.

Methods

Retrospective data interrogation was used. With the help of the trust IT department, the last 50 patients who received the treatment prior to July 2018 were identified in the electronic data system. A clinician then reviewed each patient’s notes, making use of Excel spreadsheets. Data extracted included all treatment specifics and outcomes recorded on the services ENM treatment template, whether patients had TENS and/or acupuncture for the same problem, and whether medication was reduced following treatment. Contemporaneous clinic notes, discharge letters and discharge coding were reviewed too.

Results

A wide variety of causes for neuropathic symptoms were represented, with the largest group being lumbosacral radiculopathy (18%). Just under half (48%) of patients had some response. Of those, 42% had 100% pain relief following a treatment and 75% had more than 50% pain relief. Pain relief lasted from 12 to 24 hours, to more than a week. Forty-two percent of the responders could reduce their pain medication. Seven of the responders continued to self-treatment, of which three patients bought the machines and four others could maintain the effect with another electronic device. Three patients were referred for spinal cord stimulation. In total, 24% had four treatments and 44% had more than four by a clinician, averaging 7.6 treatments. Acupuncture and TENS had similar response rates where trialled, but the three groups of responders were not similar. Two-thirds of patients were discharged with completed pathways following ENM.

Conclusion

When offered, ENM had the potential to help approximately one in two patients with an area of neuropathic pain. It could enable responders to reduce their medication burden. The effect seemed different from TENS or acupuncture. The numbers of clinician-performed treatments were acceptable. It aided general self-management and discharge in the majority. Problems were the cost of the machines prohibiting self-treatment. Team discussion considered an overall independently beneficial modality. The service would continue providing ENM in a protocol similar to acupuncture (goal-orientated and a fixed maximum number). Alternative lower cost stimulators would also be explored.

56

MANAGING PAIN IN OLDER PEOPLE WITH PALLIATIVE CARE NEEDS: A REVIEW OF THE LITERATURE

Category: Older People

Margaret Dunham – Nursing & Midwifery, Sheffield Hallam University, Gary Bellamy – Faculty of Health, Education, Medicine & Social Care, Anglia Ruskin University

Background

The population of the United Kingdom is getting older with those aged 85 and over predicted to double by mid-2041 to 3.2 million. Within this ageing population, a significant proportion will have a palliative diagnosis related to cancer or other diseases, including lung disease, heart disease and dementia. Many of these non-curable diseases have a high symptom burden including pain and have a poorer prognosis than most cancers. Pain in older people is known to be poorly controlled and the consequence of uncontrolled pain is associated with falls and frailty. Hence, many older people with complex needs and associated co-morbidities may benefit from tailored palliative care provision including appropriate pain management.

Aims

To conduct a critical review of the literature regarding the management of pain in older people with palliative care needs and establish the current evidence base for good practice particular to their needs.

Methods

A literature search was undertaken utilising the Cochrane Database of Systematic Reviews, Medline, AMED, PsychINFO and CINAHL for research published between 2009 and April 2018. The search terms included pain, pain management, older people, hospice, palliative, terminal and dementia; associated MESH terms were incorporated. Exclusion criteria included opinion pieces, palliative sedation, assisted dying, surgical and radiological interventions. Retrieved papers were hand-searched and assessed for suitability and methodological quality. Identified papers were all subjected to peer review.

Results

From the search, 155 articles were identified and abstracts read. Studies focused exclusively on people over 65, related to palliative pain care management, are scarce and the available evidence base lacks high-quality RCT findings. Only five articles, related to the provision of palliative and end-of-life care pain management for older adults, met the criteria for inclusion. The same author had published two of these papers extracted from the same study. The articles reviewed focused on cancer, mixed acute and chronic end-of-life care pain management in various settings that included hospital, hospice and the community. Studies were mainly retrospective, longitudinal cohort, cross-sectional and non-randomised design studies.

Conclusion

The limited available evidence suggests the importance of specialist palliative care teams for pain management of older adults at the end of life. No evidence relating the palliative and end-of-life care pain management practices for non-cancer, co-morbid or other long-term conditions such as COPD, heart failure or dementia were identified during the course of the review. Despite acknowledgement of this ageing population, the paucity of identified articles highlights the lack of evidence on this important area of practice. Further evidence is required to inform good clinical practice and palliative pain management for older adults with these conditions.

57

EVALUATING THE EFFICACY OF EXTERNAL NEUROMODULATION IN CHRONIC FOCAL NEUROPATHIC PAIN

Category: Other (Audit)

Gemma Roberts – Pain Service, Department of Anaesthetics, Cardiff & Vale University Health Board, Shefali Kadambande – Pain Medicine, Department of Anaesthetics, Cardiff & Vale University Health Board

Background

An estimated 8% of the UK population have persistent chronic neuropathic pain. This is often severely debilitating and is associated with significant impingement on the physical, economic and emotional well-being and quality of life of patients. Neuropathic pain can be extremely challenging to manage and current management guidelines appear heavily weighted towards pharmacotherapy; however, this carries the burden of significant side effects. In March 2017, an external neuromodulation (EN) clinic was set up in the University Hospital of Wales. EN is a non-invasive form of peripheral neuromodulation that can serve as a treatment modality for focal neuropathic pain. An electrical current is applied to the peripheral nerves to ameliorate chronic pain through preferential activation of myelinated fibres, inducing long-term depression of synaptic efficacy. Observational studies have demonstrated excellent reproducible pain relief in a large percentage of patients (Goroszeniuk and Goroszeniuk, 2003; Johnson et al., 2015; Johnson and Goebel, 2015).

Aims

The aim of this service evaluation project was to evaluate the impact of introducing an outpatient external neuromodulation service for patients with moderate to severe focal neuropathic pain. The primary outcomes were reduction in pain scores and medication usage.

Methods

We applied transcutaneous EN to 35 eligible patients. The procedure entailed the application of a 2 Hz frequency and amplitude between 3 and 15 mA electrical stimulus transcutaneously to a targeted area or nerve supplying the area of intractable pain. The duration of stimulation was 5–10 minutes in each case. Outcome measures were pain scores using the Brief Pain Inventory which (includes NRS and quality-of-life indicators), percentage relief and analgesic changes. All were recorded pre-treatment and at follow-up.

Results

A total of 35 new patients were seen between March 2017 and November 2018. The initial treatment was performed by a consultant and the two subsequent treatments by the Clinical Nurse Specialist (CNS). Responders were defined as those who reported any pain relief. We had an 83% response rate. Nearly half of patients (48%) rated their pain relief between 70% and 90%. Of the 29 patients who were rated as responders, 6 patients stopped all of their analgesic medications (21%) and a further 10 reduced their medications (34%). Four patients were not taking any medications (due to side effects). Two patients, despite rating the treatment as not being effective, actually managed to stop all of their medications during the treatment period. Reduced pain scores were noted in all patients who were rated as being responders.

Conclusion

EN has been shown to be a simple, cheap, effective, non-invasive treatment for focal neuropathic pain conditions: (1) it can be offered in an out-patient clinical environment and is an easy to repeat procedure; (2) it reduces the need for medications and their related side effects; (3) it can improve the quality of life in patients with chronic pain and reduce interference with activities of daily life; (4) it can avoid the need for more invasive treatments; and (5) it can help reduce the burden of chronic pain in a variety of chronic neuropathic conditions, for example, occipital neuralgia, brachial plexopathy and ulnar neuropathy.

58

OPIOID AWARE: SELF-REPORTED PRACTICES OF HEALTHCARE WORKERS INVOLVED IN THE MANAGEMENT OF HOSPITALISED CHRONIC PAIN INPATIENTS ON HIGH-DOSE OPIOIDS

Category: Other (Audit)

Sujesh Bansal – Anaesthetics & Pain Management, Manchester University NHS Foundation Trust, Ying Gong – The University of Manchester, Mowafak Abdelghani – Anaesthetics & Pain Management, Manchester University NHS Foundation Trust, Elizabeth Purser – Pain Management, Manchester University NHS Foundation Trust, Kaream El-Said Dawoud – Manchester University NHS Foundation Trust

Background

The number of prescription opioid-related deaths has also increased in the United Kingdom as previously seen in the United States of America. This growing public health crisis highlights the need for better opioid prescribing practices in pain patients; to balance risk versus benefit of prescribing and continuing patients on opioids to ensure patient safety. The Opioid Risk Tool (ORT) is a brief, self-report screening tool designed for use with adult patients in primary care settings to predict which individuals may develop aberrant drug-related behaviours when prescribed opioids for chronic pain. The Faculty of Pain Medicine has also introduced the Opioid Aware Programme with an aim to enhance patient education and to improve prescribing practices, as well as to promote a culture of appropriate clinical decision making concerning the use of opioids.

Aims

This survey was designed to determine the awareness of ‘Opioid Risk Tool’, ‘Opioid aware’ programme and prescribing practices among clinicians (doctors, nurses, pharmacists and pain specialists) who have looked after inpatients on high-dose opioids.

Methods

An online survey to assess the awareness of opioid aware programme and prescribing practices of the clinical teams (hospital doctors, nurses and pharmacists) of a Tertiary NHS Foundation Trust and General Practitioners and pain specialists from the North West England who looked after these inpatients in community and provided pain specialist care was conducted over a period of 5 weeks. Survey included 18 questions on the theme on awareness of ‘Opioid Aware’ programme management and support of inpatients on high-dose opioids. Microsoft Excel Spreadsheet was used for data entry and analysis. Data obtained were evaluated quantitatively by the frequency, mean, mode and percentage distribution.

Results

A total of 100 anonymous responses were received; which included 39 hospital doctors, 18 pain specialists, 16 dispensing nurses, 14 pharmacists and 13 GPs. Despite the fact that 76% of the surveyed clinicians were involved in the care of patients on high-dose opioid treatments, only 16% were aware of the Opioid Aware Programme developed by the Faculty of Pain Medicine and 20% aware of the Opioid Risk tools. Only 55% of pain specialists were aware of the details of opioid aware programme! Only 46% of the responders informed their patients of the side effects due to high-dose opioids and only about 30% regularly give specific information regarding the legislations and potential problems with driving to the patients at the point of prescription. Only 38% of the GPs referred patients on high-dose opioids to secondary specialist care and only 15% offer opioid trial before starting patients on opioid treatment.

Conclusion

Several deficiencies were identified in the current practices with regard to opioid drug counselling as well as treatment planning and monitoring in the long run. Current guidelines and opioid treatment resources need to be better publicised so that primary and secondary health care professionals are aware of recommended practices and care pathways for the use of opioids in managing chronic pain. In order to address the current deficiencies in opioid prescribing practices as well as drug counselling, standardised training programme should be developed for medical students, doctors in training and prescribers.

59

DO LIDOCAINE INFUSIONS IMPROVE PAIN IN FIBROMYALGIA PATIENTS?

Category: Other (Audit)

Mohammad Misurati – Pain Management, Sandwell and West Birmingham Hospitals NHS Trust, Bethany Fitzmaurice – Pain Management, Sandwell and West Birmingham Hospitals NHS Trust, Julia Blackburn – Pain Management, Sandwell and West Birmingham Hospitals NHS Trust, Lynne Harrison – Pain Management, Sandwell and West Birmingham Hospitals NHS Trust, Hussein Nagi – Pain Management, Sandwell and West Birmingham Hospitals NHS Trust

Background

Sandwell and West Birmingham Hospitals (SWBH) NHS Trust have been conducting lidocaine infusions for >17 years. We are currently the only centre in the West Midlands to offer this intervention to new patients, with a subsequent dramatic increase in turnover in the last 5 years. Patients are able to receive up to four infusions per year. The most common indication is fibromyalgia. The goal of treatment is to break the continuous cycle of chronic pain. Current pharmacotherapy for fibromyalgia has limited efficacy. There is a large population of treatment-refractory patients. Pharmacological rationale: effects on multiple receptors, attenuates peripheral and central sensitisation, anti-inflammatory effects including reducing circulating cytokines. Lidocaine half-life is 120 minutes; duration of pain relief outlives the infusion time and plasma half-life of lidocaine. Therefore, the intervention may temporarily ‘reset’ the abnormal pain regulation seen in fibromyalgia.

Aims

There remains variable evidence on the efficacy of lidocaine infusions in chronic neuropathic pain, specifically fibromyalgia. Therefore, our primary aim was to evaluate clinical and therefore cost-effectiveness of day-case intravenous lidocaine infusions. Our secondary aim was to evaluate the safety profile of our current lidocaine administration protocol at SWBH Trust.

Methods

We perform the infusion in a day-case setting. The cost per patient session is £600. Patients receive intravenous lidocaine either at a dose of 1 mg/kg bolus over 1 minute than 3 mg/kg over 1 hour, or 5 mg/kg over 2 hours. Heart rate (HR) and blood pressure (BP) are monitored every 30 minutes, or continuous electrocardiogram (ECG) if medical history dictates. We gained prospective approval from the clinical effectiveness department at SWBH Trust. March–April 2017: pre-infusion questionnaires filled by patients on day of infusion. The questionnaire included the following scores: Generalized Anxiety Disorder-7 (GAD-7) (anxiety), Patient Health Questionnaire-9 (PHQ-9) (depression), Numeric Rating Scale NRS (0-10), sleep disturbance (out of 10) and EQ5D5L (standardised measure of health status). Questionnaires were repeated 12 weeks after intervention via telephone to evaluate improvement in pain and sleep disturbance. Data collected for 89 patients (10 did not answer). Post-infusion NRS and sleep disturbance scores derived using patient-reported percentage improvement. Analysed using MedCalc version 2 statistical software (Kruskal–Wallis test).

Results

Out of 89 patients, 83 patients received lidocaine infusion for fibromyalgia. Other indications included psoriatic arthritis, chronic widespread pain, multiple sclerosis, failed back surgery and post-polio syndromes. Analgesic benefit: Mean NRS pre-infusion was 8.23. Mean analgesic benefit was 55% (p < 0.000001) and mean post-infusion NRS scores 3.74. Analgesic duration: 39.3% patients experienced pain relief for >3 months, with 11.2% had pain relief for as long as 4–5 months. 53.7% were able to wean their analgesics, some managing to stop their oral and transdermal opiates. Sleep disturbance: Mean sleep disturbance pre-infusion reported as 8.66 (out of 10), mean improvement in sleep was 34% (p < 0.000001) and mean score post-infusion 5.87. Side effects: 13.5% of patients experienced minor side effects during the infusion. None required active measures other than slowing the infusion. 16.9% of patients reported side effects following the infusion, examples were ‘felt drunk for 1 week’, ‘mild headache for 2 days’ and ‘nausea, stomach pains for 1 week’.

Conclusion

Lidocaine infusions are cheap, safe and effective in the management of fibromyalgia syndrome (FMS). In >17 years of lidocaine infusion at SWBH, there has not been any major adverse effects, for example, convulsions. There was one recent adverse effect: unilateral weakness, intralipid given and recovered within a couple of hours. Responders enjoyed a tremendous impact on their quality of life – over half successfully weaning their analgesics and reporting less sleep disturbance, and over two-thirds experiencing improved mobility. Further research will explore comparing the two different regimens and the use of pain prediction models, with a view to targeting responders versus non-responders

60

ASSESSING THE BURDEN OF CHRONIC PAIN IN OSTEOARTHRITIS AND CHRONIC LOW BACK PAIN WHEN UNTREATED AND TREATED WITH PRESCRIPTION MEDICATIONS

Category: Other (research)

Hannah Haswell – Medical Affairs, Pfizer Ltd., Philip G Conaghan – Rheumatology, University of Leeds, Greg I Coates – Medical Affairs, Pfizer Ltd., Peter C Clewes – Medical Affairs, Pfizer Ltd., Samantha Howland – Medical Affairs, Pfizer Ltd., Michael J Doane – Real World Evidence, Kantar Health, Dena H Jaffe – Real World Evidence, Kantar Health, Erika Dragon – Medical Affairs, Pfizer Ltd., Lucy Abraham – Patient and Health Impact, Pfizer Ltd., Lars Viktrup – Statistics, Eli Lilly and Company, Andrew Bushmakin – Statistics, Pfizer Inc., Joseph C Cappelleri – Statistics, Pfizer Inc

Background

Chronic pain affects between one-third and one-half of the population of the United Kingdom, corresponding to nearly 28 million adults. Osteoarthritis (OA) is a chronic, progressive musculoskeletal condition that results in structural changes in the joint and can cause pain, swelling and stiffness. Chronic low back pain (CLBP) is characterised by pain and muscle tension or stiffness. Both are common conditions in the UK population although data on prevalence and severity, particularly of CLBP, are limited for UK cohorts. For both OA and CLBP, pharmacotherapies have either limited effectiveness or are limited in their appropriate treatment length by safety or other concerns. Despite the high prevalence and limited treatment options for both OA and CLBP, to date there is a shortage of data on the humanistic and economic burden, particularly comparing those being treated with prescription (Rx) medications versus those who are Rx-untreated.

Aims

Assess the burden of chronic pain in the United Kingdom from osteoarthritis (OA) and chronic low back pain (CLBP) and to determine whether burden differs by patient self-reported pain severity and treatment status (Rx-treated or Rx-untreated) using data from the 2016 and 2017 self-administered online National Health and Wellness Survey (NHWS).

Methods

Data were examined from UK respondents to the NHWS; a large, nationally representative, cross-sectional, general health survey of adults. Patients included in the present analyses were those who self-reported a diagnosis of CLBP (n = 389) or OA (n = 1151), who reported current pain lasting ?3 months for CLBP or within the last year for OA, and who completed the pain module in the survey. Neuropathic or phantom limb pains were excluded. To assess burden of chronic pain the following measures were used: health status (EQ-5D-5L utility scores), productivity loss (Work Productivity and Activity Impairment: General Health (WPAI-GH) and Healthcare Resource Utilization (HCRU) (General practitioner and total healthcare provider visits within the past 6 months). Generalised linear models were used to assess whether patients with CLBP or OA differ by treatment status and pain severity. Mild Rx-Untreated served as the reference group. No comparisons are made between OA and CLBP cohorts in this study.

Results

Both conditions showed similar trends. Health status (EQ-5D-5L utility scores): Participants with moderate/severe pain (Rx-Treated and Rx-Untreated) reported lower health status (mean = 0.35(CLBP-Rx-Treated), 0.57(CLBP-Rx-Untreated), 0.34(OA-Rx-Treated), 0.53 (OA-Rx-untreated)) than those with mild pain Rx-Untreated (mean = 0.64(CLBP), 0.63(OA)) (p < 0.05). Mild pain Rx-Treated participants also reported lower EQ-5D-5L scores (mean = 0.54 (CLBP), 0.55 (OA)) than those with mild pain Rx-Untreated (mean = 0.64 (CLBP), 0.63 (OA)) (p < 0.05). Productivity Loss (WPAI): Those with moderate/severe pain, Rx-Treated and Rx-Untreated (mean = 61.3% (CLBP-Rx-Treated), 41.9% (CLBP-Rx-Untreated), 75.5% (OA-Rx-Treated), 51.5% (OA-Rx-untreated)), and mild pain Rx-Treated (mean = 51.0% (CLBP-Rx-Treated), 46.0% (OA-Rx-Treated)), reported higher levels of overall work productivity impairment than those with mild pain Rx-Untreated (mean = 21.1% (CLBP-Rx-untreated), 23.7% (OA-Rx-untreated)) (p < 0.05). Similar trends were seen for activity impairment. Healthcare Resource Utilisation: Those with moderate/severe pain Rx-Treated (mean = 3.4 (CLBP-Rx-Treated), 3.0 (OA-Rx-Treated)) and mild pain Rx-Treated (mean = 3.4 (CLBP-Rx-Treated), 2.8 (OA-Rx-Treated)) reported more GP visits than those with mild pain Rx-Untreated (mean = 2.0 (CLBP-Rx-untreated), 1.9 (OA-Rx-untreated)) (p < 0.01). Similar trends were seen for total healthcare provider visits.

Conclusion

This survey data from NHWS show a sizable burden on UK patients and the health service as measured by health status, work productivity and activity, and HCRU. The burden appears greater for patients treated with prescription medications and those who reported moderate-severe pain compared with those reporting mild pain who were untreated. HCRU appears high for all groups, especially those treated with prescription medications regardless of reported pain severity with the greatest burden in primary care. Given the prevalence of these conditions, this topic warrants further investigation to better understand the overall burden of chronic pain in the United Kingdom.

61

MY FUTURE: USING STORY COMPLETION METHODS TO EXAMINE HOW ADOLESCENTS WITH COMPLEX REGIONAL PAIN SYNDROME THINK ABOUT THEIR FUTURE

Category: Paediatric

Abigail Jones – Department of Psychology and Centre for Pain Research, University of Bath, Line Caes – Division of Psychology, University of Stirling, Abbie Jordan – Department of Psychology and Centre for Pain Research, University of Bath

Background

Adolescence is a challenging time for all individuals and includes several key tasks such as identity development. Identity development involves identifying future aspirations, with positive, realistic future aspirations contributing to a better quality of life. Complex regional pain syndrome (CRPS) can present additional challenges for adolescents. However, little is known about how CRPS affects how adolescents think about their future, and their future aspirations.

Aims

To explore how adolescents who have CRPS think about their future and how parents of adolescents who have CRPS think about their child’s future.

Methods

This study comprised two groups of participants: adolescents (14–25 years) with CRPS and parents of adolescents (14–25 years) with CRPS (these were not parent-child dyads). A total of 30 parents and 44 adolescents took part. Participants were predominately female (1 male parent, 5 male adolescents). Participants were presented with a story stem through online survey software that asked them to describe either their own (adolescent) or their child’s (parents) future 10 years after completing secondary school. Stories were analysed using inductive Thematic Analysis.

Results

Thematic analysis resulted in the development of three themes across both participant groups. The first theme captured the idea that CRPS is a burden that is always present, but is unseen by others. This creates a sense of difference and separation from others. This separation appears to be dominant in the lives of the adolescents in the present, and something they see as not only likely to continue into their future, but will be increasingly dominant as time goes on. The second theme captured how CRPS exacerbates the unpredictability of their futures. Participants presented a range of possible futures, but acknowledged that they cannot tell what the future holds due to the day-to-day variability in pain-related functioning. The third theme captured the dual impact of CRPS on young people’s futures, both denying opportunities available to others but also providing adolescents with an enhanced sense of maturity.

Conclusion

Findings show that concerns about the overwhelming impact of CRPS on adolescents’ futures are dominant in the minds of adolescents and parents. Specifically, CRPS makes the future hard to predict and plan, and sets the adolescent apart from their peers. However, there may be some developmental advantages associated with CRPS in adolescence, such as an enhanced sense of maturity.

62

OPIATE TAPERING WITHIN THE GP CONSULTATION

Category: Primary Care

Sarah Parsons – Norwich Road Surgery

Background

Prescriptions for opiate medications have increased. Alongside this, deaths where an opiate is mentioned in the death certificate have also increased. Dosages of >100 mg equivalents of morphine significantly increase the risk of overdose by a factor 8.9 compared with a factor of 2.0 in those taking <20 mg morphine equivalents. GP primary care consultations offer an opportunity to reduce high-dose opiate prescriptions, but time and expertise may be seen as a barrier. The 10-minute consultation model as well as the complexities of chronic pain can preclude a discussion of side effects of high-dose opiates, the risks of overdose and misuse in the GP consultation. This audit is to demonstrate whether opiate tapering is possible and effective within a primary care setting.

Aims

This 10-month project in a single GP surgery of 1000 patients was intended to provide an opiate tapering service for patients on high-dose opiates within the 10-minute consultation to reduce risks of harm, overdose and side effects, and to encourage self-management of chronic non-cancer pain.

Methods

A prospective audit was undertaken in March 2018 using PresQIPP software to identify patients on opiate doses of ?120 mg morphine equivalents per day. A further audit was conducted in December 2018. A letter was sent to identified patients inviting them in for a 10-minute face-to-face appointment with a GP with a special interest in pain management. Included in the letter were two patient information leaflets regarding opiates and pain, and opiates and driving. Those patients that responded were offered an opiate tapering programme combined with education in self-management. The aim was to reduce opiate dosages by 10% per week, but the time frame was determined by the patient. An opiate monitoring template within Systmone or Ardens was used at each consultation. This allowed for easy identification of monitoring and standardisation of consultations, ensuring that a biopsychosocial model was encompassed.

Results

A total of 17 patients were identified in the initial audit. Letters were sent to 10 patients during the audit period. This allowed the GP to gain confidence and experience in tapering opiates. All patients that responded were agreeable to a tapering programme. Three patients died during the audit time period. The causes of death were not directly due to opiates. Eleven patients engaged in a tapering programme. Two patients have been successfully weaned off all opiates. One of these patients was taking Oxycodone 200 mg per 24 hours. We have 12 remaining patients on high-dose opiates. Nine patients are currently still engaged in a tapering programme. Three of these nine patients are now on doses <120 mg morphine equivalents. Two patients are under the care of pain clinic and not on the primary care programme. No patients using fentanyl patches were invited to taper opiates in this current audit cycle.

Conclusion

It is feasible and possible to engage patients who have chronic pain to taper opiates and reduce the risk of overdose and side effects within the primary care setting and within the 10-minute consultation model. Ongoing education of staff and a lead GP is essential to a successful programme. The limited number of patients on high-dose opiates in a practice allows GPs to understand each patient’s biopsychosocial issues and follow the patient up on a flexible and regular basis. The next step for this surgery is to address tapering for patients on high-dose fentanyl patches.

63

THE EFFECTS OF PEER LED, CHRONIC PAIN EDUCATION IN PRIMARY CARE ON ATTITUDES TO SELF-MANAGEMENT: AN NHS AND THIRD SECTOR PARTNERSHIP

Category: Primary Care

Martin Dunbar – Glasgow Pain Management Programme, NHS Greater Glasgow and Clyde, Monica McCowatt – Glasgow Pain Management Programme, NHS Greater Glasgow and Clyde, Heather Wallace – Board of Trustees, Pain Concern

Background

SIGN 136(1) found evidence that supported self-management can improve outcomes and the quality of life of those living with chronic pain. It goes on to recommend pain education and self-management advice be provided early on. Those with chronic pain who attend secondary care services usually receive this advice, but despite the Scottish Service Model (see Figure 1) suggesting that this should be accessible in community settings, there is little provision in primary care.

Aims

To evaluate the acceptability, and the impact, of providing an introduction to chronic pain self-management on attitudes and beliefs around self-management among people in the community living with chronic pain.

Methods

Members of the Glasgow Pain Management Programme (GPMP) multidisciplinary team designed a series of presentations that covered topics including understanding the nature of chronic pain, the management of day-to-day activity, stress and sleep problems and pain flare-ups. Previous GPMP patients and post-graduate psychology student volunteers were trained to deliver these presentations at six community sites across Glasgow. Those attending the classes were asked to provide written feedback. The ratings from 198 people who attended the classes were summarised and the free-text comments were analysed using thematic analysis.

Results

Those attending the classes were typically over 50 years old and had suffered pain for over 10 years. The classes were well received (see Table 1) with 98% indicating that they would recommend the class to others.

Table 1.

Evaluation of the education topics.

Understanding pain	Excellent/Very Good/Good: 96%	Fair/Poor: 4%
Managing activity	Excellent/Very Good/Good: 96%	Fair/Poor: 4%
Stress management	Excellent/Very Good/Good: 94%	Fair/Poor: 6%
Sleep management	Excellent/Very Good/Good: 90%	Fair/Poor: 10%
Flare-up management	Excellent/Very Good/Good: 94%	Fair/Poor: 6%

Based on the prevalence of words in the responses provided, a number of themes emerged. A super-ordinate theme called ‘changes in thinking, behaviour, and attitude towards the management of pain’, with sub-ordinate themes called ‘thoughts less focused on a medical management’, ‘feeling more hopeful about the future’ and ‘greater peer support’.

Conclusion

The classes were well-received and attendees reported thinking differently about self-management of their pain.

64

THE NAVIGATOR TOOL INTERVENTION – A PILOT EVALUATION OF A NOVEL TOOL TO ENHANCE COMMUNICATION IN CONSULTATIONS ABOUT CHRONIC PAIN IN PRIMARY CARE

Category: Primary Care

R Blomkvist – Research Pain Concern, P Bell – Board of Trustees, Pain Concern, K Gordon – University of Strathclyde Glasgow, M Dunbar – Institute of Health and Wellbeing, University of Glasgow, Blair Smith – Population Health Science, University of Dundee, Graham Kramer – General Practice, Annat Bank Practice, Paul Cameron – Population Health Science, University of Dundee, Heather Wallace – Board of Trustees, Pain Concern

Background

Self-management has been highlighted as one of five recommended treatment strategies for living with long-term pain [SIGN 136]. It has been shown to improve patients’ quality of life with minimal side effects or risks. Despite the recent attention that has been given to self-management techniques, patients receive little or no support in this from primary care. Movements such as House of Care and Realistic Medicine advocate that self-management should not be faced alone by the patient, but that a whole system approach is needed. Research (Gordon et al., 2016) has shown several barriers to the constructive discussion of self-management in primary care appointments, leading to patients feeling un or mis-informed about the role they play in the management of their pain. Our research team developed the Navigator Tool Intervention (NTI) to overcome some of these barriers by improving the communication between healthcare professionals and chronic pain patients in primary care.

Aims

To develop and trial the Navigator Tool Intervention in primary care through analysis of questionnaires, feedback forms and semi-structured interviews with patients and healthcare professionals.

Methods

A communication aid (The Navigator Tool), with Health Care Professional (HCP) training, that sought to facilitate interactions between HCPs and patients around self-management of chronic pain, was developed. The feasibility of using the tool was examined in a small, randomised controlled trial of 35 patients and 5 healthcare professionals. In this pilot, outcomes of pain self-efficacy, satisfaction with consultation and participation in decision-making were compared between control and intervention groups. Qualitative data were gathered through feedback forms and interviews to assess the usability of the intervention, with a focus on satisfaction with communication.

Results

Analysis of interviews and feedback forms suggests several positive outcomes from using the intervention, and a number of practical barriers to its successful implementation. The intervention was helpful in aiding patients and healthcare professionals to see the bigger picture of the pain condition, leading to engaged and efficient consultations, highlighting a range of self-management strategies and facilitating positive emotions. Its use in primary care was limited by the clinical and personal characteristics of the patient who used it and the flexibility in the consultation style conducted by the healthcare professional. A number of changes to the paper-based tool were suggested.

Conclusion

Using the Navigator Tool in primary care has potential to bring several constructive outcomes to support self-management of chronic pain. Interestingly, the qualitative analysis suggests that the tool has the potential to address a number of the difficulties in chronic pain consultations that previous research (Gordon et al., 2016) had identified. The feedback from this study has been used to further refine the intervention in order to maximise potential benefit. Further evaluation is ongoing.

65

QUANTITATIVE SENSITIVITY TESTING IN PAEDIATRIC PATIENTS WITH CHRONIC PAIN: A SYSTEMATIC REVIEW AND META-ANALYSIS

Category: Psychology

Daniel Schoth – School of Psychology, University of Southampton, Philippa Broadbent – School of Psychology, University of Southampton, Holly Brown – School of Psychology, University of Southampton, Navin Down – School of Psychology, University of Southampton, Victoria Gibbons – School of Psychology, University of Southampton, Olivia Ranger – School of Psychology, University of Southampton, Jin Zhang – School of Psychology, University of Southampton

Background

Paediatric chronic pain is persistent or recurring pain of any aetiology lasting longer than 3 months. Quantitative sensory testing (QST) refers to a range of non-invasive techniques for exploring somatosensory processing, including positive and negative sensory phenomena. QST is psychophysical in nature, relying on the individual’s subjective report to a standardised stimulus. QST has a wide range of clinical applications, with research establishing its utility to assess the functional status of the somatosensory nervous system, therefore increasing our understanding of underlying pain mechanisms. QST is feasible, reliable and reproducible in children, including children as young as 4 years old when using thermal stimuli. The primary objective of this review is to examine the relationship between established QST measures and pain or disability in paediatric chronic pain. The second is to assess whether the strength of the relationship is moderated by variables related to the QST method and pain condition.

Aims

This review will examine (1) the use of QST in paediatric chronic pain (modalities, outcome measures and anatomical test sites); (2) the reliability of QST; (3) the ability of QST to differentiate patients with chronic pain from healthy controls; and (4) differences between anatomical test sites.

Methods

Web of Science, Medline, PsychINFO, CINAHL, PubMed, Scopus, The Cochrane Library and Open Grey databases will be searched from database inception with English language as a search limit. Search terms include three concept blocks: (1) pain – pain*, ache*, abdominal pain, arthritis, headache*, musculoskeletal pain, fibromyalgia; (2) population – boy*, girl*, child* teenager*, youth*, adolescent*, young*, schoolchild*, school child*, juvenile*, paediatric, pediatric; and (3) QST – quantitative sensory test*, sensory test*, QST, threshold, tolerance, pressure, electrical, warm, heat, hot, cool, cold, mechanical, hyperalgesia, hyperaesthesia, allodynia, sensitisation, sensitivity. Reference lists of all obtained articles will also be inspected.

Results

An initial scoping search of 270 records has been conducted, 23 of which met the inclusion criteria and have been retained for review. Seven studies were conducted in the United States, four in Denmark, two each in Canada, Germany, Italy, Norway and Spain, and one each in Brazil and the Netherlands. Seventeen studies recruited a healthy control comparison group. Pressure pain was the most commonly explored parameter, which was included in all, but two studies. Five studies explored thermal pain, and two studies mechanical pain. A full systematic search review is currently underway, and full results will be presented at the ASM.

Conclusion

The results of this review will be informative for clinicians and researchers working with paediatric patients with chronic pain. Increased use of QST has been advocated in young populations in order to more fully understand mechanisms underlying conditions such as cerebral palsy, migraine and persistent post-operative pain.

66

THE IMPACT OF COMORBID NEUROVASCULAR PAIN ON THE PSYCHOSOCIAL FUNCTIONING OF PATIENTS WITH NEUROPATHIC AND MUSCULOSKELETAL OROFACIAL PAIN

Category: Psychology

Jared G Smith – Population Health Research Institute, St George’s, University of London, Aalia Karamat – Department of Oral Surgery, King’s College London Dental Institute, Lydia N Melek – Oral and Maxillofacial Surgery, Department Faculty of Dentistry, Alexandria University, Tara Renton – Department of Oral Surgery, King’s College London Dental Institute

Background

Orofacial pain (OFP) is a complex, heterogeneous set of illnesses that present as pain in the region of the face and oral cavity. Orofacial pain is a common affliction, affecting up to 26% of the population, with an estimated UK prevalence of chronic OFP of 7%. Chronic OFP is often very debilitating, dramatically affecting physical health, psychological health, employment and economic well-being of individuals. Studies measuring the psychological burden of chronic OFP have predominantly focussed on specific OFP conditions, most obviously musculoskeletal conditions (temporomandibular disorders; TMD) and conditions associated with neuropathic pain such as trigeminal neuralgia. However, both clinical and population-based studies suggest a high rate of comorbid headache disorders in patients with TMD, and to a lesser extent, in those with neuropathic OFP. Yet little is known about the specific impact of comorbid neurovascular pain on the psychological and affective functioning of patients with musculoskeletal and/or neuropathic OFP.

Aims

The objective of the study was to assess the impact of comorbid neurovascular pain on the psychosocial functioning of patients with musculoskeletal and/or neuropathic orofacial pain conditions.

Methods

The study sample was derived from 352 consecutive patients attending the OFP Clinic at a hospital in South London from January 2016 to January 2017. Patients were aged 18 years and above, presenting with OFP. Clinical examination of the patients was performed by trained clinicians in OFP. A diagnosis or diagnoses (in the case of multiple conditions associated with OFP) was/were made according to the International Headache Society Classification, Research Diagnostic Criteria for Temporomandibular Disorders and the International Association for the Study of Pain. Data for patients were collected prospectively and included sociodemographic information, diagnosis and clinical history. Most patients also completed a small number of self-report, standardised questionnaires intended to measure pain experience, (oral) health-related quality of life and psychological function. Patients were grouped together according to broad symptomatic classes of OFP (musculoskeletal, neuropathic) and comparisons made between those with and without comorbid neurovascular pain.

Results

Of the 352 patients attending the OFP service, 306 (86.9%) had a confirmed diagnosis of musculoskeletal (TMD) and/or neuropathic OFP; 220 (71.9%) of these had completed one or more measures and constituted the study sample. Most patients were female (73.2%) with a mean age of 49.6 years (range = 19–80). Comorbid neurovascular pain was present in 47 (21.4%) patients (14 neuropathic OFP; 28 TMD; 5 neuropathic OFP and TMD). Compared to patients without comorbid neurovascular pain (116 neuropathic OFP, 49 TMD, 8 neuropathic OFP and TMD), these patients had longer condition duration, higher (pain) VAS scores at assessment and were more likely to report experiencing chronic pain as part of their condition. Patients with comorbid neurovascular pain also presented with significantly higher anxiety levels, had lower pain self-efficacy and there was a trend towards higher pain catastrophising – these effects were weakened in analyses that controlled for pain severity.

Conclusion

This study indicates that a significant proportion of patients attending an OFP clinic present with headache disorders in addition to musculoskeletal and/or neuropathic OFP and suggests these patients experience higher levels of pain and are more functionally impaired in the domains of anxiety and pain self-efficacy. The findings extend previous studies demonstrating comorbidity between migraine and psychological dysfunction and research suggesting individuals with comorbid migraine and TMD pain present social impairments significantly greater than the singular disturbances. Neurovascular pain symptoms in patients with TMD and/or neuropathic OFP may require a different interpretation and treatment approach with respect to psychological input.

67

EVALUATION OF A CULTURALLY ADAPTED PAIN MANAGEMENT PROGRAMME

Category: Psychology

Razia Bhatti-Ali – Pain Management Services, INHEALTH, Mohammad Shoiab – Pain Management Services, INHEALTH, Rehana Hussain – Pain Management Services, INHEALTH

Background

The experience of pain is powerfully influenced by culturally based attitudes, beliefs and values as they determine the emotional, physiological and spiritual construction of the pain experience (Lipton and Marbach, 1984). Beliefs and values mediate pain coping strategies such as stoicism, spiritual coping, hypervigilance and catastrophising (Brady et al., 2015). For non-English speakers, health providers often depend upon interpreting services; however, interpreting service may be linguistically equivalent but not always conceptually and culturally appropriate (Fletcher, 2006). Beliefs about pain and the expectations about managing pain are likely to be influenced by cultural values, often very different to Western models of service delivery. Therefore, culturally grounded pain management services addressing socio-cultural aspects are crucial elements to providing an equitable service in managing pain and disability (Torres-Cueco, 2018).

Aims

The primary aim was to assess the effectiveness of a culturally adapted Pain Management Programme (PMP) delivered in the mother tongue of the participants. The standard 18-hour PMP was culturally adapted for a group of Urdu speaking South East Asian patients referred to the INHEALTH pain management service.

Methods

The culturally adapted pain management programme was held between June and July 2018. The sessions were delivered by two Urdu-speaking psychologists and a physiotherapist. Seven referred patients (2 male, 5 female) were recruited to the 18-hour PMP delivered over a period of 6 weeks. One participant failed to attend after the first session and therefore the data for this participant were removed from the analysis. The Urdu translated Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and the Pain Self-Efficacy Questionnaire (PSEQ) were used as outcome measures and administered before and after the PMP. The content of the PMP was based on a culturally adapted version of the standardised model and was delivered in Urdu by facilitators who incorporated a CBT and Acceptance & Commitment (ACT) model of learning to live with pain. The ACT framework for pain management was adapted with metaphors and stories relevant to the cultural background of the group.

Results

Outcome data were analysed using t-tests. There was a statistically significant change in anxiety (t (3) = 4.7, p < 0.01), depression (t (3) =5, p < 0.01) and self-efficacy (t (3) = 8.18, p < 0.001) following the programme. The participants reported significant improvements in self-efficacy, anxiety and depression following the programme. Five patients made significant improvements on all three outcomes in self-efficacy, anxiety and depression following the programme. Qualitative data yielded positive results with the participants reporting that they had a better understanding of their chronic pain and were more accepting of their pain. ‘Being able to talk in my own language has increased my knowledge about my condition as well as knowing what to do’ … ‘ I feel I have accepted my illness’.

Conclusion

The results from this pilot suggest there is strong value in delivering a language-specific and culturally adapted PMP for the South Asian community. This approach enabled the successful engagement of the patient group by breaking down cultural and language barriers enabling the patients to use a holistic approach to pain management while increasing awareness of the cultural perception and its role in affecting the experience of persistent pain. This facilitated a willingness to avail support to use self-management strategies and increase the confidence to reduce dependency on medication and medical interventions as a way of coping with pain.

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THE CENTRALISATION OF PAIN SERVICES FROM MULTIPLE SITES INTO ONE COMMUNITY PAIN HUB: THE PATIENT’S EXPERIENCE

Category: Service Management

Simon Braude – Pain Medicine, Royal Free Hospital, Anne Marie Williams – Day Surgery, Edgware Community Hospital, Lucy Ward – Pain Medicine, Royal Free Hospital, Arif Ghazi – Pain Medicine, Royal Free Hospital

Background

In May 2018, the process of transferring pain services from Barnet Hospital, Chase Farm Hospital and Royal Free Hospital into one community pain hub at Edgware Community Hospital was commenced. The pain interventional procedures were the first part of the pain service restructuring process, which were moved from three sites into one theatre at Edgware Community Hospital. The move was to facilitate a greater amount of expertise on one site, to promote a dedicated theatre team specifically allocated to pain procedures and to result in a more cost-effective service. However, there were some initial concerns over unfamiliarity, as patients within our service had been used to treatment at other sites, inconvenience of increased travel time and there was not an option for overnight stays at Edgware for complex cases.

Aims

The aim of our survey was to track our patients’ journeys for a pain procedure from clinic to discharge and determine levels of patient satisfaction. We wanted to look specifically at areas where changes to the service may affect patients as well as identify areas to improve our service.

Methods

We designed a survey to look at aspects of the patient journey including the consent process, communication prior to the procedure, medical and nursing care on the day of the procedure and information given on discharge. There were 10 questions on the survey and a section for patients to write additional relevant information. The survey was performed between 10th and 23rd July 2018. It was handed to patients by nursing staff prior to discharge.

Results

A total of 62 responses were received from 65 patients who had procedures in this time period. These numbers reflect a reduction to the usual case load in response to safety concerns for the initial adjustment period at the new site. It was noted though that in some cases individual patients did not complete all the questions. These procedures were performed under the care of four different consultants. 62/62 patients were satisfied with the communication prior to the procedure in clinic. 58/62 noted that they were given more than 1 week notice regarding the date and time of the procedure. 60/62 were satisfied with the clarity of pre-procedure instructions regarding fasting, stopping relevant medications and need for an escort on procedure day. 61/61 patients felt any relevant questions they had regarding the procedure were adequately answered. 62/62 patients felt that theatre staff were professional and reassuring. 61/61 patients felt their dignity and privacy were maintained during the day. 61/61 patients were satisfied with the nursing care and 60/60 patients felt they were given sufficient information on discharge. Overall satisfaction with the service showed 60/61 reported being ‘very satisfied’.

Conclusion

This survey demonstrated high levels of patient satisfaction throughout their patient journey in a new community pain hub. We have shown that when moving multiple pain services to a single site one can provide excellent quality multidisciplinary care early in this transition. In addition, this demonstrates the advantages of a dedicated theatre team for pain procedures in a single operating theatre.

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EVIDENCED-BASED ADMINISTRATION

Category: Service Management

Chad Taylor – Pain Management Centre, States of Jersey, Health & Community Services, Jonathan Bond – Pain Management Centre, States of Jersey, Health & Community Services

Background

With budgets in pain services being drawn ever tighter, the need for clinicians to not have their time taken up doing administrative tasks is becoming more and more essential. In 2017, a Specialist Pain Practitioner at the Jersey Pain Management Centre reduced their working hours. The multidisciplinary team (MDT) decided that the most efficient use of the resources freed up would be to employ an MDT coordinator to lift some of the administrative burden from the clinical team. While the job description stressed the need for high levels of IT literacy and interpersonal skills, the successful applicant also had experience in the areas of research methods and statistical analysis. This background combined with a comprehensive training programme has facilitated the administrative staff’s integration into the clinic’s existing culture of constant re-appraisal and evidence-based practice.

Aims

The aim of the project was to reduce the administrative burden on the MDT through the recruitment of an MDT coordinator and to assess the impact in an empirical and measurable way.

Methods

As part of the 6-month induction process, the MDT coordinator sat in on every 1:1 and group intervention in the clinic. The MDT coordinator also received training in all software systems utilised in the clinic and a course in the ‘Lean’ or ‘Kaizen’ efficiency system. The duties the MDT co-coordinator lifted from the clinical staff included management of all patient databases, waiting lists and elective procedure lists; all non-clinical telephone contact with patients not already handled by the booking clerks (explaining treatment pathways and options to patients); auditing clinic efficiency metrics and preparing monthly dashboards; purchasing all non-clinical supplies, coordinating with engineering and IT departments; updating and distributing patient information leaflets; and facilitating MDT meetings and ensuring decisions made are auctioned. The MDT coordinator also led on projects to improve operating practices within the clinic to improve efficiency and reduce waste which were then presented at audit alongside clinical audits.

Results

Twelve months after the introduction of the MDT coordinator, measurable improvements in the functioning of the clinic had been achieved and presented to the MDT. A project to remove excess process around referrals had reduced the average time for receipt of referral to consultant triage from 3 weeks to less than 1 week. Through the instigation of a regular Pain Management Programme (PMP) waiting list review meeting, the average time from being triaged for MDT assessment to attendance at a PMP dropped from 310 to 140 days. A project to reduce ‘batch processing’ of incoming opt in questionnaires contributed to a reduction in numbers of patients waiting >90 days by 150. An increase in the number of 1:1 appointments with the consultant physiotherapist by 27% has been credited to a reduction in her administrative duties facilitated by the MDT coordinator.

Conclusion

The introduction of an MDT coordinator has been a huge success for the Jersey Pain Management Centre. Central to this success has been placing a high priority on high IT literacy, numeracy and research skills; a comprehensive induction programme; a stress on evidence-based improvement; and the integration of the administrative staff into the MDT culture. Diverting funds from clinical to administrative staffing will always be a controversial decision; however, when done well, the resultant reduction in administrative burden can translate into clinicians being able to deliver more clinical hours with shorter waiting times.