A Whole-Person Model of Care for Persistent Pain: From Conceptual Framework to Practical Application

Cut-off scores of the Depression Anxiety Stress Scale-8: Implications for improving the management of chronic pain

AIM

Mental distress, non-specific symptoms of depression and anxiety, is common in chronic pelvic pain (CPP). It contributes to poor recovery. Women's health nurses operate in multidisciplinary teams to facilitate the assessment and treatment of CPP. However, valid cut-off points for identifying highly distressed patients are lacking, entailing a gap in CPP management.

DESIGN

This instrumental cross-sectional study identified a statistically derived cut-off score for the Depression Anxiety Stress Scale-8 (DASS-8) among 214 Australian women with CPP (mean age = 33.3, SD = 12.4, range = 13-71 years).

METHODS

Receiver operator characteristic curve, decision trees and K-means clustering techniques were used to examine the predictive capacity of the DASS-8 for psychiatric comorbidity, pain severity, any medication intake, analgesic intake and sexual abuse. The study is prepared according to the STROBE checklist.

RESULTS

Cut-off points resulting from the analysis were ordered ascendingly. The median (13.0) was chosen as an optimal cut-off score for predicting key outcomes. Women with DASS-8 scores below 15.5 had higher analgesic intake.

CONCLUSION

CPP women with a DASS-8 score above 13.0 express greater pain severity, psychiatric comorbidity and polypharmacy. Thus, they may be a specific target for nursing interventions dedicated to alleviating pain through the management of associated co-morbidities.

IMPLICATIONS FOR PATIENT CARE

At a cut-off point of 13.0, the DASS-8 may be a practical instrument for recommending a thorough clinician-based examination for psychiatric comorbidity to facilitate adequate CPP management. It may be useful for evaluating patients' response to nursing pain management efforts. Replications of the study in different populations/countries are warranted.

Pain hygiene: A content analysis of student nurses' perspectives

Pain hygiene (PH) is a new concept that has not been well-defined. A qualitative content analysis was conducted to understand this newly developed concept. Based on the responses from 78 students, the perceptions of the meaning of the term "pain hygiene" and differences between the term "pain hygiene" and "sleep hygiene" through their participation in open-ended surveys was described. Using content analysis, four themes emerged to present students' meaning of the term "pain hygiene": prevention of worsening of pain; cleanliness or hygiene practices to manage pain; self-care to manage pain; and physical and psychological management of pain. Two themes emerged illustrating differences between PH and sleep hygiene: practices that contribute to a better quality of life and condition, and better sleep with no pain. As a newly developing concept, PH can be used to make changes in pain assessment, prevention, and pain management strategies for all people with pain, which can enrich their quality of life and bring change in pain care outcomes.

Pain management in eldercare employees - the role of managers in addressing musculoskeletal pain and pain-related sickness absence

Purpose

Managers’ knowledge and behaviors in addressing musculoskeletal pain and sickness absence is not well understood. We investigated the association between managers’ knowledge and behaviours in relation to employees’ pain and their future risk of musculoskeletal pain and associated sickness absence.

Methods

The prospective study included 535 eldercare employees, and 42 managers from 20 nursing homes. Managers’ self-reported knowledge and behaviors in relation to employees’ pain were grouped using Principal Components Analysis. Eldercare employees reported pain-related sickness absence, and number of days with musculoskeletal pain repeatedly over 1 year. We investigated associations using mixed-effects regression models.

Results

We identified four types of managers’ knowledge and behaviors: 1) Pain-prevention (actions for prevention of employee pain), 2) Pain-management (actions to assist employees manage pain), 3) Pain-entitlements (communicating entitlements to employees with pain), and 4) Pain-accommodations (ability to facilitate workplace accommodations for employees with pain). The employees of managers with higher scores on knowledge of pain-entitlements reported fewer days of pain-related sickness absence (β = -0.62; 95%CI [-1.14; -0.10]). The employees of managers with higher scores on pain-management were more likely to report low back pain (β = 0.57; 95%CI [0.02; 1.11]). We found several key associations between the knowledge and behaviors measures and pain-related sickness absence (interactions).

Conclusion

Managers’ knowledge and behaviors in relation to employees’ pain were associated with employees’ future musculoskeletal pain and sickness absence. The relationships are complex, suggesting that a multifaceted approach is needed to ensure that managers are adequately informed on how to manage and accommodate employees with musculoskeletal pain to reduce sickness absence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12785-x.

Diet and Chronic Non-Cancer Pain: The State of the Art and Future Directions

Nutrition plays an important role in pain management. Healthy eating patterns are associated with reduced systemic inflammation, as well as lower risk and severity of chronic non-cancer pain and associated comorbidities. The role of nutrition in chronic non-cancer pain management is an emerging field with increasing interest from clinicians and patients. Evidence from a number of recent systematic reviews shows that optimising diet quality and incorporating foods containing anti-inflammatory nutrients such as fruits, vegetables, long chain and monounsaturated fats, antioxidants, and fibre leads to reduction in pain severity and interference. This review describes the current state of the art and highlights why nutrition is critical within a person-centred approach to pain management. Recommendations are made to guide clinicians and highlight areas for future research.

Recommendations for the Development of Socioeconomically-Situated and Clinically-Relevant Neuroimaging Models of Pain

Pain is a complex, multidimensional experience that emerges from interactions among sensory, affective, and cognitive processes in the brain. Neuroimaging allows us to identify these component processes and model how they combine to instantiate the pain experience. However, the clinical impact of pain neuroimaging models has been limited by inadequate population sampling - young healthy college students are not representative of chronic pain patients. The biopsychosocial approach to pain management situates a person's pain within the diverse socioeconomic environments they live in. To increase the clinical relevance of pain neuroimaging models, a three-fold biopsychosocial approach to neuroimaging biomarker development is recommended. The first level calls for the development of diagnostic biomarkers via the standard population-based (nomothetic) approach with an emphasis on diverse sampling. The second level calls for the development of treatment-relevant models via a constrained person-based (idiographic) approach tailored to unique individuals. The third level calls for the development of prevention-relevant models via a novel society-based (social epidemiologic) approach that combines survey and neuroimaging data to predict chronic pain risk based on one's socioeconomic conditions. The recommendations in this article address how we can leverage pain's complexity in service of the patient and society by modeling not just individuals and populations, but also the socioeconomic structures that shape any individual's expectations of threat, safety, and resource availability.

Improvement in pain interference and function by an allied health pain management program: Results of a randomized trial

BACKGROUND

Chronic pain is a significant health problem worldwide and requires a biopsychosocial treatment approach. Access to traditional pain medicine specialist services is limited and innovative treatment models are required to support patients in tertiary care. The study evaluated the clinical effectiveness and safety of the Treatment Access Pathway (TAP), an allied health expanded scope model of care which included innovative group assessment and collaboration with patients to create individualized treatment plans.

METHODS

One hundred and eighty-one patients referred to a tertiary level chronic pain service were randomly allocated to either the TAP or the waitlist study groups. Primary (pain interference) and secondary outcome measures were collected at recruitment and again at 6 months. Per-protocol analyses were utilized due to high participant attrition (46% across groups).

RESULTS

The TAP group reported greater reductions in pain interference at 6 months than waitlist group (0.9, 95% CI: 0.2-1.6), with more than half of the TAP group (52%) reporting clinically significant improvement. In addition, statistically significant differences between the TAP and waitlist groups were observed for objective measurements of walking endurance (5.4 m, 95% CI: 1.7-9.1); and global impressions of change (1.4 unit decrease, 95% CI: 1-1.9). Nil adverse events were recorded.

CONCLUSIONS

The study suggests that an expanded scope allied health model of care prioritizing patient choice and group-based interventions provides modest benefits for tertiary-referral chronic pain patients. TAP warrants further investigation as a potentially viable alternative for tertiary healthcare where traditional pain services are unavailable or have long waiting lists.

SIGNIFICANCE

The study tests effectiveness and safety of an expanded scope allied health-led chronic pain program. Despite a high attrition rate, the study showed reduced pain interference and increased physical function in those who completed the protocol. The results are promising and support introduction of this model as an adjunct to existing traditional chronic pain models of care, with a particular focus on improving participant retention in the program. Additionally, the model of care can be used as a standalone chronic pain model of care where no other pain management resources are available. The study was registered on ANZCTR (Trial ID: ACTRN12617001284358).

Brief introductory group education programs for chronic disease patients in chronic disease management: a scoping review protocol

OBJECTIVE

To scope the literature available and map the range of features of brief introductory group education programs implemented in chronic disease management.

INTRODUCTION

Brief introductory group education programs are resource-efficient interventions used in chronic disease management to educate patients on basic disease concepts, self-management strategies, and to introduce specialist services. There is a lack of published research that synthesizes the characteristics, guiding principles, and outcomes reported in brief group education programs in chronic disease management. This scoping review will seek to identify brief introductory group education programs and describe the i) scope of literature available on brief introductory group education programs, ii) characteristics of programs, iii) guiding self-management principles used and the extent to which programs follow such principles, and iv) types of outcomes reported.

INCLUSION CRITERIA

Studies describing an introductory or brief group patient education program (one to four sessions, no more than eight hours) for the management of chronic disease in adults with ongoing chronic disease.

METHODS

MEDLINE, Scopus, CINAHL, Emcare, Web of Science, JBI Evidence Synthesis, and PsycINFO will be searched for English-language articles published from 2001 to the present. Titles and abstracts will be screened against inclusion/exclusion criteria, followed by full-text review, independently assessed by two reviewers. Eligible articles will be extracted and charted using a standardized data extraction form. A descriptive review to summarize and contextualize the extracted data will be conducted.

Pre-Outpatient Group Education and Assessment in Chronic Pain: A Systematic Review

BACKGROUND

Pre-outpatient interventions in chronic pain have the potential to improve patient self-management earlier in primary or secondary care, which may minimize pain chronicity and negative health outcomes. The literature for this is sparse, and there are no existing systematic reviews on this topic.

METHODS

The purpose of this systematic review is to examine the evidence for pre-outpatient group interventions in chronic pain.

RESULTS

We identified four studies that looked at this: two randomized control trials, one prospective observational study, and one descriptive study. We identified high-quality evidence that a pre-outpatient group intervention reduces waiting times, moderate-quality evidence that it results in reduced costs per patient, very low-quality evidence that it reduces health care utilization, and very low-quality evidence that it improves service throughput. There were moderate-to-low levels of participant engagement with the initiative, which varied across the included studies. For patient outcome measures, we found no evidence that a pre-outpatient group intervention improves pain intensity, very low-quality evidence that it improves pain-related interference, low-quality evidence that it increases use of pain management strategies and produces high satisfaction levels, low-quality evidence that it improves pain self-efficacy, and no evidence that it improves psychological distress.

CONCLUSIONS

Group interventions before individual appointments have the potential to provide important improvements in service delivery, including improvements in waiting times and cost per patient. Benefits for patient outcome measures are less clear. Clinical heterogeneity and high levels of bias existed in the included studies. Further research is required so that meaningful conclusions can be made about these interventions.

Emerging models for successful treatment of complex regional pain syndrome in children and young adults

Complex regional pain syndrome (CRPS) is a relatively common condition that is often not well recognised or treated adequately. Patients are usually referred to multidisciplinary pain services, but outcomes remain variable. This case report describes a recent patient with CRPS who was treated quickly and effectively through a simple explanation of the relationship between mind and body, and who then was able to modify her own thought processes and behaviours. This single intervention enabled a complete resolution of symptoms. This report illustrates the clinical application of recent insights into neuroplasticity and individually tailored patient self-management that may now offer successful treatment of an otherwise chronic and disabling condition, especially in younger patients. There are implications for doctors in current practice, as well as for the training of medical students and junior doctors.

Prioritizing a sequence of short-duration groups as the standardized pathway for chronic noncancer pain at an Australian tertiary multidisciplinary pain service: preliminary outcomes

Supplemental Digital Content is Available in the Text.

Objective:

To describe implementation and report preliminary outcomes of a resource-efficient, standardized group pathway for chronic noncancer pain.

Design:

Descriptive cross-sectional study of a group-based pain management pathway in comparison with an Australasian benchmarking data set.

Setting:

An Australian tertiary multidisciplinary pain service.

Subjects:

Patients with chronic noncancer pain actively participating in the group pathway in 2016.

Methods:

Referred patients were prioritized to a short-duration group–based standardized pain management pathway linking education, assessment, and treatment groups. Measures of pain, mood, self-efficacy, and catastrophizing and reduction in daily opioid use were collated from the Australasian data set.

Results:

In 2016, 928 patients were actively engaged with the pain service. More patients were prioritized to receive treatment in a group format in comparison with other Australasian services (68.4% vs 22%). A greater percentage of patients attended their first clinical contact within 3 months of referral (81.4%) compared with the Australasian average (68.6%). Comparable improvements in average pain intensity, pain interference, depression, anxiety, stress, pain catastrophizing, and self-efficacy were observed. There was significantly greater reduction in opioid use, including for those taking more than 40 mg of oral morphine equivalent daily dose.

Conclusion:

Implementation of a sequence of short-duration groups as the default clinical pathway resulted in shorter waiting times and noninferior outcomes in key areas for patients completing the program, compared with Australasian averages. Given the resource efficiencies of the group process, this finding has implications for service design.

Mind the Gaps: A Qualitative Study Combining Patients' and Nurses' Reflections on Pain Care

Chronic noncancer pain is a serious health problem, one that is often associated with physical debility and emotional suffering. Although chronic noncancer pain is one of the primary reasons that people seek medical care, a significant body of evidence indicates that chronic pain is underdiagnosed and undertreated. There is a consensus among professional stakeholders in pain care that there is a need to strengthen quality, capacity, and competence in pain management at all levels of health care. Thus, there is a need for more in-depth knowledge of both the recipients and the providers of pain care, and qualitative studies can contribute to this. The aim is to explore and combine the perspectives of patients receiving pain care and registered nurses providing care at pain clinics. A multimethod design was based on two qualitative studies consisting of semistructured interviews with patients receiving pain care (N = 10) and nurses providing pain care at pain clinics (N = 10). Qualitative content analysis was applied to interpret and abstract their experiences. The themes developed from triangulation revealed significant gaps between ideal pain care and actual practice: "Dissonance in reflections on personalized care," "A corresponding need for improved information flow in all levels," and "A corresponding need for improved structure in pain care." We suggest a stronger commitment to efficient information flow and person-centered communication to facilitate the patient involvement and self-management. In addition, more resources, education, and training are necessary to enable nurses and other professionals to act upon guidelines and ensure effective pain care.

From (Ontario Ministry of Health and Long-Term Care) policy to implementation: A retrospective look at a community-based patient-centered model of care for chronic pain

Background: Chronic pain is one of the most widely recognized, disabling, and expensive health problems in Canada. Interdisciplinary multimodal pain management is effective in helping chronic pain patients lessen symptoms and reclaim functionality, but most patients lack access to such treatments.

Aim: The aim of this study was to describe the development and implementation of a publicly funded and patient-centered model of care in the community.

Methods: The study was set in the Pain & Wellness Centre (PWC) in Vaughan, the only community-based chronic pain clinic in Ontario funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC) as a demonstration project of a template for similar future community clinics. The study is descriptive, including a brief review of the Ontario comprehensive pain strategy framework and an overview of the PWC and the process involved in the development of an interdisciplinary pain program (IDP), based on the biopsychosocial model of chronic pain management.

Results: During a 2.5-year period, the PWC has offered 1055 new patient medical consultations and 1921 follow-up visits and admitted 242 patients in the IDP program (demonstrating significant success in patient outcomes at the 3-month exit from the program). It established robust outcomes research, organized educational programs for pain trainees, and cultivated a collaborative relationship with the Toronto Academic Pain Medicine (TAPMI) network and the community at large.

Conclusions: This demonstration program has shown the feasibility and applicability of the principles of the MOHLTC comprehensive pain strategy, providing an effective, evidence-based, and accountable approach to chronic pain diagnosis and management in the community.

Nurses' experiences with health care in pain clinics: A qualitative study

BACKGROUND

Recent research has focused on the effectiveness of different treatment regimens in pain clinics, where a call for more multifaceted treatment has been highlighted. Less attention has been paid to improvements within pain clinics, and how registered nurses-who usually play a key role-perceive and experience the accessibility, treatment options and follow-up offers at public pain clinics.

OBJECTIVE

The overall aim was to explore and describe how nurses experience health care provided to patients with chronic non-cancer pain at pain clinics.

METHODS

We used 10 individual interviews with nurses working at 10 different public pain clinics in Norway. The interviews were analyzed using qualitative content analysis.

RESULTS

One theme was developed from the content analysis: "Nurses' striving to provide whole-person care in pain clinics." The nurses experienced allocation of limited resources as challenging, especially when the dilemma between accepting new patients from the waiting list and offering follow-up to existing patients became apparent. Multifaceted treatment was perceived as vital, although resources, priorities, and theoretical understanding of pain within the team were challenging.

CONCLUSIONS

The needs for multifaceted and integrated treatments in chronic pain management were obvious, although this approach appeared to be too demanding of resources and time. Stronger cooperation between pain clinics in specialist care and health care providers in primary care to ensure better patient flow and treatment is required. Emphasis is placed on coherent theoretical approaches to pain management within the team in the pain clinics to ensure whole person care.

Therapeutic alternatives for supporting GPs to deprescribe opioids: a cross-sectional survey

Background

GPs are central to opioid strategy in chronic non-cancer pain (CNCP). Lack of treatment alternatives and providers are common reasons cited for not deprescribing opioids. There are limited data about availability of multidisciplinary healthcare providers (MHCPs), such as psychologists, physiotherapists, or dietitians, who can provide broader treatments.

Aim

To explore availability of MHCPs, and the association with GP opioid deprescribing and transition to therapeutic alternatives for CNCP.

Design & setting

Cross-sectional survey of all practising GPs (N = 1480) in one mixed urban and regional Australian primary health network.

Method

A self-report mailed questionnaire assessed the availability of MHCPs and management of their most recent patient on long-term opioids for CNCP.

Results

Six hundred and eighty-one (46%) valid responses were received. Most GPs (71%) had access to a pain specialist and MHCPs within 50 km. GPs' previous referral for specialist support was significantly associated with access to a greater number of MHCPs (P = 0.001). Employment of a nurse increased the rate ratio of available MHCPs by 12.5% (incidence rate ratio [IRR] 1.125, 95% confidence interval [CI] = 1.001 to 1.264). Only one-third (32%) of GPs reported willingness to deprescribe and shift to broader CNCP treatments. Availability of MHCPs was not significantly associated with deprescribing decisions.

Conclusion

Lack of geographical access to known MHCPs does not appear to be a major barrier to opioid deprescribing and shifting toward non-pharmacological treatments for CNCP. Considerable opportunity remains to encourage GPs' decision to deprescribe, with employment of a practice nurse appearing to play a role.

Establishment of the Australasian Electronic Persistent Pain Outcomes Collaboration

Objective

Chronic pain is experienced by one in five Australians and is estimated to be the nation's third most costly health problem. In 2013, a chronic pain treatment outcomes registry was established, with the goals of evaluating treatment of chronic pain in multidisciplinary centers, establishing a benchmarking system to drive quality improvement and providing answers to important questions regarding types of treatment ("dose," intensity, and response) and which treatment is appropriate for different patients. This paper describes the development and the first-phase implementation of the registry.

Methods

A minimum data set of primarily patient-rated measures was developed for use within pain management services. Governance structures and protocols for data collection were established, and software and resources created, to support pain management services.

Results

Data collection commenced in 21 centers in Australia and is being implemented in over 20 others across Australia and New Zealand within the first two years. Feedback in the initial phase has already resulted in improvements to the software and reports, as well as minor changes to the data set. Centers have submitted high-quality data describing the demographic and clinical characteristics of patients referred to specialist pain services.

Conclusions

The electronic Persistent Pain Outcomes Collaboration has been established for Australasia and is strongly supported by specialist societies and consumer groups. The next phase will increase the proportion of follow-up data in order to realize the registry's goals of evaluation, benchmarking, and research to improve outcomes and services for patients experiencing persistent pain.

Assessment of Adults Experiencing Chronic Non-Cancer Pain: A Randomized Trial of Group Versus Individual Format at an Australian Tertiary Pain Service

OBJECTIVE

To compare the outcomes of a new group assessment format with conventional individual assessment.

DESIGN

A randomized controlled trial.

SETTING

An Australian tertiary hospital multidisciplinary pain service.

PATIENTS

Adults referred with chronic non-cancer pain.

METHODS

Following attendance at an education and orientation group, 211 participants were randomized to either a group assessment format (focused on supported self-assessment) or individual assessment. Follow-up occurred 3 months post-assessment and prior to subsequent pain service intervention. Outcome measures were pain intensity, pain interference, self-efficacy, psychological distress, health care utilization beyond the pain service, waiting time, participant satisfaction, and implementation of self-management strategies.

RESULTS

Seventy-two participants undertook group assessment and 90 were assessed individually. Follow-up data were collected on 57 group and 72 individual assessment participants. Results revealed no significant differences between the two assessment formats in outcome with the exception of wait-times. Median wait-time to the first offer of assessment was 47 days for the group format and 144 days for individual.

CONCLUSIONS

Group assessment provides a viable alternative to conventional individual assessment. The group assessment reduced wait-times while delivering otherwise comparable outcomes.

Patient perspectives about the healthcare of chronic musculoskeletal pain: Three patient cases

BACKGROUND

Consideration of the patient's perspective in healthcare is important because it may inform holistic and contextually relevant management strategies.

OBJECTIVES

The purpose of this study was to explore patients' experiences and perspectives about their chronic musculoskeletal (CMSK) pain and its management in the private healthcare sector in South Africa. This work was done as a pilot study to test, adapt and finalize an interview schedule.

METHODS

A descriptive, qualitative study was conducted. The sampling was purposive. Three patients with CMSK pain were recruited to participate in in-depth individual interviews. The interviews were recorded and transcribed ensuring confidentiality. Inductive, thematic content analyses of the transcripts were undertaken. Initial codes were assigned and a code book developed, which was applied to the transcripts to develop categories and themes.

RESULTS

Four themes emerged from the data: (1) the participants sought understanding about the pain's origin and the reason for pain persistence; (2) pain impacted their lives in multiple ways; (3) the participants depended on healthcare providers (HCP) for guidance and support; and (4) they had the option of acceptance of chronic pain.

CONCLUSION

The participants' knowledge about their health condition had important implications as it influenced their perspectives on pain and its management. The pain presented the participants with several challenges, which included developing an understanding about pain and coping with the impact of pain in their lives. HCPs were perceived to play an important role in empowering or disempowering the participants.

Persistent musculoskeletal pain and productive employment; a systematic review of interventions

A systematic analysis of the literature was undertaken to determine which characteristics of workplace interventions are most effective in assisting people with persistent musculoskeletal pain (PMP) to remain productively employed. Databases of Medline, PsychINFO, CINAHL and Embase were searched using MeSH and other relevant terms. Studies that reported on interventions at, or involving, the workplace were included. Interventions were considered as either focused on the individual or multilevel. Outcome measures assessed included: job loss, productivity, sick leave, pain and cost benefit. A quality assessment was undertaken using GRADE criteria with development of impact statements to synthesise the results. Eighteen relevant articles (14 studies) were identified for inclusion in the review. No high-level evidence for workplace interventions to assist people with PMP were identified. Low numbers of participants and limited studies resulted in downgrading of evidence. However, individually focused interventions will probably reduce job loss and sick leave, but are unlikely to reduce pain. Multilevel focused interventions will probably result in decreased sick leave and provide some cost benefit. The evidence on productivity was limited and of poor quality. Further research is required because sustainable employment for individuals with PMP is important and understanding what works is necessary to ensure effective workplace interventions are developed.

An analysis of multidisciplinary staffing levels and clinical activity in Australian tertiary persistent pain services

OBJECTIVE

To document staffing (medical, nursing, allied health [AH], administrative) in Australian multidisciplinary persistent pain services and relate them to clinical activity levels.

METHODS

Of the 68 adult outpatient persistent pain services approached (Dec'08-Jan'10), 45 agreed to participate, received over 100 referrals/year, and met the contemporaneous International Association for the Study of Pain criteria for Level 1 or 2 multidisciplinary services. Structured interviews with Clinical Directors collected quantitative data regarding staff resources (disciplines, amount), services provided, funding models, and activity levels.

RESULTS

Compared with Level 2 clinics, Level 1 centers reported higher annual demand (referrals), clinical activity (patient numbers) and absolute numbers of medical, nursing and administrative staff, but comparable numbers of AH staff. When staffing was assessed against activity levels, medical and nursing resources were consistent across services, but Level 1 clinics had relatively fewer AH and administrative staff. Metropolitan and rural services reported comparable activity levels and discipline-specific staff ratios (except occupational therapy). The mean annual AH staffing for pain management group programs was 0.03 full-time equivalent staff per patient.

CONCLUSIONS

Reasonable consistency was demonstrated in the range and mix of most disciplines employed, suggesting they represented workable clinical structures. The greater number of medical and nursing staff within Level 1 clinics may indicate a lower multidisciplinary focus, but this needs further exploration. As the first multidisciplinary staffing data for persistent pain clinics, this provides critical information for designing and implementing clinical services. Mapping against clinical outcomes to demonstrate the impact of staffing patterns on safe and efficacious treatment delivery is required.

The assessment for living with aphasia: reliability and construct validity

The Assessment for Living with Aphasia (ALA) is a pictographic, self-report measure of aphasia-related quality-of-life. Research was undertaken to assess test-re-test reliability, construct validity, and the ability to discriminate aphasia severity. The ALA was administered to 101 participants with aphasia on two occasions. Test-re-test reliability was evaluated using intra-class correlations and internal consistency using Cronbach's alpha. Three reference measures were administered to assess construct validity. A focus group reported on ease of administration and face validity. Analysis identified 15 out of 52 rated items for elimination. For the remaining items, test-re-test reliability was excellent for the total score (ICC = .86) and moderate-to-strong for a priori domains adapted from the WHO ICF (.68-.83). Internal consistency was acceptable-to-high. Significant correlations were observed between the ALA and reference tests (SAQOL-39, .72; p < .001; VASES, .62, p = .03; BOSS CAPD, -.69; p = .008). The language impairment domain discriminated between all aphasia severity groups, while mild aphasia was different from moderate and severe aphasia in participation and total scores. The ALA was reportedly easy to administer and captured key aspects of the experience of living with aphasia. Results suggest acceptable test-re-test reliability, internal consistency and construct validity of the ALA.

Ceasing intrathecal therapy in chronic non-cancer pain: an invitation to shift from biomedical focus to active management

Objective

To report long term experience (1997–2009) of intrathecal (IT) therapy for chronic non-cancer pain in the context of our team’s increasing emphasis on active management.

Design

Descriptive case series.

Setting

Australian tertiary multidisciplinary pain center, Hunter Integrated Pain Service (HIPS).

Intervention

This case series reports the changing use of IT implanted drug delivery systems (IDDSs) for chronic non-cancer pain over 13 years. Initially IT therapy was used selectively following multidisciplinary assessment and double blind IT trial. Typical therapy combined opioid with clonidine. Multidimensional management was offered. Treatment strategy changed in 2003 due to HIPS experience of limited therapeutic gains and equivocal support for IT therapy in the literature. Subsequently IT therapy was no longer initiated for non-cancer pain and those on established regimes were encouraged to shift to oral/transdermal opioids with greater emphasis on active management. Patient education and consultation were key elements. Where IT cessation was elective gradual dose reduction commenced as an outpatient. In elective and urgent cases ketamine infusion and oral clonidine were used during hospital admissions to cover the switch to oral/transdermal opioids. Over the study period transition occurred to a broader management framework in which IT therapy for chronic non-cancer pain was no longer supported by HIPS.

Results

25 patients were managed using IDDSs; 8 implanted by HIPS and 17 by other teams. Dose escalation and adverse effects were common. 24 of 25 patients ceased IT therapy; 7 (29%) with urgent IDDS related complications, 16 (67%) electively and 1 due to an unrelated death. The remaining patient returned to her original team to continue IT therapy. One post-explantation patient transferred to another team to recommence IT therapy. The remainder were successfully maintained on oral/transdermal opioids combined with active management.

Waiting in pain: a systematic investigation into the provision of persistent pain services in Australia

OBJECTIVES

To document and describe outpatient persistent pain management services in Australia.

DESIGN, PARTICIPANTS AND SETTING

Systematic survey conducted between 1 December 2008 and 31 January 2010 of 57 services providing outpatient care to adult clients with persistent pain, plus five specialised paediatric services throughout Australia.

MAIN OUTCOME MEASURES

Service structure, including funding processes; activity, including client numbers, access to specialised services (inpatient care, pain relief interventions); waiting times; and use of allied-health-professional-based pain management programs.

RESULTS

Of 68 services identified, 57 participated in the study. The median waiting time from referral receipt to initial clinical assessment for a publicly funded outpatient adult pain management service was 150 days, compared with 38.5 days for a privately funded service (P<0.05). There was substantial variability among providers in range of services offered, including provision and duration of allied-health pain management programs. The level of service provision for children and rural patients is notably lower than that reported for urban adult constituents.

CONCLUSIONS

Persistent pain management services are currently unable to meet service requirements adequately, and waiting times are more prolonged for publicly funded than privately funded services. Greater service provision is required in rural areas and for children.

Understanding Chronic Pain in a Lifestyle Context

This article reviews both traditional and emerging aspects of pain medicine within the context of a “whole-person,” lifestyle-based approach. This is consistent with contemporary systems theory formulations of chronic disease in general. A traditional approach sees ongoing pain as a fixed biological disorder and much of its management as the task of medically palliating or learning to cope. Within this framework, chronic pain has been conceptualized by some authors as a disease in its own right based on underlying alterations in nervous system processing. This explains the stronger correlation of chronic pain with neural sensitization than with structural change in bodily tissues. However, recent research findings are expanding current views of causation and management, and there is now a growing recognition that pain-related nervous system changes are potentially reversible. The so-called paradox of plasticity proposes that the same property of changeability in the nervous system that allows chronic pain to develop can also lead to its resolution. Nutrition and personal story are key aspects of an emerging whole-person approach and can be combined with traditional biomedical and cognitive behavioral interventions to enhance therapeutic gains. An interesting hypothesis deriving from recent research is that multiple unhelpful aspects of lifestyle contribute to systemic metaflammation, which in turn spills over to sensitize the nervous system and facilitate pain-related transmission. Therefore, addressing lifestyle factors therapeutically has the potential to desensitize the nervous system and reduce pain.