In the present case, the process was not an iterative one and hence the method used is an approximation of Task Analysis. The hypothetical model of patient change was developed and data was then examined to establish whether it contained examples of the hypothesised shifts. For example, it was hypothesised that prior to involvement in a PMP, the patient might experience a reliance on medical management of their chronicpain. Following participation in a PMP, it was hypothesised that the same patient may have acquired self-management skills and the confidence to utilise them such that, for example, they no longer depend on analgesic medication on a regular basis. The data of each patient were examined in order to identify the presence or absence of a series of similar examples (seven in this model) and thereby test the “expert” model. A further hypothesis was developed regarding the data of individual patients. The more examples of the various shifts that could be identified from the qualitative data of each individual, the more improved that individual patient would be, according to objective, quantitative data.
involved in a large number of emotions, psychological states, stresses, and pathologies. The role of these cells may be more complicated than previously thought (Cleary et al., 2008; Lau and Vaughan, 2014; Salas et al., 2016). Despite the overwhelming evidence for the major role of the RVM as a relay station, it is without doubt that the descending pathways also require a forebrain loop (Millan, 2002). There is also evidence for anterior cingulate cortex (ACC) projections regulating spinal neurones (Gu et al., 2015; Kang et al., 2015) and being able to selectively modulate the pain experience. The ACC is involved in the processing and modulation of pain affect, and offers a further target for manipulating the pain signature. Understanding the role the ACC plays requires more sophisticated paradigms rather than relying primarily on the reflexive behaviour from an aversive stimulus. The role of the ACC and pain processing is comprehensively described in a recent review article (Fuchs et al., 2014). The dorsolateral and lateral sector of the midbrain PAG has differential downstream effects on the nociceptive reflexes evoked by activity in both the unmyelinated (C-fibre) and the myelinated (A-fibre) nociceptors (McMullan and Lumb, 2006a, 2006b). This differential control of nociceptive reflexes is also seen following RVM stimulation (Lu et al., 2004) demonstrating that these descending endogenous systems have A and C fibre specificity offering further complexity but nonetheless attractive targets for analgesia interventions (Waters and Lumb, 2008). In the mature adult rat, descending inhibition is targeted to spinal neurones with a strong afferent C fibre input. However, in the first few weeks postnatally the system is controlled differently, with greater descending facilitation particularly targeted to the A fibre input (Koch and Fitzgerald, 2014). The evolutionary reason proposed for this A fibre input is to provide the dorsal horn with low level, non-noxious, tactile input thereby promoting a development of the animal’s sensory networks. The switch from facilitation to inhibition as the animal matures is primarily dependent on endogenous opioid levels in the RVM (Hathway et al., 2009) with GABA and endocannabinoid levels also playing a role (Hathway et al., 2012;
The goal of physiotherapy for chronicpain is to maximise and maintain the patients’ functional ability, without contributing to any increase in pain. Passive modalities are less likely to be used, as they are believed to reinforce dependence on external factors when the patient should be encouraged to take responsibility for their own improvement . Patients are taught that pain does not necessarily imply that tissue damage is taking place, and that avoiding activity can actually worsen pain in the long run through deconditioning. The physiotherapist may also help to validate the patient’s condition, explaining that results of physical examinations, magnetic resonance imaging (MRI) scans, and other diagnostic tests often correlate poorly with pain severity and should not be relied upon as a measure of disability. Physical treatment is based on a set of stretches and light aerobic exercises performed on a daily basis, to regain muscle strength and improve range of movement that can be performed without exacerbating pain. A review of exercise therapy for chronic low-back pain concluded that it is slightly effective at decreasing pain and improving function .
Abstract: Chronicpain following inguinal hernia repair is a common problem and feared complication. Up to 16% of people experience chronicpain following the repair of a groin hernia. The aim of this review was to provide an overview of treatment strategies for patients with chronicpain following inguinal hernia repair based on best practice guidelines and current clinical routines. The optimal management of chronicpain following inguinal hernia surgery should begin with a thorough clinical examination to rule out other causes of chronicpain and to rule out a recurrence. A scaled approach to treatment is recommended. Initially, watchful waiting can be tried if it can be tolerated by the patient and then systemic painkillers, escalating to blocks, and surgery as the final option. Surgery should include mesh removal and triple neurectomy following anterior approaches or mesh and tack removal following a posterior approach. The diagnosis and treatment strategies should be performed by or discussed with experts in the field. Keywords: inguinal hernia, chronicpain, management, surgery, pharmacology, radio frequency
1/3 - 2/3 of practitioners deemed entry level pain education as less than adequate, compared to over half of the osteopaths in this study indicating their painmanagement education was adequate. Despite this however, over half of respondents described chronicpainmanagement teaching as having been only briefly covered and indicated that they considered graduate level education as the least useful source of painmanagement information. It is possible that osteopaths believed they have gained adequate painmanagement education via its inclusion in a variety of subjects throughout all years of osteopathic education. Conversely some respondents may have considered their pain education as having been briefly covered due to the fact there is not a sole subject at university dedicated to painmanagement. However perhaps
There are several articles in the medical literature that examine the outcomes resulting from the use of both established biomedical models of chronicpainmanagement and TCM treatment modalities. One meta- analysis compared management strategies for sciatica wherein the authors provided “new data to assist shared decision-making” with findings that supported the effectiveness of nonopioid medications, epidural injections, spinal manipulation and acupuncture. 26
Background: It is widely recognized that both doctors and patients report discontent regard- ing painmanagement provided and received. The impact of chronicpain on an individual’s life resonates beyond physical and mental suffering; equal or at times even greater impact is observed on an individual’s personal relationships, ability to work, and social interactions. The degree of these effects in each individual varies, mainly because of differences in biological factors, social environment, past experiences, support, and belief systems. Therefore, it is equally possible that these individual patient characteristics could influence their treatment outcome. Research shows that meeting patient expectations is a major challenge for health care systems attempting to provide optimal treatment strategies. However, patient perspectives and expectations in chronicpainmanagement have not been studied extensively. The aim of this study is to investigate the views, perceptions, beliefs, and expectations of individuals who experience chronicpain on a daily basis, and the strategies used by them in managing chronicpain. This paper describes the study protocol to be used in a cross sectional survey of chronicpain patients.
Patients with concomitant renal insufficiency may benefit more from fentanyl. If symptoms are exacerbated to the point of requiring hospitalization, keeping the patient nil by mouth for a short period of time may help reduce pancreatic stimu- lation and hence pain. Like in every chronicpain condition requiring narcotic medication use, chemical dependency is always a concern and this needs to be carefully and frequently examined by the health care provider, especially in patients who may still have addiction issues with alcohol or smoking. A psychiatric evaluation may be necessary to exhaustively assess chemical dependency. Other medications such as nortriptyline and gabapentin may be necessary in providing neuropathic pain, especially if pancreatic nerve involvement is considered. 17 Use of an acute or chronicpainmanagement
Chronicpain is a common disorder associated with significant psychological comorbidity and functional disabi- lity. The epidemiological study has reported approximately 20% of the adult Australian population have chronicpain and one third of people with chronicpain have high levels of pain related disability  . Chronicpain often causes psychological distress such as depression, anxiety, poor self-efficacy and health-related quality of life and has negative social ramifications such as unemployment, loss of working days and reduced job effec- tiveness  . Since chronicpain is complex and multi-dimensional in its nature, the current model of chronicpainmanagement is characterized by multi-faceted medical, physical and psychological interventions by a mul- tidisciplinary team, with an emphasis on improving pain coping, acceptance, self-management to improve psy- chological factors, physical functioning and quality of life -. Systematic reviews and meta-analyses have found that intensive multidisciplinary painmanagement programs are more effective than waiting lists, no treat- ment, or unidisciplinary treatment -.
Here we describe an intensive outpatient interdisciplinary program for the management of chronic back pain which appears to have good short-term clinical results in terms of reduction in functional disability and pain relief. The limita- tions of this study are its retrospective nature, the lack of a control group, and the short duration of follow-up. However, one important advantage is the inclusion of elderly patients suffering from chronic back pain. Further investigation is needed to define the long-term results, improvement of isolated spinal disorders, interindividual differences in pain ratings, and their dependence on chronification, age, gender, occupation, coping strategies, fear-avoidance beliefs, and possibly immigration status.
Patients randomized to ziconotide (n = 112) or placebo (n = 108) started IT infusion at 0.1 mg/hour (2.4 mg/day), increasing gradually (0.05–0.1 mg/hour increments) over 3 weeks. The ziconotide mean dose at termination was 0.29 mg/hour (6.96 mg/day). Patients’ baseline VASPI score was 80.7 (SD 15). Statistical significance was noted for VASPI mean percentage improvement, baseline to Week 3 (ziconotide [14.7%] vs placebo [7.2%; P = 0.036]) and many of the secondary efficacy outcomes measures. Significant AEs reported in the ziconotide group were dizzi- ness, confusion, ataxia, abnormal gait, and memory impair- ment. Discontinuation rates for AEs and serious AEs were comparable for both groups. Slow titration of ziconotide, a nonopioid analgesic, to a low maximum dose resulted in significant improvement in pain and was better tolerated than in two previous controlled trials that used a faster titration to a higher mean dose. However, compared with the two previ- ous studies 14,38 the current study had a higher incidence of
unsupported and misunderstood (see Bair et al., 2009; Health Talk Online & University of Oxford, 2012c; Kang, et al., 2013; Matthias, et al., 2010; Partners Against Pain, 2013; Rope, 2008). Moreover, there were observable changes in the control group- specifically an increased sense of pain disability and decreased sense of wellbeing. Although these results were not statistically significant, they are meaningful because they indicate that individuals with chronicpain may not improve or may deteriorate if not given adequate skills and support. No statistical significance was found for the hypotheses that participants who completed the course would show improvement in their perception of pain, report having better coping skills to deal with pain, feel better prepared to communicate about their pain, display a better sense of self- advocacy regarding pain control and living with pain, and exhibit a more proactive attitude. A likely explanation for the lack of statistical significance is the small sample size. Several participants reported improvements, but the data did not change enough for statistical
normally non-noxious stimuli), hyperalgesia (exaggerated pain reactivity to noxious stimuli), swelling of distal extremities, and indicators of autonomic dysfunction (i.e., cyanosis, mottling, and hyperhidrosis). The usual age of onset is between 9 and 15 year and the girls : boys ratio is 6:1. Childhood CRPS differs from the adult form in that lower extremities rather than upper extremities is most commonly affected. The incidence of CRPS in children is unknown, largely because it is often undiagnosed or diagnosed late, with the diagnosis frequently delayed by nearly a year. 11
We searched the literature and spoke to key experts on behavioural change theory and models of persisting pain. We considered the following psychological theoretical models and learning and behaviour modi ﬁ cation techni- ques: social cognitive 16 17 and cognitive behavioural theory, 18 19 including psychological ﬂ exibility (accept- ance and commitment therapy, ie, the acceptance of internal experiences or things that cannot be changed countered by behavioural change techniques that are designed to reorientate people towards meaningful activ- ity, 20 21 theory of planned behaviour and reasoned action 22–24 (including emotional rationalisation) and health belief models. In addition, we looked at attention control techniques 25 and physical movement to underpin and inform our intervention. Figure 1 illustrates the rela- tionship between theory and course design.
As approved by the local research and ethics board, men with a CP/CPPS diagnosis were recruited through the Urology Prostatitis Clinic (JCN). All men were invited to participate by letter, and then a discussion of the program ensued with potential participants. Once men agreed to par- ticipate in the program, we collected informed consent. All participants were suffering from refractory CP/CPPS. There was no monetary incentive for participating in the program. A weekly 8-session self-management program designed specifically for men diagnosed with CP/CPPS was devel- oped. One author (DT) has experience developing similar risk factor reduction programs. 18 The session content was
This interest in the endocrine responses to stimuli led to my development of a number of immunoassays for pituitary hormones, especially growth hormone, lutenising hormone, follicle stimulating hormone and thyroid stimulating hormone. A collaboration then evolved between myself and a group of surgeons who were performing hypophysectomy for the relief of terminal cancer pain. It was known that alcohol ablation of the pituitary could relieve cancer pain in about 70% of patients18 but the mechanism was unknown19. The degree of pituitary functional loss, and its effects, were also unknown at this time. Thus, it was decided to study the effect of hypophysectomy on pituitary function. Pituitary function was tested before; and 6 and 12 weeks after, pituitary ablation, by measuring the response at 30 minute intervals for 2 hours to releasing hormone stimulation and hypoglycaemic stress. The results showed again that pain relief was achieved, but that destruction o f the pituitary was variable. Pain relief was not related to loss of any particular hormone or to the degree of pituitary destruction. The mechanism for this effect remains controversial20.
A thorough physical examination looking for sites of chronic infections is critical. Chronic infections such as periodontal disease, sacral decubitus, and foot ulcerations are often ignored or underreported by patients. Natural skin flora should be reduced before surgery as well as screening for high counts of nasal Staphylococcus aureus. A high number of nasal carriers of S. aureus are usually asymptomatic and will only be detected by screening. A large multicenter trial showed a reduction from 7.7% to 3.4% in SSI with the preoperative treatment of intranasal mupirocin and skin decolonization with chlorhexidine. The reduction was most pronounced in the occurrence of deep SSI. Patients in the decolonization group applied mupirocin ointment 2% (Bactroban, GlaxoSmithKline plc, London, UK) in both nares twice daily in combination with daily body washes with chlorhexidine gluconate soap, 40 mg/mL (HiBiScrub, Mölnlycke Health Care, Sweden) for 5 days. 33
model that has been proposed as a potential solution to this mismatch is a stepped-care approach. In a stepped-care model, brief but effective interventions are offered to a population universally (or to those who screened positive for distress), and only if patients fail to benefit from the brief approach requiring minimal resources are more intensive psychosocial services offered. The efficacy of a stepped-care model rests upon the efficacy of minimal interventions, which are typi- cally those administered in the form of self-help or Internet- delivered interventions. Although in the RA literature, there is a long history of self-management approaches that have been shown to result in improvements in disability and pain, most of these are facilitated face-to-face in group formats. 32