A systematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, thoracotomy or mastectomy

BACKGROUND: Perioperative neuropathic pain is under-recognized and often undertreated. Chronic pain may develop after any routine surgery, but it can have a far greater incidence after amputation, thoracotomy or mastectomy. The peak noxious barrage due to the neural trauma associated with these operations may be reduced in the perioperative period with the potential to reduce the risk of chronic pain. DATABASES AND DATA TREATMENT: A systematic review of the evidence for perioperative interventions reducing acute and chronic pain associated with amputation, mastectomy or thoracotomy. RESULTS: Thirty-two randomized controlled trials met the inclusion criteria. Gabapentinoids reduced pain after mastectomy, but a single dose was ineffective for thoracotomy patients who had an epidural. Gabapentinoids were ineffective for vascular amputees with pre-existing chronic pain. Venlafaxine was associated with less chronic pain after mastectomy. Intravenous and topical lidocaine and perioperative EMLA (eutectic mixture of local anaesthetic) cream reduced the incidence of chronic pain after mastectomy, whereas local anaesthetic infiltration appeared ineffective. The majority of the trials investigating regional analgesia found it to be beneficial for chronic symptoms. Ketamine and intercostal cryoanalgesia offered no reduction in chronic pain. Total intravenous anaesthesia (TIVA) reduced the incidence of post-thoracotomy pain in one study, whereas high-dose remifentanil exacerbated chronic pain in another. CONCLUSIONS: Appropriate dose regimes of gabapentinoids, antidepressants, local anaesthetics and regional anaesthesia may potentially reduce the severity of both acute and chronic pain for patients. Ketamine was not effective at reducing chronic pain. Intercostal cryoanalgesia was not effective and has the potential to increase the risk of chronic pain. TIVA may be beneficial but the effects of opioids are unclear

Prevalence of chronic pain in Libya before and after the uprising of 17 February 2011.

Two questionnaires were translated into Arabic and culturally adapted to measure chronic pain and neuropathic pain in the general population in Derna, Libya (1, 2), and then in a country-wide survey. A point prevalence of chronic pain and neuropathic pain in Libya was determined. The findings of this series of studies suggested that the prevalence of chronic pain in Libya, which was 19.6%, is similar to the average European estimate (3) despite the cultural dissimilarities of the two regions (4) and the environmental differences surrounding the surveyed samples. The studies of chronic pain in Libya conducted by our pain research team, which involved a PhD student sponsored by the Libyan High Education Authority, indicated that Libyan women were found to have more chronic pain conditions than men. These sex and gender differences in chronic pain highlighted a general trend in epidemiological studies in many parts of the world (5). However, this programme of studies on prevalence of chronic pain was conducted just before the uprising of 17 February 2011 in Libya, and one should be cautious about the validity of some of the findings’ implications for immediate pain management priorities in the country. For example, the findings of the pre-conflict survey that being an old woman with children carries double the risk of having a chronic pain condition compared to a young person with no children may have changed as a result of the war which claimed the lives of around 30,000 Libyans and caused serious injuries to more than 20,000 young men. There is an urgent need for a new programme of studies using the PRIME approach on prevalence, impact, and economic cost of chronic pain (6) in post-conflict Libya. This should inform the health authorities in Libya and help plan management of chronic pain conditions resulting from the conflict. This will also serve as a model that can be applied to other countries from the developing world experiencing similar conflicts (7)

Differences in Swedish and Australian medical student attitudes and beliefs about chronic pain, its management, and the way it is taught

Background and aims: Medical students receive training in the management of chronic pain, but the training is often suboptimal. Considering that the basis for physician’s knowledge is their medical education, it is important to explore the attitudes and beliefs of medical students with respect both to chronic pain management and to their views on current pain education. Therefore, the aim of this study was to compare Swedish and Australian medical student’s attitudes and beliefs about patients with chronic pain, and their perceptions regarding their chronic pain management education. Methods: An online survey was conducted with final year Australian and Swedish medical students from two different universities between December 2016 and February 2017. Attitudes and beliefs towards chronic pain patients were measured using the Health Care Providers’ Pain and Impairment Scale (HC-PAIRS). A thematic analysis was conducted on open end questions regarding their views on their education and important skills for chronic pain management. Results: A total of 57 Swedish and 26 Australian medical students completed the HC-PAIRS scale. The Swedish medical students showed statistically significantly lower total mean HC-PAIRS scores compared to Australian medical students (46 and 51, respectively). Australian students had statistically significantly higher scores than the Swedish students for two of four factors: functional expectations and need for cure, whereas no significant differences were seen for the factors social expectations or for projected cognition. From the open end questions it was evident that final year medical students are knowledgeable about key chronic pain items described in clinical guidelines. However, both cohorts described their chronic pain training as poor and in need of improvement in several areas such as more focus on the biopsychosocial model, working in multidisciplinary teams, seeing chronic pain patients and pharmacological training. Conclusions: Attitudes and beliefs are formed during medical education, and our study exploring attitudes of medical students towards chronic pain and how it is taught have provided valuable information. Our survey provided detailed and cohesive suggestions for education improvement that also are in line with current clinical guidelines. This study indicates that the Swedish final year students have a more positive attitude towards chronic pain patients compared to their Australian counterparts. The majority of students in both cohorts perceived chronic pain management education in need of improvement. Implications: This study highlights several areas of interest that warrant further investigation, for example, the impact of a changed medical curriculum in alignment with these clinical guidelines requested by students in this survey, and correspondingly if their attitudes towards chronic pain patients can be improved through education. Further, we conclude that it would be valuable to align the implementation of the HC-PAIRS instrument in order to achieve comparable results between future studies

Narrative Medicine: Improving Patient Care and Shifting Office Culture

Chronic pain and depression are both prevalent in the Unites States and often co-exist in the same population. According to the literature, there is no consensus between providers as to the best practice of treating chronic pain and concomitant depression. Narrative Medicine, a medical model that uses a patient’s illness narrative to make meaning of their disease, allows patients to tell their stories of chronic pain and other important aspects about their life, while it helps providers better understand patients’ experiences with pain. This project will assess the current culture and attitudes of providers treating chronic pain conditions at the Center for Family Medicine at Eastern Maine Medical Center. It will also assess their current understanding of Narrative Medicine and the Northwestern Life Story Interview. We found that providers who dread visits with patients with chronic pain conditions are more likely to feel less confident when treating those patients.https://scholarworks.uvm.edu/fmclerk/1282/thumbnail.jp

Chronic Pain: Improving Patient Awareness of Management Options

Chronic pain affects 100 million Americans and places a significant burden on patients and their families. Opioids are frequently used to manage chronic pain, and their potential for misuse, addiction, and adverse effects are of growing concern in Vermont. Increasing patient awareness of different pain management options could decrease patient suffering and mitigate the opioid epidemic. This project aimed to educate patients on chronic pain management and resources available in Franklin County.https://scholarworks.uvm.edu/fmclerk/1270/thumbnail.jp

An exploration of attitudes towards psychological interventions for pain management amongst Maltese pain chronic sufferers

Chronic pain is a living reality for many individuals. Research reveals that individuals are often reluctant to seek psychological help. Chronic pain research and attitudes towards psychological treatment among a Maltese chronic pain population is solely lacking. This study sought to explore attitudes towards psychological interventions for the management of chronic pain amongst persons with chronic pain. A grounded theory methodology was adopted. Interviews were conducted with 21 participants. Five superordinate categories comprising 12 sub-categories were generated. An attitude model reflecting inter-relationships between categories was developed. The theory entitled ‘Readiness to Try What Ever it Takes’ reveals that a number of facilitating factors contribute to the formation of positive attitudes to psychological help-seeking. Although the study did not reveal polarized views in relation to gender, impeding factors comprising negative affect, lacking resources and stigma hinder help-seeking behaviour. Most participants were unfamiliar with psychological services for pain management. Findings also indicate that individuals who perceive a link between psychological factors and pain are not necessarily more inclined to access psychological help, mostly because help-seeking behaviour is influenced by an array of psychosocial factors which are difficult to quantify. Service uptake can be enhanced by adopting a bio-psychosocial framework incorporating cultural factors and a multi-disciplinary approach to treatment involving not just health care professionals, but also significant others who influence the chronic pain sufferers’ decision-making, including family members and the clergy.peer-reviewe

Towards a science and practice of resilience in the face of pain

The primary objective of this paper is to discuss how a resilience approach to (chronic) pain may advance our current understanding of (mal)adaptation to pain. Different resilience perspectives are described, and future challenges for research, prevention and treatment of (chronic) pain are discussed. Literature searches were performed in Web of Science and PubMed to identify relevant literature on risk and resilience in the context of pain. Resilience can be best defined as the ability to restore and sustain living a fulfilling life in the presence of pain. The Psychological Flexibility Model, the Broaden-and-Build Theory, and Self-Determination Theory are described as theories that may provide insight into resilience within the context of (chronic) pain. We describe how a resilience paradigm shifts the outcomes to pursue in pain research and intervention and argue the need for including positive outcomes in addition to negative outcomes. Psychological flexibility, positive affect and basic psychological needs satisfaction are described as potentially important resilience mechanisms with the potential to target both sustainability and recovery from pain. A resilience approach to chronic pain may have important implications for the prevention and treatment of chronic pain problems, as it may give specific indications on how to empower patients to continue living a fulfilling life (in the presence of pain)

Prevalence and impact of chronic widespread pain in the Bangladeshi and White populations of Tower Hamlets, East London

The prevalence and impact of chronic pain differ between ethnic groups. We report a study of the comparative prevalence and impact of chronic pain in Bangladeshi, British Bangladeshi and White British/Irish people. We posted a short questionnaire to a random sample of 4,480 patients registered with 16 general practices in the London Borough of Tower Hamlets and conducted a longer questionnaire with patients in the waiting areas at those practices. We distinguished between Bangladeshi participants who were born in the UK or had arrived in the UK at the age of 14 or under (British Bangladeshi) and those who arrived in UK at the age of over 14 (Bangladeshi). We obtained 1,223/4,480 (27 %) responses to the short survey and 600/637 (94 %) to the long survey. From the former, the prevalence of chronic pain in the White, British Bangladeshi and Bangladeshi groups was 55, 54 and 72 %, respectively. The corresponding figures from the long survey were 49, 45 and 70 %. Chronic widespread pain was commoner in the Bangladeshi (16 %) than in the White (10 %) or British Bangladeshi (9 %) groups. People with chronic pain experienced poorer quality of life (odds ratio for scoring best possible health vs. good health (or good vs. poor health) 5.6 (95 % confidence interval 3.4 to 9.8)), but we found no evidence of differences between ethnic groups in the impact of chronic pain on the quality of life. Chronic pain is commoner and, of greater severity, in Bangladeshis than in Whites. On most measures in this study, British Bangladeshis resembled the Whites more than the Bangladeshis

Short-term prospective memory deficits in chronic back pain patients

Objective: Chronic pain, particularly low back pain, is widespread. Although a great deal is known about the impact that this has on quality of life and physical activity, relatively little has been established regarding the more cognitive effects of pain. This study aims to find out whether individuals with chronic pain experience memory deficits in prospective memory (PM), the process of remembering to do things at some future point in time. Examples of PM include remembering to keep an appointment, such as a visit to a clinic, or to perform a particular task, such as paying a bill on time. Methods: The PM of 50 participants with chronic pain was compared with 50 pain-free participants. Each participant completed the Prospective Memory Questionnaire, which assesses three aspects of prospective memory (short-term habitual, long-term episodic, and internally cued), and records the use of strategies to aid remembering. Results: In comparison to those not in pain, participants with chronic pain had significantly impaired short-term prospective memory, an effect which was evident even after co-varying use of analgesics and other drugs. Conclusions: These findings provide new insights into prospective memory dysfunction in people with chronic pain. Possible mechanisms for this dysfunction are discussed and suggestions for future research given

What influences chronic pain management? A best–worst scaling experiment with final year medical students and general practitioners

Background: Chronic pain education is an essential determinant for optimal chronic pain management. Given that attitudes and preferences are involved in making treatment decisions, identifying which factors are most influential to final year medical students’ and general practitioners’ (GPs) chronic pain management choices is of importance. This study investigates Swedish and Australian students’ preferences with respect to a chronic pain condition, using a best–worst scaling (BWS) experiment, which is designed to rank alternatives. Methods: BWS, a stated-preference method grounded in random utility theory, was used to explore the importance of factors influencing chronic pain management. Results: All three cohorts considered the patients’ pain description and previous treatment experience as the most important factors in making treatment decisions, whereas their demographics and voices or facial expressions while describing their pain were considered least important. Factors such as social support, patient preferences and treatment adherence were, however, disregarded by all cohorts in favour of pain assessment factors such as pain ratings, description and history. Swedish medical students and GPs show very high correlation in their choices, although the GPs consider their professional experience as more important compared to the students. Conclusion: This study suggests that the relative importance of treatment factors is cemented early and thus underline the critical importance of improving pain curricula during undergraduate medical education